WILSON ON THE SKIN. 
ON DISEASES OE THE SKIN. 
BY ERASMUS WILSON, F R. S., 
Author of “A System of Human Anatomy,” &c. 
A NEW AMERICAN, FROM THE LAST AND IMPROVED LONDON EDITION, 
In one large and handsome octavo volume, extra cloth, $2 75. 
Also, with fifteen Steel Plates, of which eight are exquisitely colored, |7 00. 
As a practical guide to the classification, diagnosis, and treatment of the diseases of the 
skin, the book is complete. We know nothing, considered in this aspect, better in our lan- 
guage ; it is a safe authority on all the ordinary matters which, in this range of diseases, 
engage the practitioner’s attention, and possesses the high quality—unknown, we believe, 
to every older manual—of being on a level with science’s high-water mark—a sound book 
of practice.—London Medical Times. 
We have read this edition of Wilson on Diseases of the Skin with unusual interest, and 
cannot hesitate to recommend it as the most complete and satisfactory work on the subject 
now extant.—Medical Examiner. 
The “Diseases of the Skin,” by Mr. Erasmus Wilson, may now be regarded as the stand- 
ard work in that department of medical literature.—Medico-Chirurg. Review. 
It is extremely minute, accurate, and comprehensive, though concise; the treatment, 
though succinctly, is amply indicated; and the work will fairly contest with that of Rayer, 
the merit of being the best on the subject which we possess.—The New York Journal of 
Medicine. 
THE SAME AUTHOR—(Just Issued.) 
HEALTHY SKIN: 
A POPULAR TREATISE OX THE SKIN AND HAIR, THEIR PRESERVATION AND 
MANAGEMENT. 
SECOND AMERICAN, FROM THE FOURTH AND REVISED LONDON EDITION. 
WITH NUMEROUS ILLUSTRATIONS. 
In one neat royal 12mo. volume, of about three hundred pages; extra cloth, $1. 
THE SAME AUTHOR. 
ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, 
AND ON 
SYPHILITIC ERUPTIONS. 
WITH FOUR EXQUISITE COLORED PLATES, PRESENTING MORE THAN THIRTY 
VARIETIES OF SYPHILITIC ERUPTIONS. 
In one beautiful octavo volume, extra cloth, $2 25. 33LANCIIAIID & LEA 
HAVE JUST ISSUED AN 
ATLAS OF CUTANEOUS DISEASES. 
BY J. MOORE NELIGAN, M.D., M.R.I.A., &c., 
In one very handsome quarto volume, extra cloth. 
WITH SPLENDID COLORED PLATES, 
PRESENTING NEARLY ONE HUNDRED ELABORATE REPRESENTATIONS OF DISEASE, 
COLORED AFTER NATURE. 
Price $4 50. 
This beautiful volume has been prepared by the author as an accompaniment 
to his “Practical Treatise.” No pains have been spared to render the 
figures accurate and trustworthy portraits of a class of affections which, perhaps 
more than any other, require this mode of pictorial elucidation, and as the two 
works contain references from one to the other, taken together they may be said 
to constitute a complete manual on the pathology, diagnosis, and treatment of 
cutaneous affections. 
A compend which will very much aid the practitioner in this difficult branch of diag- 
nosis. Taken with the beautiful plates of the Atlas, which are remarkable for their accu- 
racy and beauty of coloring, it constitutes a very valuable addition to the library of a 
practical man.—Buffalo Med. Journal, Sept. 1856. 
Nothing is often more difficult than the diagnosis of disease of the skin; and hitherto the 
only works containing illustrations have been at rather inconvenient prices—prices, indeed, 
that prevented general use. The work before us will supply a want long felt, and minister 
to a more perfect acquaintance with the nature and treatment of a very frequent and trou- 
blesome form of disease.— Ohio Med. and Surg. Journal, July, 1856. 
The lithographs are so colored as to he true and faithful representations of those ninety 
varieties of a class of diseases whose exact diagnosis is thus made plain and easy, and which, 
in the absence of such aid, or a long and attentive study, is so difficult that very few practi- 
tioners seriously attempt it. The work is cheap, and no practitioner ambitious of a high 
professional status can afford to dispense with such helps.—Nashville Journal of Medicine, 
Sept. 1856. 
One of the handsomest of the many reprints that the eminent publishing house of 
Blanchard & Lea have given to the medical profession of this country is the set of illustra- 
tions of cutaneous diseases by Dr. Neligan. As specimens of the lithographic art, we doubt 
whether superior can he found in any of the numerous works on skin diseases that have, 
from time to time, been issued from the celebrated publishing houses of the Old World.— 
Louisville Review, July, 1856. 
Neligan’s Atlas of Cutaneous Diseases supplies a long existent desideratum much felt by 
the largest class of our profession. It presents, in quarto size, sixteen plates, each contain- 
ing from three to six figures, and forming in all a total of ninety distinct representations of 
the different species of skin affections, grouped together in genera or families. The illustra- 
tions have been taken from nature, and have been copied with such fidelity that they pre- 
sent a striking picture of life; in which the reduced scale aptly serves to give, at a coup 
d/ceil, the remarkable peculiarities of each individual variety. And while thus the disease 
is rendered more definable, there is yet no loss of proportion incurred by the necessary con- 
centration. Each figure is highly colored, and so truthful has the artist been that the most 
fastidious observer could not justly take exception to the correctness of the execution of the 
pictures under his scrutiny.—Montreal Med. Chronicle. A 
PRACTICAL TREATISE 
os 
DISEASES OE THE SKIN. 
BY 
J. MOORE NELIGAN, M.D., M.R.I.A., 
HONORARY FELLOW OF THE SOCIETY OF PHYSICIANS OF SWEDEN; 
PHYSICIAN TO JEUVIS-STREET HOSPITAL ; AND LECTURER ON PRACTICE OF MEDICINE IN TOE 
DUBLIN SCHOOL OF MEDICINE. 
Second American (Edition. 
PHILADELPHIA: 
BLANCHARD AND LEA. 
1857. PHILADELPHIA I 
T. K. AND P. G. COLLINS, PBINTEKS. TO 
ROBERT J. GRAVES, M.D, F.R.S., M.R.I.A, 
THIS VOLUME IS INSCRIBED, 
AS A MARK OF PROFESSIONAL RESPECT 
AND OF PRIVATE ESTEEM. AMERICAN PUBLISHERS’ NOTICE. 
In supplying the demand which has called for another 
edition of this little work, the publishers have inserted in 
their appropriate places references to the figures of Dr. 
Neligan’s very handsome “Atlas of Cutaneous Dis- 
eases,” just issued by them. The object of the author, in 
the preparation of his Atlas, was to supply a series of 
illustrations adapted to the present volume, presenting 
those points of diagnosis which cannot be conveyed by mere 
description, however graphic; the two works may therefore 
be regarded as constituting together a single treatise. 
Philadelphia, April, 1857. rREFACE. 
In submitting the observations contained in the following 
pages to the profession, the author has been influenced 
chiefly by a desire to offer, as an aid to the diagnosis and 
treatment of an important class of diseases, the results of 
an experience acquired during several years’ special atten- 
tion to the study of cutaneous eruptions. Of late years the 
British medical press has abounded with monographs on 
other special affections, hut few have been published on 
those of the skin; he has, therefore, thought that a concise 
practical treatise on them might find favor with the pro- 
fession. 
As regards the plan adopted in the construction of the 
work, the only points requiring notice are the omission of 
the details of cases which might be cited, to prove the cor- 
rectness of the views propounded, and the slight reference 
to other writers on the same subject: for both the only 
apology he has to offer, is his anxious desire to condense X 
PREFACE. 
the inquiry he proposed to himself, within as narrow limits 
as possible, being fully aware “how great an evil a great 
book” is to the physician busily engaged in practice. 
17 Merrion Square, East Dublin, 
June 1, 1852. CONTENTS. 
CHAPTER I. 
Classification 13 
CHAPTER II. 
Exanthemata 30 
CHAPTER III. 
VeSICULC • 63 
CHAPTER IV. 
Pustule 116 
CHAPTER V. 
Papulae 145 
CHAPTER VI. 
Squamc 168 
CHAPTER VII. 
Hypertrophic 199 
CHAPTER VIII. 
Hemorrhagic 226 XII 
CONTENTS. 
CHAPTER IX. 
Macula 237 
CHAPTER X. 
Cancrodes 246 
CHAPTER XI. 
Dermatophyte 264 
CHAPTER XII. 
The Sypiiilides 281 
CHAPTER XIII. 
Diseases of the Appendages of the Skin 304 
CHAPTER XIV. 
Therapeutics of Diseases of the Skin 309 
Index 327 DISEASES 
OF THE SKIN. 
CHAPTER I. 
CLASSIFICATION. 
There is no class of diseases which should interest the 
practitioner or student to a greater degree than those of 
the skin, and they are especially deserving of study in con- 
sequence of the difficulties which attend their diagnosis, 
and the obstinacy with which they resist most of the re- 
medial measures that have been hitherto proposed for their 
treatment. It is only by prolonged practical experience, 
acquired after a careful and properly directed study of 
their varied characters, and an investigation into their 
peculiar pathology, that even a moderate degree of know- 
ledge of them can be obtained. In their early stages they 
are often simple and uncomplicated in form, and, conse- 
quently, easy to be recognized; but when they become 
chronic they are generally so changed and altered, that it 
is often very difficult to discover to what special class or 
order the peculiar form of disease under observation may 
belong. 
The skin, which covers the entire of the external sur- 
face of the body, has many uses in the animal economy; 
and, therefore, a diseased condition of it is attended, not 
alone with vast inconvenience to the person affected, but 
is also usually accompanied by a greater or less amount 
of derangement of the health generally. It is the organ 
or medium of touch; serves for the defence of the muscles, 
bones, bloodvessels, and nerves placed beneath it; is, more- 14 
CLASSIFICATION. 
over, the organ of absorption and excretion; and, as some 
recent physiological writers have well observed, agrees, in 
many of its functions and properties, with the mucous 
membrane, of which it is manifestly a continuation,—the 
mucous membrane protecting the internal parts of the body, 
while the skin protects those that are external; there is 
consequently a remarkable agreement between them. In 
deranged conditions of the skin, the mucous membrane 
becomes more or less engaged; and, in diseases which affect 
the mucous membrane, the functions of the skin, as regards 
absorption and excretion, are also affected to a greater or 
less degree. 
Owing to the great obscurity which so long enveloped 
the study of this class of diseases, and the late period in 
the history of medicine at which any attempt was made to 
classify them at all regularly, a great deal is left for the 
inquirer, even of the present day, to clear up. Yet we 
have abundant evidence, in the writings of the Jewish, the 
Egyptian, the Arabian, the Greek and the Roman legis- 
lators and physicians, of their existence from the remotest 
antiquity; and that they were very numerous, often occur- 
ring as scourges of mankind, is easily proved by a reference 
to the Leprosy of the Jews, and the Elephantiasis of the 
Greeks and of the Arabians. Of late, much has been ex- 
pected from the employment of the microscope in discover- 
ing the exact nature of diseases of the skin, but in this ex- 
pectation we have, as yet, been more or less disappointed. 
It is true, that by its aid much valuable information has 
been gained, as to the normal structure of the skin, yet 
but little addition has been hitherto made thereby to our 
knowledge of its diseased conditions, more particularly with 
reference to their diagnosis and treatment, as based on 
minute anatomy. There is one important fact, however, 
which has been attained by the use of the microscope in 
the investigation of the nature of diseases of the skin, 
namely, the discovery that, in certain affections, a vegetable 
production—a cryptogamic plant—is present on the cuta- 
neous surface, and is evidently intimately connected with 
their true pathology. A difference of opinion exists as to 
whether these vegetable growths are the cause or the con- 
sequence of the disease in which they have been found to CLASSIFICATION. 
15 
occur; but there can be no doubt now that all, or at least 
nearly all, dermatologists admit the truth of the discovery, 
and consequently believe in the existence of these vegetable 
growths, a new classification, containing a group or order, 
of which the presence of these fungi will form the essential 
character, must be constructed. 
An important point of view in which diseases of the skin 
must be regarded, and one that adds much to their interest, 
is the effect they produce upon the system generally. We 
sometimes find that in persons who have labored even for 
a long time under these affections, but little constitutional 
derangement is, in many cases, caused by them—so little, 
indeed, that it has often been doubted whether the existence 
of an affection of the skin, in a chronic form, tends to 
shorten life, or should be taken into account in coming to 
a conclusion as to eligibility, in a medical examination, for 
assurance. For my own part I believe that as long as the 
individual remains unaffected with any acute or inflam- 
matory affection, the existence of a skin disease will not, in 
any respect, diminish the average chances of longevity ; 
yet I have no doubt but that a person laboring under any 
general cutaneous affection, the existence of which unques- 
tionably deranges the functions of this extensive membrane, 
must be more or less liable to have the symptoms of an 
ordinary acute disease, such as fever or any of the internal 
inflammations, aggravated, and the treatment rendered more 
difficult and complicated by its presence. Thus, although 
a chronic affection of the skin may not directly tend to 
shorten life, yet it may do so indirectly. As, however, these 
various points will be more fully considered in speaking of 
each eruption individually I shall not dwell on them at pre- 
sent, but proceed to describe the classification of diseases of 
the skin which I propose to adopt. 
No subject in the study of medicine has created more 
difficulty, or for a longer period tended to retard its ad- 
vancement, than that of nosological arrangements. It 
was at one time believed to be impossible to understand 
the nature of diseases or their proper treatment, without 
an intimate knowledge having been previously acquired of 
their classification, and we therefore find that all the writers 
on medicine of the last, and of the commencement of the 16 
CLASSIFICATION. 
present century, sedulously devoted themselves to devise new 
systems, each more complicated than the other. As regards 
diseases generally, it is now agreed by all that the less 
complicated and more simple the classification under which 
they are arranged, for the purposes of description or of 
teaching, the more advantageous is it for the acquirement 
of a knowledge of them ; and fewr, therefore, take the trou- 
ble of making themselves acquainted with the labored sys- 
tems of Cullen, Sauvages, Mason Good, or the many noso- 
logists of their day. Simplicity, I need scarcely say, is of 
equal advantage in classifying any special set of diseases, 
as those of the skin; yet even in our own time it seems to 
me to he strangely overlooked by dermatologists; writer 
after writer, impelled, as it were, by an ambition to devise 
something novel, propounds a new classification, careless 
how complicated and difficult of being comprehended it may 
be, provided only it differs from those which preceded. 
As in the arrangement of objects of natural history, so 
in that of diseases, a classification may be either artificial 
or natural; the former being based on external appearances, 
or those which come directly under the cognizance of our 
senses, without any respect to intimate nature, structure, or 
properties; while the latter has especial regard to natural 
qualities, as a bond of affinity. In addition to these two, 
a third has been adopted by some writers on diseases of the 
skin, which may be called a local or regional arrangement 
—that is, one in which they are placed in groups, de- 
pendent on the part of the body upon which they are 
seated; but, of course, in this system, regard must also be 
had to the individual character and form of the various 
eruptions. 
Of the many systems of classification of diseases of the 
skin which have been, from time to time, proposed, two 
especially of those of the earlier writers are worthy of 
notice, not alone as being the first which had any preten- 
sions to accuracy or completeness, but as forming, to a cer- 
tain extent, the basis of most of those which have been 
since propounded—I allude to the artificial system of Willan, 
and the natural one of Alibert. Although Willan adopted, 
as the groundwork of his classification, an arrangement CLASSIFICATION. 
17 
originally proposed by Plenck—following out the idea of 
Riolanus put forth nearly a century previously—of placing 
diseases of the skin in groups, according to their form and 
appearances, yet from the accuracy and appropriateness of 
his nomenclature, which is that now almost universally em- 
ployed, and the clearness with which he defined the leading 
features of his general divisions or orders, it is correctly 
regarded as being the first important step made to the cor- 
rect understanding of diseases of the skin. Alibert, in the 
first instance, following Turner, an Englishman, who was 
himself preceded by Mercurialis, adopted a regional classi- 
fication, dividing all eruptions into two classes, as they were 
situated on the head or on the trunk of the body; but this 
he soon abandoned for a natural system, which, though 
grandly conceived, did not survive its author, being found 
too complicated and difficult of application when attempted 
to be reduced to practice. 
In Willan’s system, cutaneous diseases are divided into 
eight orders, characterized by the form of the eruption, 
viz:— 
Papulae. 
Squamae. 
Exanthemata. 
Bullae. 
Vesiculse. 
Pustulm. 
Tuberculse. 
Maculae. 
The distinctive features of the eruptions, by which these 
orders are characterized, he defined as follows; and here I 
may again remark that his nomenclature and definitions are 
still in use, and generally recognized as correct:— 
1. Papula (Pimple).—Avery small and accuminated ele- 
vation of the cuticle, with an inflamed base, not containing 
a fluid, nor tending to suppuration. 
2. Squama (Scale).—A lamina of morbid cuticle, hard, 
thickened, whitish, and opaque. 
3. Exanthema (Rash).—Red patches on the skin, vari- 
ously figured, in general confluent, and diffused irregularly 
over the body, leaving interstices of a natural color. 
4. Bulla (Bleb).—A large portion of the cuticle detached 
from the skin by the interposition of a transparent, watery 
fluid. 
5. Vesicula (Vesicle).—A small, orbicular elevation of 18 
CLASSIFICATION. 
the cuticle, containing lymph, which is sometimes clear 
and colorless, but often opaque and whitish, or pearl- 
colored. 
(3. Pustula (Pustule).—An elevation of the cuticle, with 
an inflamed base, containing pus. 
7. Tubercula (Tubercle).—A small, hard, superficial tu- 
mor, circumscribed and permanent, or proceeding very 
slowly to suppuration. 
8. Macula (Stain).—A permanent discoloration of some 
portion of the skin, often with a change of its texture, but 
not connected with any disorder of the constitution. 
Alibert, in his natural arrangement, considers cutaneous 
diseases to resemble a tree, which he terms Varbre des der- 
matoses, and the branches of which constitute the various 
divisions or groups, which are subdivided into genera. His 
primary groups, which are twelve in number, he designates 
as follows :— 
Dermatoses Eczemateuses. 
“ Exanthema- 
“ teuses. 
“ Teigneuses. 
“ Dartreuses. 
“ Canc^reuses. 
“ L^preuses 
Dermatoses Veroleuses. 
“ Strumeuses. 
“ Scabieuses. 
H^mateuses. 
“ Dyschroma- 
“ teuses. 
“ Heteromorphes. 
Biett, the immediate and most celebrated pupil of Ali- 
bert, soon perceiving the difficulties which the complicated 
system of his master, though based on the natural affinities 
of the various eruptions of the skin, threw in the way of 
their successful diagnosis, forsook it for that of Willan, 
which he modified and so far improved that all the artificial 
systems of classification which have been proposed since his 
time include the changes made by him. 
Viewed abstractedly, it is manifest that a classification 
of diseases of the skin which, as a natural system is sup- 
posed to do, takes into account not merely the form but 
the essential nature and pathological characters of a cuta- 
neous eruption, should possess many advantages, both prac- 
tical and theoretical, over an artificial arrangement which 
takes cognizance merely of the alterations of the skin which 
cause the eruption, or, in other words, regards solely the CLASSIFICATION. 
19 
apparent changes in the cutaneous structure of the part 
affected. Consequently, we find that most modern writers 
on the subject have bestowed their attention on the construc- 
tion of a perfect natural system, but hitherto, in my opinion, 
without success; amongst them all there are, I think, two 
only at all deserving of notice, that of Erasmus Wilson in 
England, and of Cazenave in France. 
Wilson adopts, as the basis of his arrangement, the 
anatomy and physiology of the skin, a groundwork -which, 
owing to the additions recently made to our knowledge of 
this structure by microscopic investigation, and the degree 
of certainty which extended observation has stamped upon 
it, has been well employed by him, and renders his system 
of classification justly entitled to be designated a natural 
one. He constitutes four primary divisions of the subject, 
viz:— 
1. Diseases of the Derma. 
2. Diseases of the Sudoriparous Glands. 
3. Diseases of the Sebiparous Glands. 
4. Diseases of the Hairs and Hair Follicles. 
Of the first, five secondary divisions are made: 1. Inflam- 
mation of the Derma; 2. Hypertrophy of the Papillce of 
the Derma; 3. Disorders of the Vascular Tissue of the 
Derma; 4. Disorders of the Sensibility of the Derma; 5. 
Disorders of the Chromatogenous Functions of the Derma. 
The first of these subdivisions constitutes six groups, viz: 
a. Congestive Inflammation, divided into two sub-groups; 
the first including those affections, in which both the mucous 
membranes and the Derma are inflamed, and which are 
attended with constitutional symptoms of a specific kind; 
and the second, those in which the derma alone is engaged, 
and in which there are no specific constitutional symptoms; 
b. Effusive Inflammation; c. Suppurative Inflammation ; 
d. Depositive Inflammation ; e. Squamous Inflammation ; /. 
Inflammation from the presence of Acari. 
Of the second primary divisions, three secondary are con- 
stituted, as the diseases are attended with, 1. Augmenta- 
tion; 2. Diminution; 3. Alteration of Secretion. 
Of the third, five secondary divisions are made, as the 
diseases of the sebiparous glands are dependent on, 1. Aug- 20 
CLASSIFICATION. 
mentation ; 2. Diminution ; 3. Alteration ; 4. Detention, 
of Secretion; and 5. In which the Grlands and adjacent 
Tissues are infilamed. 
And the fourth constitutes six secondary divisions: 1. 
Augmented Formation ; 2. Diminished Formation ; 3. Ab- 
normal Direction of the Hair; 4. Alteration of Color; 5. 
Diseases of the Hairs; and, 6. Diseases of the Hair Follicles. 
M. Cazenave, adopting likewise an anatomical basis for 
his natural system, arranges diseases of the skin in eight 
groups:— 
1. Inflammations. 
2. Lesions of Secretion. 
3. Hypertrophies. 
4. Deteriorations. 
5. Hemorrhages. 
6. Lesions of Sensibility. 
7. Foreign Bodies. 
8. Diseases of the Appen- 
dages. 
The first group contains four Orders: 1. Non-Specific 
Eruptions, which may exist in an acute or chronic state; 
2. Non-Specific Eruptions, existing always in a chronic 
state; 3. Acute Specific Eruptions; 4. Chronic Specific 
Eruptions. 
The second group is divided into three Orders: 1. Lesions 
of the Follicular Secretions; 2. Lesions of the Epidermic 
Secretions; 3. Lesions of the Coloring Secretion. 
The third group, which constitutes but a single order, is 
defined to consist in an abnormal development of the parts 
affected. 
The fourth group contains those diseases which have a 
tendency to destroy the parts attacked. 
The fifth group is characterized by the presence of blood, 
more or less altered, without its proper vessels. 
The sixth group is divided into two orders : 1. General 
or Local Ilypersesthesia; 2. Anaesthesia. 
In the seventh group are placed those diseases which 
seem to depend on the presence of parasitical insects or 
animalcules. 
The eighth consists of two orders: 1. Diseases of the 
Hair; 2. Diseases of the Nails. 
Both these natural systems, the most perfect that have 
yet been proposed, present, in some respects, great advan- 
tages over artificial classifications, yet, I think, for many CLASSIFICATION-. 
21 
reasons, are not to be preferred. Could we, for example, 
predicate that the various eruptive diseases, placed by Wil- 
son or Cazenave in the group of inflammations, were inva- 
riably characterized by inflammatory action, we should re- 
ceive an important aid, not alone in diagnosis, but in treat- 
ment. But such is not the case in the classification of 
either. Both place scaly diseases of the skin in the same 
natural group, though in a different subdivision, with the 
eruptive fevers; yet can any two classes of diseases be more 
different in their nature ? The former characterized by a 
chronic inflammation of so low a form that it is very doubt- 
ful whether it should be designated as inflammation at all; 
while the latter are especially marked by high inflammatory 
action: the former tedious and slow in their progress, 
often lasting for years; the latter, acute and rapid, run- 
ning their course in a few days: the former requiring a 
prolonged constitutional treatment, and the latter demand- 
ing immediate and active remedies. Thus an erroneous 
impression, acquired from a supposed natural affinity between 
two eruptive diseases, may lead to error, both in diagnosis 
and treatment. 
Another important objection to the employment of a 
natural system of classification in the study of diseases of 
the skin is, that, being more complicated, and not so easy 
of comprehension, it is more difficult to be borne in mind 
than an artificial arrangement, and thus great obstacles are, 
by its adoption, thrown in the way of the student at the 
very threshold of his inquiry. No artificial classification 
of diseases of the skin can possibly be perfect, for different 
persons will, of course, form different ideas of the external 
characteristics and features of individual eruptions; yet it 
is an arrangement which seems to me to be better adapted 
for attaining a knowledge of the subject; and this, after 
all, is the only important use of any system of classification. 
It is especially one more easy to be remembered. It is one 
which aids us considerably at the bedside, for it requires a 
less complex process of reasoning than a natural classifica- 
tion, to discover by its agency w'hat may be the disease in 
any special case. It is, therefore, this which I purpose to 
adopt. 
A regional classification of eruptive diseases, although it 22 
CLASSIFICATION. 
is not adapted for a general inquiry into affections of the 
skin, possesses much value in their individual study, as they 
often present great differences in character and even in 
form, and frequently require peculiar modifications in treat- 
ment dependent on the region on which they may occur. I 
have thus adopted it in a small work which I published a 
few years since on Eruptive Diseases of the Scalp, and also 
in an Essay on those which affect the face, which appeared 
in the eleventh volume of the New Series of the Dublin 
Quarterly Journal of Medical Science. Were I to propose 
a regional system of classification, I would suggest that 
cutaneous eruptions should be divided into three groups: 1. 
Those which occur on parts of the body constantly exposed 
to the air; 2. Those wThich appear on parts that are pro- 
tected from the atmosphere by clothing; and, 3. Those 
which affect the hairy scalp. The first group should be sub- 
divided into those which occur on the face (and neck in 
females), and on the hands; for as the latter, especially in 
several trades and occupations, are exposed to various mat- 
ters which cause irritation, and as the skin there differs 
anatomically, in some respects, from that on the face, erup- 
tive diseases which affect them often present different appear- 
ances, as they are seated on either. Vesicular eruptions, 
in especial, present a peculiar character when they occur 
upon parts of the body covered with hair,—as, for example, 
on the scalp. If a blister be applied to the surface of the 
scalp, deprived of the hair, the blister, in common language, 
is said not to rise; the epidermis upon this part of the body 
being not only somewhat thicker than elsewhere, except on 
the soles of the feet and palms of the hands, but being 
bound down by the numerous involutions which constitute 
the hair follicles. When, therefore, a vascular eruption 
occurs upon the scalp, there is no apparent vesicle; and 
this, I believe, will account for that great difference of opi- 
nion which exists amongst writers as to the nomenclature of 
certain eruptive diseases of the scalp, I allude especially to 
the forms of Herpes. 
The chief improvements which have been made on Wil- 
lan’s original classification are contained in the systems of 
Biett, of Cazenave and Schedel in their joint work, and of 
Dr. Hughes Bennett of Edinburgh. Dr. Bennett’s modifica- CLASSIFICATION. 
23 
tion of Biett’s arrangement has been published in the Edin- 
burgh Monthly Journal of Medical Science for April, 1850, 
and is, in many respects, deserving of commendation. 
The great difficulty in devising an artificial system of 
classification of cutaneous diseases depends upon the changes 
which, in the progress of the disease, all eruptions undergo, 
with respect to their characteristic form and appearance. 
These changes are often so great that it is sometimes almost 
impossible to diagnose to what order a special eruption may 
belong in its advanced stage, and it is therefore made to 
occupy a different place in different systems. For example, 
observers differ as to whether scabies, common itch, is a 
vesicular, a pustular, or a papular eruption. It certainly 
changes rapidly, in most cases, from vesicular to pustular, 
or the vesicles become mixed up with pustules; but, in my 
opinion, it is always, in its primary stage, a vesicular 
eruption. In most diseases of the skin, we are, however, 
by careful observation, able to discover the elementary form 
of the eruption in the early stage of the disease: and from 
experience we shall always be able to diagnose, even in its 
most extreme changes, what the primary form was. This, 
of course, can only be learned by prolonged practical ex- 
perience. 
In proceeding to describe the system of classification of 
diseases of the skin which I intend to adopt, I wish, in 
limine, to disclaim any pretensions to originality. My chief 
object is to endeavor to simplify a subject which has often 
not received from the student and practitioner the attention 
it merits, owing to the difficulties with which complicated 
arrangements and ever-changing nomenclature have in- 
vested it. I shall therefore take advantage of the labors of 
those who have preceded me, and endeavor to reduce the 
grouping together of cutaneous eruptions to as few sub- 
divisions as attention to accuracy will admit. 
Mr. Plumbe was, I believe, the first modern writer to 
omit those affections which are correctly termed Eruptive 
Fevers from the catalogue of diseases of the skin. Fabre, 
in his recently published Bibliotfdque du Medecin-prati- 
cien, has followed his example, as also has Dr. Hughes 
Bennett in his proposed modification of Biett’s system. On 
this subject Mr. Erasmus Wilson remarks : “It may be said 24 
CLASSIFICATION. 
that the diseases comprised in the first sub-group [those 
characterized by inflammation of the derma and mucous 
membranes, with constitutional symptoms of a specific kind], 
viz : Rubeola, Scarlatina, Variola, &c., though heretofore 
considered and treated of as diseases of the skin, are, in 
reality, diseases of the system, of which the alteration in 
the skin is a symptom of comparatively secondary im- 
portance. I cheerfully assent to the validity of this argu- 
ment, but I am nevertheless unwilling to lose a group of 
diseases so rich and important to their illustration of the 
pathological changes wrought in and upon the skin by active 
inflammation.” Independent of these high authorities I 
would, for my own part, have no hesitation in excluding 
eruptive fevers from being described amongst diseases of 
the skin; to consider them still as such is directly opposed 
to the advanced position of modern pathology, and can only 
tend to diffuse incorrect ideas as to their essential nature. 
A few recent dermatologists have included amongst dis- 
eases of the skin some constitutional affections, in which an 
eruption—of a special form always—occurs as a concomi- 
tant symptom, and, as regards the peculiar affection, is but 
secondary, and more or less unimportant. The diseases to 
which I allude are not met with in the British Islands; they 
are the Frambaesia or yaws of South America and of the 
coast of Africa, the Radesyge of the north of Europe, and 
the Pellagra of Italy and of Austria. These have, I con- 
sider, no better claim to be classed amongst diseases of the 
skin than has the Plague, in consequence of its being 
attended with malignant pustules and boils. I shall, there- 
fore, omit them from my arrangement. 
I propose to divide cutaneous diseases into ten Groups or 
Orders, as follow:— 
1. Exanthemata. 
2. Vesiculc. 
3. Pustulc. 
4. Papulc. 
5. Squamc. 
6. Hypertrophic. 
7. Hemorrhagic. 
8. Maculc. 
9. Cancrodes. 
10. Dermatophytc. 
Adding two supplementary groups, Syphilides and DiS 
EASES OF TIIE APPENDAGES OF THE SKIN. CLASSIFICATION. 
25 
The disease contained in the Order Exanthemata are 
characterized by the occurrence, on a greater or less ex- 
tended surface of the skin, of a blush of inflammatory red- 
ness, usually more or less elevated, which terminates in 
epidermic desquamation, in the form of fine mealy scales. 
The most essential character of the Order is, that the red- 
ness momentarily disappears on pressure with the finger. 
In one form of eruption, classed amongst the exanthemata, 
namely, erysipelas, the epidermis is very commonly raised 
in large blebs by serous effusion; but this is evidently caused 
by the intensity of the inflammation which is present, takes 
place in the progress of the disease, and is not a constant 
or essential symptom. In general, the redness is in large 
uncircumscribed patches, or uninterruptedly diffused over 
the surface; but in some forms it occurs in well-defined, 
regular spots. The essential nature of the exanthemata is, 
that they are inflammatory, and they seem to have their 
seat in the vascular rete of the derma. This Order corre- 
sponds with the second sub-group of the first group of the 
first secondary division of Wilson’s Natural System, defined 
by him as “ Inflammation of the derma, without constitu- 
tional symptoms of a specific kind.” It contains four genera, 
ERYTHEMA, ERYSIPELAS, URTICARIA, ROSEOLA. 
The YesicuLjE are characterized by an eruption of vesi- 
cles or blebs, which consist in an elevation of the epidermis, 
varying in size, in some forms minute (vesicles), and in some 
of tolerable magnitude (bullse or blebs), containing a trans- 
parent, serous fluid, which, with the progress of the disease, 
becomes opaque, and dries into thin scales or hard crusts. 
The fluid by which the elevation of the epidermis is caused 
in the vesiculae is at first transparent and albuminous, but 
after a short time becomes opaque, and often puriform. 
This order nearly corresponds with the second group of the 
first secondary division of Wilson, which he defines as 
“Effusive Inflammation of the Derma.” It contains five 
genera: eczema, herpes, pemphigus, rupia, scabies. 
Wilson places scabies in a distinct sub-group, defining it to 
be “ Inflammation of the derma, from the presence of 
acari.” 
The third Order, Pustule, is characterized by the erup- 26 
classification. 
tion of Pustules,—rounded elevations of the epidermis con- 
taining pus, which, bursting, form scabs or thick crusts. 
The pustules may be of small size, and closely aggregated 
together, or large and isolated; the former constituting the 
Psydracia, the latter, the Pldyzacia, of Willan; a psydra- 
cious pustule being defined by him to be “ a minute pustule, 
irregularly circumscribed, producing but a slight elevation 
of the cuticle, and terminating in a laminated scab,” and a 
phlyzacious one, “ of a larger size, raised on a hard, circular 
base of a vivid red color, and succeeded by a thick, hard, 
dark-colored scab.” The epidermic covering of a pustule 
is much thicker than that of a vesicle, consequently it takes 
a longer time to maturate, or, in other words, to burst and 
form a scab or crust; but in their advanced stage the diag- 
nosis between the two is sometimes not unattended with 
difficulty. The eruptions placed in this order correspond 
with those classed by Wilson in the third group of his first 
secondary division : “ Suppurative Inflammation of the 
Derma.” The genera are three in number: ACNE, impe- 
tigo, ecthyma. Wilson, however, puts acne in a group, 
the definition of which that he gives being, “ Inflammation 
of the glands and adjacent textures.” 
The Papules are characterized by an eruption of minute, 
solid elevations,—pimples,—generally reddish, but some- 
times of the natural color of the skin, containing neither 
serum nor pus, terminating in the desquamation of fine 
scales, and almost invariably attended with intolerable itch- 
ing. In some forms, the top of the pimple is of a reddish 
brown or black color, but this merely depends on the acci- 
dental presence of a small, dried crust of blood, usually 
effused by scratching. This Order contains two genera : 
lichen, prurigo. It corresponds with the fourth group of 
Wilson’s first secondary division, which he defines: “De- 
positive inflammation of the derma.” 
The eruptive diseases contained in the Order Squamjs are 
characterized by the secretion of dry, laminated, whitish 
scales on the cutaneous surface, usually occurring in patches, 
often of a circular form. The scales, which are somewhat 
elevated above the level of the skin, readily fall off, to be 
again rapidly renewed; the part which they cover is of a 27 
CLASSIFICATION. 
smooth, glistening aspect, reddish, and dry. The Order 
corresponds with the fifth group of the first secondary 
division of Wilson’s classification : “ Squamous inflamma- 
tion of the derma.” It contains two genera: psoriasis, 
PITYRIASIS. 
In the Order IIypertropiile, I include those diseases 
which are characterized by an hypertrophied condition of 
the derma or epidermis, or of both, or of the hair follicles. 
The term has been used much in this sense by Simon, in his 
“ Anatomical Description of Diseases of the Skin and 
from him I have adopted it. In its application it is nearly 
synonymous with the of former artificial sys- 
tems of classification. The latter term, although probably 
not so faulty, when first employed to designate a group of 
cutaneous diseases, is, I think, highly objectionable at pre- 
sent, when it is invariably understood to designate a peculiar 
morbid deposit, and its application in any other sense must 
tend to cause confusion. Wilson, in his Natural System, 
has a group in which are placed those affections that con- 
sist in an “ hypertrophied state of the papillae of the derma;” 
but I propose to extend the application of the term, and to 
include in the Order those diseases in which the hypertrophy 
affects the other cutaneous structures. I shall place in it 
nine genera : ichthyosis, molluscum, stearrikea, ele- 
phantiasis, VERRUCyE, CLAYUS, CALLOSITATES, CONDYLO- 
MATA, NyEVI. 
The characteristics of the seventh Order, IIemorriiagiyE, 
scarcely require to be defined. In it there is a morbid 
alteration of the capillary circulation, accompanied by a 
changed or diseased condition of the blood, in which this 
fluid, escaping from its proper vessels, is extravasated in 
rounded spots or patches beneath the epidermis, and also 
beneath the epithelium of the mucous and serous membranes. 
Bursting through the latter finer structure, more or less 
bleeding usually takes place from the surfaces of both these 
membranes. It contains but one genus, purpura. 
The Order MacuLyE is characterized by an alteration in 
the color of the skin, occurring usually in large patches, 
and unattended with any eruption. The natural color may 
be deepened, diminished, or altered in hue, and the affec- 28 
CLASSIFICATION. 
tion has its scat evidently in the apparatus of the skin 
■which secretes the pigmentary matter. The Order corre- 
sponds with the fifth secondary division of Wilson : “ Dis- 
orders of the Chromatogenous Function of the Derma.” 
It contains two genera, vitiligo, which includes albinoismns, 
and ephelis. 
The Order Cancrodes contains those diseases of the skin 
in which many of their features resemble cancerous affec- 
tions. They are characterized by a degree of semi-malig- 
nancy, usually attended with foul ulceration of a slow and 
insidious nature, often with severe stinging pain, and a 
marked tendency to return after apparent cure, or after ex- 
cision, in the same or in remote parts of the cutaneous sur- 
face. It contains two genera: lupus, kelois. 
The tenth Order, Dermatophyte, I have adopted from 
Bennett. It includes those diseases of the skin which de- 
pend on, or are characterized by the presence of, parasitic 
plants. It contains two genera : porrigo, sycosis. 
Of the two supplementary Orders, the first—the Syphil- 
ides—contains those eruptions of the skin which are ordina- 
rily termed secondary, being caused by, or consequent on, the 
introduction of the venereal virus or poison into the system ; 
and the second includes diseased conditions of the hair and 
nails. 
This classification, in the drawing up of which I have had 
chiefly in view an attempt to simplify what is admittedly a 
difficult study, may be tabulated as follows:— classification. 
29 
ORDER. GENERA. 
1. Exanthemata, . . Erythema, Erysipelas, Urtica- 
ria, Roseola. 
2. Vesiculc, . . . Eczema, Herpes, Pemphigus, 
Rupia, Scabies. 
3. Pustulc, . . . Acne, Impetigo, Ecthyma. 
4. Papulae, .... Lichen, Prurigo. 
5. Squamae, .... Psoriasis, Pityriasis. 
6. Hypertrophic, . . Ichthyosis, Molluscum, Stear- 
rhoea, Elephantiasis, Ver- 
ruca, Clavus, Callositates, 
Condylomata, Naevus. 
7. Hemorrhagic, . . Purpura. 
8. Maculc, .... Vitiligo, Ephelis. 
9. Cancrodes, . . . Lupus, Kelois. 
10. Dermatopiiytc, . . Porrigo, Sycosis. 
Supplementary Groups: 
Sypiiilides. 
Diseases of the Appendages of the Skin. 30 
EXANTHEMATA. 
CHAPTER II. 
EXANTHEMATA. 
The term “Exanthemata” was employed by the ancient 
writers on medicine to designate every variety of eruption 
of the skin ; but in modern days, and more especially since 
the time of Willan, it has been restricted to denominate a 
peculiar group of cutaneous diseases,—one so well defined 
by external appearances, that there is no difficulty in diag- 
nosing any of its forms during all their stages. They are 
characterized by the sudden appearance, on a greater or less 
extended portion of the skin, of an inflammatory redness 
in variously shaped patches, which momentarily disappear 
on pressure, are usually attended with a slight elevation of 
the surface, and terminate in exfoliation of the epidermis. 
The diseases belonging to this Order are almost invariably 
accompanied by more or less inflammatory fever, and they 
thus constitute a natural group. In the treatment of them, 
however, we should be careful not to let this idea of inflam- 
mation being one of their marked characters, lead us to 
take too exclusive a view as to the remedial measures indi- 
cated ; for the attendant inflammation may be either of a 
low asthenic form, as it frequently is, or it may assume a 
highly sthenic type. 
In Erysipelas, one of the diseases included amongst the 
Exanthemata, the epidermis is often elevated by serous 
effusion into bullae, or even large blisters, which has induced 
some writers to describe it as a vesicular eruption; but 
these vesications are not a constant or necessary feature of 
erysipelas, and when they do occur are evidently dependent 
on the high degree of local inflammation which may be pre- 
sent. 
The four genera belonging to the Order are: Erythema, 
Erysipelas, Urticaria, Roseola. ERYTHEMA. 
31 
ERYTHEMA. 
Erythema (Inflammatory blush) consists in an eruption 
of superficial, deep-red stains or patches, more or less cir- 
cumscribed, and slightly elevated, attended with heat and 
tingling, and terminating either in resolution, or with slight 
furfuraceous desquamation. It is non-contagious, of a mildly 
febrile character, and rarely a disease of much importance; 
most forms of it terminating in a few days, and seldom 
becoming chronic. 
The erythematous eruption very frequently appears on 
the skin in the course of many acute affections, especially 
fevers and inflammatory diseases; often occurs in dropsies, 
when it affects the depending parts of the body or those 
exposed to pressure; may be produced by irritation of the 
cutaneous surface, as by the friction of the clothes or of the 
opposed surfaces of the skin, as when it appears in the 
axillae or in the groins; and is likewise caused on the un- 
covered parts of the body by exposure to harsh winds, or to 
the sun in travelling. The eruption may appear on any 
part of the cutaneous surface, but some of its forms occur 
with great regularity in certain regions of the skin. 
Several varieties of erythema have been noticed by der- 
matologists, but all of them may, I think, be described 
under three heads:— 
Erythema simplex. 
“ papulatum. 
“ nodosum. 
Erythema simplex (Atlas, PI. I. Fig. 1), under which I 
include the E. fugax, E. laeve, E. intertrigo, E. marginatum, 
and E. circinnatum of other writers, is generally a very 
mild form of eruption of the skin, requiring but little atten- 
tion, unless when it assumes a chronic character,—as in- 
tertrigo, when neglected, or when the causes by which it is 
produced are continued, not unfrequently does. It appears 
in the form of uncircumscribed red patches, seldom exceed- 
ing the size of the palm of the hand, and scarcely elevated 
above the surrounding skin ; it generally occurs in the course 
of some inflammatory disease, when, owing to the patches 32 
EXANTHEMATA. 
suddenly disappearing, and again as suddenly re-appearing 
on some other part of the body, it has been termed erythema 
fug ax ; it also assumes the same character as indicative of 
or connected with derangements of the digestive organs, or 
obstructed menstruation. The usual seat of this sub-variety 
is on the face, the neck, the trunk, or the upper extremities; 
there is no constitutional disturbance marking its occurrence, 
and the only local symptom is a slight degree of heat in the 
part attacked. Thus, then, it would appear to be a very 
unimportant disease, were it not for a remark of Hippocrates, 
the truth of which has been confirmed by most modern ob- 
servers, that the occurrence of erythema fugax in fevers or 
acute diseases is an unfavorable sign. 
This form of erythema, when it occurs in dropsical per- 
sons, presents a bright red, smooth, and shining aspect, 
whence it has been termed erythema Iseve (Atlas, PI. I. 
Fig. 2). It usually appears in rather large patches, which 
spread rapidly, and, if exposed to continued pressure, may 
end in ulceration, and even in mortification when the vital 
powers are very low. 
The sub-variety, which has been denominated intertrigo, 
occurs very commonly amongst children, whose fine skin 
may have been chafed from any local irritation, as from the 
surface not being sufficiently cleansed from dirt or from the 
natural secretions; it also appears in adults, especially 
during hot weather, in whom it is usually produced by the 
friction of opposed surfaces of the skin, or by rubbing of 
the clothes. In its commencement it is characterized by the 
ordinary appearances of an erythematous eruption, but 
affecting, as it chiefly does, those parts of the cutaneous 
surface in which the sebaceous glands most abound, it is 
soon attended with a diseased exudation from both the seba- 
ceous and sudoriparous glands, and the parts are coated 
with moisture of a fetid and acrid character, which keeps up 
the inflammatory irritation, and may even cause troublesome 
ulceration. The two other sub-varieties of erythema simplex 
were named by Willan from the form which they assume, 
the one, circinnatum, which occurs in small, round, slightly 
elevated patches, while the other, marginatum (Atlas, PI. 
I. Fig. 5), is more elevated at the edges than in the centre, ERYTHEMA. 
33 
the margin being thus well-defined,—the patches are gene- 
rally of a deep-red hue. The former occurs, for the most 
part, during some inflammatory disease, with the cessation 
of the acute symptoms of which it usually disappears; and 
the latter seems to be a form which erythema simplex fre- 
quently assumes in the old. 
Erythema papulatum (Atlas, PI. I. Fig. 3) is of frequent 
occurrence, especially in young persons about the age of 
puberty, and in females in whom the menstrual functions 
may have been obstructed. It appears most generally on 
the backs of the hands and fingers, but also occurs on the 
face, the neck, and other parts of the body. It is character- 
ized by an erythematous blush on an uncircumscribed sur- 
face of the skin, on which there are numerous small, round 
elevations, about the size of a pea, of a deeper red hue, the 
portions of the skin between the elevations being always of 
a paler or less bright color. The commencement of an 
attack of this variety is attended with some fever, headache, 
and slight nausea, and there are heat and a disagreeable 
sensation of tingling in the affected parts, which are also 
slightly sore to the touch. This form of the eruption is of 
no great importance, lasting usually for only a few days, 
and very rarely assuming a chronic character. Sometimes 
rather larger elevations are intermixed with the others, or 
they may all from the commencement assume the size of a 
nut or a marble, when the variety has been named 
tuberculatum; it presents this character most frequently on 
the extremities; the raised spots are there harder to the 
touch, attended with more local annoyance, and the erup- 
tion more frequently becomes chronic. 
Erythema nodosum (Atlas, PI. I. Fig. 4), is so called 
from the appearance which the eruption presents. It usu- 
ally occurs on the anterior aspect of the lower extremities, 
generally from the knee to the ankle. I have seen a few 
cases in which it was situated on the back of the arms, and 
have also occasionally seen a few spots on the anterior sur- 
face of the body. It appears in distinct rounded or oblong 
red patches, from half an inch to even two inches in diame- 
ter, with a well-defined border, circumscribed, and slightly 
elevated in the centre,—but the elevation is more apparent EXANTHEMATA. 
to the eye than to the finger when passed over the part. 
The centres of the patches or knots are of a somewhat 
brighter color than the borders, which have a dark red 
blush; the general redness fades but slightly on pressure, 
which, however, causes pain, and on the pressure being re- 
moved the color immediately re-appears. This form of 
erythema is most generally met with in young girls from 
the age of 14 to 19 or 20, rarely appearing in males. It 
has been described by some as being connected with a 
deranged state of the menstrual functions, but in my expe- 
rience I have rarely seen it produced by such a cause. It 
is attended with more fever than any of the forms of ery- 
thema, being generally ushered in with nausea, sometimes 
even vomiting, pains in the back, loins, and head, together 
with loss of appetite and slight shivering. This state may 
continue for from twelve to twenty-four hours. The patient 
then feels a sensation of heat and tingling on the fronts of 
the legs, and on examination the characteristic eruption is 
seen. The knots or patches appear simultaneously over the 
surface, not coming out in succession, increase in size and 
become harder and more painful for three or four days, then 
deepen in color until the eighth or tenth day, when they 
begin to fade, and passing often through the green and yel- 
low stages of a bruise, disappear with slight desquamation 
of the epidermis in about a fortnight or three weeks from 
the commencement of the attack. 
The seat of erythema is manifestly in the vascular struc- 
ture of the derma, the nervous functions being but little 
affected; the causes by wThich it is produced have been 
already adverted to. An epidemic of erythema has been 
described as having occurred in Paris in 1828-29, as a 
complication of a painful affection of the extremities, thence 
termed Acrodynia, which raged there at that period. M. 
Cazenave, who witnessed it in the Ilopital St. Louis, de- 
scribes its characters as consisting in “ an erythematous 
circle of a crimson color appearing on the soles of the feet, 
and on the palms of the hands, covering a space of from a 
third to two-thirds of an inch, and disappearing under the 
pressure of the finger; it presented the peculiarity that the 
portion of the skin which surrounded it was generally of a 
yellowish color, swollen and very hard, while the affected ERYTHEMA. 
35 
patch was manifestly depressed and very painful to the 
touch. These spots of erythema also appeared occasionally 
on the thighs, the scrotum, and in the axilla.” 
The diagnosis of any of the forms of erythema is in very 
few instances attended with much difficulty. It may be 
mistaken for the milder forms of erysipelas, especially in 
their early stage, hut the blush of erythema is of a deeper 
red, and less livid than that of erysipelas, is not attended 
with the same amount of local tumefaction, burning heat, 
and pain, and is marked by much less disturbance of the 
system generally, and much less fever. That form of ery- 
thema simplex which has been named fugax has sometimes 
been mistaken for urticaria evanescens; they are both exan- 
thematous eruptions; hut in the latter the eruption disap- 
pears and re-appears with constant rapidity, generally in 
the same places; while erythema fugax, though nearly 
equally evanescent, does not return to the same parts; it 
is, too, unattended with the acute itching and annoying 
tingling so characteristic of urticaria, and moreover occurs 
in the course of some disease of the general system, while 
urticaria evanescens is an idiopathic affection. Erythema 
papulatum has sometimes been mistaken for some of the 
eruptive fevers, as for measles or scarlatina; but its local 
character, its appearance upon the hands, and its papular 
elevation, serve to distinguish it from measles, in which the 
eruption is of a crescentic form, of a duller red color, and 
attended with a catarrhal fever. As regards scarlatina, 
the bright redness of the efflorescence and the acute inflam- 
matory fever, together with the sore throat of that disease, 
should suffice to render the diagnosis easy. Intertrigo 
may be confounded with chronic eczema, occurring behind 
the ears, in the axillae, or in the groins; the latter, how- 
ever, is a vesicular eruption in its primary stage, and as it 
advances is marked by the copious serous discharge, tume- 
faction, and deep red fissures, which so remarkably charac- 
terize the disease. 
The prognosis in any form of erythema is, of course, very 
favorable; all the varieties being of a slight character, lasting 
but for a short time, and the patient recovering without any 
detriment to the general health. 
Treatment.—In the very common form of erythema sim- EXANTHEMATA. 
plex, caused by exposure to the heat of the sun or harsh 
winds in travelling, nothing further is required than anoint- 
ing the parts affected with some mild oleaginous application, 
such as cold cream or fresh olive oil: a common domestic 
remedy, but not so efficacious yd the cream of cow’s milk. 
"When the eruption occurs in the course of any acute disease, 
no local application should be used except the warm bath, 
if it is not otherwise contra-indicated; and where it is symp- 
tomatic of any derangement of the digestive organs or of 
any other part or function of the general system, the con- 
stitutional, not the local affection should be treated. In 
erythema laeve the parts should be carefully protected from 
pressure, gently sponged with the dilute solution of subace- 
tate of lead warmed, then well dried, dusted over with flour, 
and enveloped in raw cotton. When the disease appears 
inclined to spread, I have found linen wet with the lead- 
wash and covered with oiled silk, the best application. 
Erythema intertrigo is sometimes very obstinate, espe- 
cially in children, when it occurs behind the ears, as it very 
frequently does. As a preventive, and in the early stages, 
dusting the parts with very finely powdered lapis cala- 
minaris is often useful; but when it becomes at all chronic, 
an ointment consisting of two grains of the carbonate of 
lead, half an ounce of white wax ointment, and half a 
drachm of glycerine, is better adapted. With some very 
chronic cases, all greasy applications seem to aggravate the 
disease, when I have seen it rapidly get well from the use 
of a lotion containing three grains of the sulphate of copper 
in an ounce of elder-flower water, applied on lint, kept con- 
stantly wet with it. In adults, intertrigo of the groins is 
occasionally very troublesome and sometimes obstinate, 
especially when the irritation is kept up by walking; the 
cucumber ointment of the French pharmaceutist has proved 
more successful in my hands in these cases than any other 
'application: in the commencement of the eruption it gene- 
rally Effects a cure in a few days, the affected parts having 
been each time previously cleansed with a moist towel, and 
then dried; it should be rather thickly smeared over them 
three times a day. If the cucumber ointment cannot be 
obtained, an ointment prepared by rubbing together two 
grains of acetate of zinc dissolved in a drachm of rose- ERYSIPELAS. 
37 
water, and an ounce of cold cream, may be substituted for 
it. Erythema papulatum is best treated in young persons 
by mild antiphlogistics, especially the saline cathartics, or 
emeto-cathartics. When the accompanying fever is at all 
well marked, and the disease occurs in robust constitutions, 
the use of a mixture containing two grains of tartar emetic 
and two ounces of sulphate of magnesia in a pint of water, 
of which a wine-glassful is taken every second hour until 
vomiting or purging be produced, is generally attended with 
much benefit. When it attacks old persons, or assumes the 
tuberculated form, tonics, as the compound tincture of bark 
in infusion of quassia or of calumba, are indicated; the 
strength also should be supported with nourishing diet, and 
wine allowed. Should this variety of erythema be asso- 
ciated with deficient or obstructed menstruation, the prepa- 
rations of iron will in general be found beneficial, unless 
the derangement be accompanied by plethora or local con- 
gestions, when of course an antiphlogistic plan of treatment 
should be adopted. 
Erythema nodosum, like the form last described, is not 
benefited by local applications, if we except the general 
warm bath which may be used every second or third day. 
The patient should remain quiet in bed, and live low until 
the feverish symptoms abate; saline antiphlogistics, the 
bowels having been previously freed by a mild mercurial 
purge, are of much service; of these, a good form is a 
mixture consisting of half an ounce of bitartrate of potash, 
a drachm of borax, two drachms of white sugar, and twenty 
fluid ounces of water, of which two ounces may be taken 
every sixth hour. While the use of the general warm bath, 
as above remarked, is usually productive of much benefit 
in this form of erythema, local baths, such as the foot-bath, 
generally aggravate the disease, in consequence of their 
determining an increased afflux of the blood to the affected 
parts. 
ERYSIPELAS. 
Erysipelas (St. Anthony's Fire) is characterized by a 
diffused shining redness of the skin, attended with burn- 
ing heat, pain, tumefaction, and a tendency to spread, 
and terminating in resolution with or without previous EXANTHEMATA. 
serous effusion beneath the epidermis, in suppuration, or in 
gangrene. It may be conveniently considered under two 
divisions:— 
Erysipelas idiopathicum 
“ traumaticum 
Cazenave arranges the varieties of it which have been 
described into three groups: True erysipelas, in which the 
inflammation is confined to the skin; Phlegmonous erysipe- 
las, in which the disease extends more or less deeply into 
the sub-cutaneous areolar tissue; and Gangrenous erysipe- 
las, in which the inflammation terminates in mortification. 
Idiopathic erysipelas (Atlas, PI. I. Fig. 6) almost inva- 
riably attacks the head and face, so much so that some 
writers, amongst others Dr. Watson, propose to restrict the 
term to that disease in which this portion of the cutaneous 
surface is diffusely inflamed; but the inflammation so fre- 
quently spreads from these parts to the integuments of the 
neck and trunk, and as in some cases it appears primarily 
even on the extremities, I cannot agree with this proposed 
restriction. In one case, that of a young man, eighteen 
years of age, who was brought into Jervis-street Hospital in 
the year 1846, every part of the cutaneous surface, even to 
the soles of the feet, was affected with idiopathic erysipelas; 
it had commenced on the integuments of one side of the face 
after exposure tp cold, and spread so rapidly that, on the 
fifth day, the the body was engaged in the disease; 
he died on the second day after his admission into the hos- 
pital, the seventh from the appearance of the eruption. 
Idiopathic erysipelas is, in nearly all cases, ushered in 
with well-marked febrile symptoms, shivering, pain in the 
back and limbs, loss of appetite, thirst, bad taste in the 
mouth, nausea, and rapid pulse, which, however, is often 
very compressible; the urine is scanty and high-colored, 
and the bowels costive. In a few cases, more especially in 
very old persons, or in broken-down habits, the local symp- 
toms are attended with very little constitutional disturbance. 
The erysipelatous inflammation frequently appears first on 
the tonsils, when the patient complains of the symptoms of 
an ordinary sore throat, but, on examination, they present 
a darker red hue than is usually present in tonsillitis, and ERYSIPELAS. 
they are also more swollen. Within the next twenty-four 
hours diffuse swelling and redness appear on some part of 
the cutaneous surface of the face or head, accompanied by 
burning heat, pain, and tension, the pain being much 
increased by the slightest touch, resting the inflamed part 
on the pillow even being often intolerable. The surface pits 
on pressure with the finger, which also causes the redness 
to fade momentarily; the affected part is bright, shining, 
and swollen, but smooth. With the progress of the disease 
the tumefaction increases much, especially where the integu- 
ments are loose, as in the eyelids and ears, and around the 
eyes, so that on the second or third day the eyes are usually 
quite closed by the swelling. 
The local inflammation generally attains its height about 
the sixth or seventh day, when, if vesications have appeared, 
they burst, and give exit to an acrid, transparent, watery 
discharge, which occasionally irritates the sound skin in 
the neighborhood over which it may flow. These vesica- 
tions rarely appear before the fifth day of the eruption, 
and run a very rapid course; they vary in size from a few 
lines to an inch or more in diameter. The constitutional 
fever, which increases with the maturation of the eruption, 
being most severe on the fifth or sixth day, when delirium 
frequently occurs, declines with the diminution of the local 
symptoms; the redness now begins to fade, the swelling 
subsides rapidly, and the disease terminates in favorable 
cases with desquamation of the epidermis on the tenth or 
twelfth day. 
When the erysipelatous inflammation extends to the sub- 
cutaneous tissue and deeper seated structures, the disease 
is denominated erysipelas phlegmonodes. This form appears 
more frequently on the extremities than on the head or 
trunk of the body. The constitutional symptoms by which 
it is ushered in, and which accompany it, are of a more severe 
character, and very frequently assume a typhoid type. As 
regards the local characteristics, the portion of the integu- 
ments affected presents a dull red or livid color, is intensely 
painful, hot, and tense, pits more deeply on pressure, and is 
more tumefied. The inflammation here very seldom ter- 
minates in resolution, suppuration usually occurring in the 
areolar tissue, with death and sloughing to a greater or less 40 
EXANTHEMATA. 
extent to this structure, occasionally ending in mortification 
of the part attacked. 
Erysipelas spreads over the cutaneous surface often with 
great rapidity, yet assuming a regularly progressive course, 
the parts on which it first appeared being those, when the 
disease ends in resolution, which first desquamate. Thus it 
sometimes occurs that the eruption is fading from the face 
and the swelling disappearing there, while the disease is be- 
ginning to show itself on the side of the head or the neck. 
Erysipelas is in an occasional case seen to assume a singu- 
larly erratic course, fading rapidly from the part on which 
it appeared, and suddenly attacking another portion of the 
skin at some distance, not spreading to it by contiguity. 
This has been made a distinct variety by some writers under 
the name of erysipelas erraticum. Dr. Graves was the first 
to notice a singular fact, as regards the mode of spreading 
of erysipelas, that when it commences at any point of the 
mesial line of the body it is very apt to spread in a symme- 
trical manner ;* that is to say, corresponding portions of the 
integuments are simultaneously attacked on both sides. 
In the course of erysipelas, the inflammation sometimes 
attacks one or more of the internal organs, as the mem- 
branes of the brain, the larynx and trachea, or the gastro- 
intestinal mucous membrane. By some this is considered 
to be a metastasis; and on this supposition it has been de- 
scribed as a distinct variety of the eruption under the name 
of erysipelas metastaticum ; but in all the cases that I have 
seen in which any internal part of the body became thus 
affected, the local erysipelatous inflammation still remained 
unchanged, and therefore it could not be correctly termed 
metastatic. 
Traumatic erysipelas has its origin in some local injury 
which may or may not have caused breach of the surface ; 
it more usually, however, succeeds the former; when it 
spreads from an ulcerated surface it is also said to be trau- 
matic. In its local characteristics it corresponds in most 
cases with the phlegmonous form of the disease, presenting, 
however, more effusion of the liquor sanguinis into the deep- 
seated tissues, in consequence, seemingly, of which, vesica- 
tions rarely appear on the surface. The inflammation is 
1 Clinical Medicine, Second Edition, vol. ii. p. 327. ERY3IPELAS. 
41 
also more diffused, spreading rapidly from the Avound, and 
unless checked by treatment, rarely becoming circumscribed. 
The parts affected, too, are more apt to become gangrenous, 
a not uncommon result in bad constitutions. The general 
symptoms of traumatic erysipelas must frequently assume a 
typhoid type, and are attendant on, not antecedent to, the 
local inflammation. In some few rare cases of this form 
both the local and constitutional symptoms are very mild, 
and do not last for a longer period than a week or ten days; 
in general, however, their duration is prolonged to from a 
fortnight to three weeks, if death does not take place at an 
early date. 
In idiopathic erysipelas death most usually occurs from 
the result of inflammation attacking some internal organ; 
but patients occasionally sink under this disease with the 
ordinary fatal symptoms of asthenic or typhus fever. The 
traumatic form often terminates in gangrene, or, the veins 
becoming inflamed, purulent deposits take place in the lungs 
or liver, and the individual dies of phlebitic pneumonia or 
hepatitis. 
Erysipelas may occur at any age, even in new-born chil- 
dren, in whom it attacks the umbilical region, from whence, 
spreading rapidly, it almost invariably proves fatal. Gene- 
ral experience seems to prove that it is more frequent in 
females than in males, and in adult life than in the very 
young or the aged. The causes of erysipelas are at times 
very obscure, yet in many cases its origin can be distinctly 
ascribed either to some local action, as in the traumatic 
form, or when it is produced by some direct irritant, or to 
some general constitutional disturbance: indeed the latter 
may be said to be always requisite as a predisposing cause. 
Thus it is often seen to arise from the same causes as those 
which under other circumstances produce fever: it follows 
exposure to cold or wet, especially when the persons so 
exposed are deprived of their usual food or stimulants; I 
saw several cases of erysipelas of the face and head occur- 
ring in car-drivers and others, who from their occupation 
were much exposed to the weather, at the time when the 
temperance movement first occurred in Ireland, and in whom 
the disease was evidently traceable to the want of the 
stimuli which they had been previously in the habit of using 42 
EXANTHEMATA. 
freely. A very fatal form of erysipelas is caused by the 
introduction of an animal poison into the system, as by the 
inoculation of morbid, matter arising from wounds received 
during dissection, from persons laboring under phlebitis, 
&c. Erysipelas may be produced by a sudden violent men- 
tal emotion, as a fit of passion,—such cases are on record, 
—in which the local determination of blood probably aids 
in the production of this disease. In young children vac- 
cination is sometimes the exciting cause of erysipelas, when 
it usually presents an oedematous character: I witnessed a 
case lately which thus arose, and in which the inflammation 
spread from the vaccine pustule on the left arm to the fin- 
gers, thence proceeded up along the fingers of the opposite 
arm, and stopped when it reached the same height on this 
arm that it originated from on the other: the child recovered. 
As to whether erysipelas is contagious or not, a singular 
difference of opinion has always existed and still exists be- 
tween the practitioners of the French and English school; 
the former laying it down as one of the characteristic defi- 
nitions of the disease that it is non-contagious, and the lat- 
ter with almost universal consent asserting that it is mark- 
edly contagious. The simultaneous occurrence of the dis- 
ease amongst a number of persons is attempted to be ex- 
plained away by the French writers on the principle that 
such persons were predisposed to it, or that an epidemic 
influence, or a peculiar atmospheric condition, reigned at 
the time. It is unquestionable that at certain seasons or 
during certain years, the contagiousness of erysipelas is more 
manifested than at other times, but this is equally true of 
all other contagious diseases. The direct proofs now accu- 
mulated are too numerous and too certain, I think, for the 
question to be any longer one of doubt, and no British sur- 
geon would, I feel confident, undertake an operation in an 
hospital in which erysipelas was present. The form of ery- 
sipelas arising from an animal poison is decidedly the most 
contagious; the medical attendants and nurses are in such 
cases generally infected, and they convey the disease even 
to others. It has been often remarked that when puerperal 
fever—which is manifestly due to the presence of a morbid 
poison in the system—prevails, wounds are very apt take on 
erysipelatous inflammation, and the disease spreads rapidly ERYSIPELAS. 
43 
by contagion; and likewise when erysipelas occurs epidemi- 
cally, that puerperal fever is apt to arise. The truth of 
these observations has been several times confirmed in the 
Rotunda Lying-in Hospital, and large surgical hospitals of 
this city. 
Persons 'who have had an attack of erysipelas are very 
liable to be again affected with it, a distinguishing feature 
between it and the eruptive fevers. 
The diagnosis of erysipelas is rarely attended with any 
difficulty. From erythema, which, however, some derma- 
tologists regard as merely a mild form of erysipelas, it is 
distinguished by the attendant constitutional symptoms, 
the smoothness of the tumefied surface, the greater degree 
of swelling, and the burning pain and tension. It differs 
from the eruptive fevers in the uniform redness which the 
inflamed surface exhibits; from phlebitis, in the absence of 
the cord-like feel which the inflamed veins present, and in 
the inflammation not spreading in lines over the track of 
the large vessels; and from synovites in the inflammation 
not being confined to, or taking its origin from, the integu- 
ments covering the synovial membranes—but in many cases 
synovitis terminates in true erysipelas. 
The prognosis in idiopathic erysipelas is in general 
favorable, unless when the disease occurs in the very old, 
in broken-down habits of body, or in extreme infancy. 
The chief indications of danger are, the attendant fever 
assuming a low typhoid type, or some internal organ be- 
coming affected. When the erysipelatous inflammation 
attacks the larynx and glottis, which may always be ap- 
prehended when it is seated on the integuments covering 
these parts, it usually proves rapidly fatal, owing to the 
tumefaction which ensues, closing up the respiratory tube. 
Erysipelas of the phlegmonous character is always more 
dangerous than when the inflammation is superficial ; and 
in the traumatic form, unless the local symptoms are very 
mild, the prognosis is always grave. 
With reference to the pathology of erysipelas it is evi- 
dently an acute inflammation of all the structures of the 
skin, the vascular rete being chiefly affected. M. Blandin 
has propounded the theory that the seat of the inflamma- 
tion is in the capillary lymphatics, and M.M. Cruveilhier 44 
EXANTHEMATA. 
and Ribes, that it is situated in the capillary veins of the 
integuments. 
The treatment of idiopathic erysipelas may be conve- 
niently considered under two heads—the constitutional 
and the local. As regards the former, many different 
views have been propounded, the supposed indications 
depending on the idea formed as to the essential nature 
of the disease. Thus those who believe it to depend on 
some deranged condition of the hepatic secretion—the 
prevalent opinion among them being that it is caused by a 
deficient secretion of bile and a consequent accumulation 
of it in the system—treat all forms of erysipelas, no matter 
what may be the age or condition of the patient, by the 
administration of remedies calculated to promote a copious 
evacuation of that fluid by the alimentary canal. Others, 
regarding it as a highly inflammatory disease, employ de- 
pletion, and other active antiphlogistics; but this plan of 
treatment, although it may succeed in the robust dwellers 
in country districts, is not at all suited for the inhabitants 
of towns or large cities. With some, the affection being 
viewed as one of asthenia, being attended with or depen- 
dent on diminished vital power, the use of tonics and 
stimulants is relied upon; while again, others, finding that 
the urine is highly acid in the early stages of the disease, 
as it is in all febrile affections, recommend an alkaline treat- 
ment. 
Seeing that these so opposite plans of treating erysipelas 
are reported by those who have proposed or adopted them 
as being attended with almost invariable success, we are 
forced to the conclusion, that in the ordinary run of cases 
constitutional treatment is of little importance. Unques- 
tionably cases occur in which there are extreme inflamma- 
tory action and high fever, demanding the use of bleeding 
and antiphlogistics; and others in which the vital power is 
so low and the accompanying fever assumes from the onset 
so marked a typhoid type, that the most powerful tonics, 
stimulants, and nutrients are clearly indicated. My owrn 
experience, which, however, it is right to say, has been 
chiefly acquired in this large and crowded city, is decidedly 
in favor of the tonic and stimulant plan of treatment. I 
ordinarily rely on the use of bark, which I give from the 45 
ERYSIPELAS. 
very commencement of the disease; in the very old or 
debilitated combining it with tincture of serpentaria, as in 
the following form :— 
O 
R. Tincturse Cinchonse, fl 3iv. 
Tincturse Serpentarise, fl 3>ij* 
Tincturge Croci, fl oj. 
Decocti Cinchonge, fl 3xj. Misce. 
“ An ounce to be taken every sixth hour.” 
At the same time giving wine and nourishing diet accord- 
ing to the circumstances of each case. 
The preparations of iron are by many preferred to those 
of bark in the treatment of this disease ; their mode of 
action would appear to be similar: the tincture of the 
sesquichloride, in the dose of from twenty to twenty-five 
drops every second or third hour, has been especially re- 
commended by Dr. and Mr. Bell, of Edinburgh, in a paper 
lately published by them.1 
I consider the use of purgatives in the early stages of 
erysipelas as decidedly objectionable: they tend to increase 
the debility, usually so important a characteristic feature 
of danger, and, determining to the mucous membrane of 
the alimentary canal and to the abdominal viscera, their 
action prevents the full development of the eruption on the 
cutaneous surface,—a circumstance to be especially avoid- 
ed in the treatment of all inflammatory diseases of the skin, 
—and thus gives rise to local congestions and transference 
of the inflammation to some internal organ. 
The use of biliary evacuants has been very strongly 
supported in an excellent practical essay published by Dr. 
Albert Walsh ;2 the remedy he recommends being tartar 
emetic, in rather minute doses,—one grain dissolved in a 
quart of some emollient drink, as whey or barley water, in 
the twenty-four hours ; he continues its use until the erup- 
tion begins to fade, when he administers sulphate of quina 
and other tonics. 
Mr. Lawrence is the chief advocate in the present day 
for bloodletting and active antiphlogistics ; but in his views, 
1 Monthly Journal of Medical Science, June, 1851. 
2 Dublin Quarterly Journal of Medical Science, Nevy Series, August, 1850. 46 
EXANTHEMATA. 
as regards the constitutional treatment of the disease, he 
has very few followers. 
If any internal organ be attacked during erysipelas, the 
most active derivatives to the surface should be employed. 
Thus, when the membranes of the brain are engaged, 
sinapisms and blisters should be applied to the legs, and 
warm stupes to the head ; active purgatives also are now 
indicated, and of these the most valuable is the turpentine 
enema. When the inflammation seizes on the larynx, 
leeches, even although great debility be present, should be 
applied beneath the angles of the jaws, and hot stuping to 
the throat, with relays of sponges assiduously employed; 
a blister to the nape of the neck is also here a valuable 
remedy. The operation of tracheotomy is not applicable 
in such cases, for the erysipelatous inflammation spreads 
rapidly downwards through the respiratory tubes, causing 
copious effusion into their sub-mucous areolar tissue. 
When erysipelas affects the scalp, the hair should be im- 
mediately cut as close as possible, with the view of keeping 
the surface cool, and of permitting local remedies to be more 
easily applied. 
In the milder forms of idiopathic erysipelas, the best and 
only local treatment requisite consists in dusting the in- 
flamed parts freely with wheaten flour or finely powdered 
starch, which may be conveniently applied from an ordi- 
nary dredging-box; the dredging should be repeated several 
times in the twenty-four hours. It allays the burning 
pain and irritation, and always proves highly grateful to 
the patient; therapeutically it appears to act by protecting 
the surface from the air, and by drying up the discharge 
as fast as it exudes from any vesications which may have 
formed. When the vesications are numerous, and the dis- 
charge excessive, I have found the addition of a drachm of 
oxide of zinc and twenty grains of finely powdered carbon- 
ate of lead to half a pound of starch of much advantage. 
In using this combination the mixed powders should be 
well shaken each time before the parts are dusted with them, 
as, in consequence of their specific gravity, the zinc and 
lead soon sink to the bottom of the vessel in which they are 
kept. 
Anointing the inflamed surface with melted lard is by ERYSIPELAS. 
47 
some preferred to the use of dusting powders. Mr. Wil- 
son speaks highly of his experience of it, having first, he 
says, employed it on the recommendation of Mr. Grantham, 
whose method is, “ to relax the skin with hot water or steam 
fomentations, and after each fomentation to saturate the 
inflamed surface with hot lard, which is afterwards covered 
with wool.” 
When erysipelas is spreading rapidly, although superfi- 
cially, over the cutaneous surface, the inflammation still 
persisting in the parts where it first appeared, inunction 
with mercurial ointment has in my experience more effect 
than any other local application in checking its progress. 
The ordinary mercurial ointment, to every ounce of which 
a drachm of glycerine has been added, should be smeared 
thickly over the inflamed surface, and on the sound skin 
for a considerable distance beyond; it need be applied only 
twice in the twenty-four hours, and if any symptoms of 
salivation be produced, its employment should be at once 
stopped. 
Acting as an impermeable varnish, and probably produc- 
ing some effect also by the compression it causes, collodion 
has been successfully employed by Spengler and Rapp as 
a local application in erysipelas ; the parts are thickly coated 
with it by means of a camel’s hair pencil, and it is renewed 
as often as may be required in consequence of its cracking 
and peeling off when dry. When the disease affects one of 
the extremities, bandaging the limb has been used with very 
favorable results: this practice originated with the Conti- 
nental school; its action seems to depend chiefly on the 
equable compression exercised on the congested capillaries 
and cutaneous veins, whereby they are emptied of the excess 
of blood contained in them; but some of the good effect pro- 
duced is also probably due to the protection from the action 
of the air thereby given. 
Phlegmonous and traumatic erysipelas demand more 
active local medication than when the inflammation affects 
the superficial layers of the integuments merely. In these 
forms of the disease many rely on topical depletion by 
leeches, by punctures, or by deep incision. While leeches 
may produce a good effect by withdrawing blood from the 
inflamed superficial vessel, the determination caused to part3 48 
EXANTHEMATA. 
on which their suction powrer is exerted is to a certain extent 
productive of mischief. The same objection does not hold 
with regard to punctures ; their employment has been highly 
advocated, amongst others, by Sir Richard Dobson, by 
Liston, and by Wilson; they should be made with a lancet, 
all over the inflamed part, at distances of from a quarter of 
an inch to an inch, according to the extent of the surface 
engaged, and penetrate to the depth of a quarter of an inch. 
As soon as they have nearly ceased to bleed, a wrarm bran 
poultice may be applied. Mr. Copland Hutchinson strongly 
recommended free incisions, and his practice has been 
adopted by Lawrence, Guthrie, and others; they should be 
made down to the subcutaneous fascia, and be several inches 
in length. When there is much deep-seated effusion of the 
liquor sanguinis, as is so frequently the case in traumatic 
erysipelas, they are decidedly productive of the best effect, 
and they should never be omitted when matter has formed. 
Nitrate of silver is used in the treatment of erysipelas 
with two intentions, to check the spread of the inflammation 
superficially, and to promote resolution in the parts which 
have been attacked. With the former view a broad line or 
cordon is made on the sound skin, at a short distance from 
the margin of the inflamed surface, by the application of a 
solid stick of the nitrate on the part, previously wet with 
pure water; when the disease is situated on one of the ex- 
tremities, this line is made to surround the limb completely. 
Mr. Iligginbottom, who amongst English surgeons is the 
chief advocate for the use of this agent, at first recommended 
the employment of the solid nitrate to the inflamed surface ; 
but in his observations, recently published, and which con- 
tain the results of his accumulated experience, he states that 
he prefers a solution containing a scruple of the salt to a 
drachm of distilled water. He gives the following direction 
for its application: “ The affected parts should be washed 
well with soap and water, then with water alone, to remove 
any particle of soap remaining, and then wipe dry with a 
soft cloth: the concentrated solution of the nitrate of silver 
is then to be applied twro or three times over the whole in- 
flamed surface, and beyond it on the surrounding healthy 
skin, to the extent of two or three inches.” In twelve hours, 
should the erysipelatous inflammation be unaffected, it is to URTICARIA. 
49 
be again applied; when vesications exist, they should be 
opened previously to the application. I prefer to use the 
nitrate of silver in the form of ointment, a drachm to the 
ounce of lard; it thus comes more completely into contact 
with the inflamed surface, does not dry up so rapidly, and 
is more easy of application to some parts of the body, as to 
the scalp. 
Sulphate of iron, both in solution and in ointment, has 
been recommended as a most valuable local application in 
erysipelas by Velpeau, but I have not seen it prove so useful 
as nitrate of silver ; the solution which he uses contains one 
part of the salt dissolved in fifteen parts of water, and the 
ointment consists of one part of the sulphate to three or 
four of lard. 
Blisters are sometimes employed writh success to prevent 
the spread of erysipelatous inflammation ; they are applied 
at the margin of the affected surface: their effect appears 
to depend on a new action being excited in the parts, and 
their use seems to prove especially of service in the erratic 
form of the disease. The only other local remedies requir- 
ing notice, are creasote, which, painted over the surface, has 
recently proved successful in the hands of some practition- 
ers ; and congelation of the surface by means of pounded 
ice and salt mixed in a bladder, which has been proposed 
by Dr. Arnott: from the use of the latter it may be appre- 
hended that some internal organ might be attacked. 
Should erysipelas assume a gangrenous tendency, in addi- 
tion to the internal administration of the most powerful 
tonics, as wine, bark, and quina, the parts ought to be enve- 
loped with a charcoal poultice, and afterwards dressed with 
lint soaked in a lotion, containing from one to two ounces 
of the solution of chlorinated soda or chlorinated lime to 
the pint of distilled water. 
URTICARIA. 
Urticaria (Nettle-rash) may be defined to consist in an 
eruption of irregularly-shaped prominent patches, or wheal- 
like elevations of the skin, of a yellowish-white or reddish- 
yellow color, which are surrounded by a diffuse redness, are 
often evanescent, and are attended with a burning sensation, 50 
EXANTHEMATA. 
tingling, and extreme itching. It is non-contagious, and is 
usually accompanied by a greater or less degree of fever ; 
and it may be either acute or chronic, in the former case 
lasting for a few weeks, in the latter for months or even 
years. The name of this disease is derived from the resem- 
blance which the eruption bears, both in appearance and 
symptoms, to that occasioned by the sting of the common 
nettle—Urtica urens. Willan describes several varieties of 
urticaria, and numerous subdivisions of it have also been 
made by other dermatologists ; but I think they may all be 
conveniently classed under three heads :— 
Urticaria febrilis. 
“ evanida. 
“ tuberosa. 
An attack of Urticaria febrilis (Atlas, PI. II. Fig. 1) is 
ushered in with the ordinary symptoms of mild fever— 
shivering, headache, hot skin, thirst, loss of appetite, pains 
in the limbs, and in many cases vomiting. In from twelve 
to twenty-four hours, the cutaneous surface becomes covered 
with numerous patches of the characteristic eruption, the 
parts on which it appears having been for a short time pre- 
viously the seat of a burning sensation, attended with ting- 
ling and itching. The wheal-like elevations generally ap- 
pear simultaneously on various portions of the body—on the 
face, the neck, over.the back, and on the anterior aspect of 
the arms and legs; they often disappear suddenly, and as 
suddenly re-appear on some other part of the skin. They 
bear much resemblance to the sting of a nettle, being slightly 
elevated, of a bright red color, with raised yellowish spots 
or lines ; in most cases the itching which attends them is 
very intense, and accompanied by a burning sensation, and 
additional patches are produced on the apparently unaffected 
surface by the patient rubbing or scratching the part. The 
eruption runs its course generally in from six to eight hours, 
but to be succeeded by a fresh crop on the same or on differ- 
ent parts of the body—in most cases appearing in the even- 
ing, and the out-break of which is attended, as before, with 
tingling and itching. Febrile urticaria is thus prolonged 
for a week or ten days, the eruption being less extensive and URTICARIA. 
51 
the constitutional symptoms less marked with each succes- 
sive crop; the general febrile symptoms subside to a certain 
extent when the rash comes fully out, but are usually again 
somewhat aggravated each time the eruption disappears. 
The epidermis of the parts which have been affected desqua- , 
mates in fine mealy scales after the disease has subsided, 
but no stain or mark is left behind. 
When the eruption does not recede and again re-appear 
as now described, but remains permanently on the surface 
on which it first presents, it assumes somewhat of a more ' 
chronic character, lasting for three or four weeks, and is 
termed urticaria perstans. This sub-variety is attended 
with milder constitutional symptoms, and with less local 
irritation and itching. In the variety named conferta (Atlas, 
PI. II. Fig. 2) the local and general symptoms are precisely 
similar to those of urticaria febrilis, but in general more 
severe ; the patches of eruption are numerous, and coalescing 
cover a much more extensive surface of the skin. A form 
of urticaria has been described under the appellation of inter-' 
mittens, in which the appearance of successive crops of the 
eruption assumes a regular intermittent type, usually quoti- 
dian, sometimes, however, more prolonged, being tertian or 
quartan, or the rash may not re-appear until the end of 
every seventh, eighth, or ninth day—coming out in the 
evening, attaining its greatest intensity during the night, 
and disappearing almost entirely before morning. Willan 
mentioned as a variety of this disease, under the name of 
subeutanea, what was manifestly chiefly a nervous irritation, 
there being constant and violent itching of the cutaneous 
surface commencing on some spot of one of the extremities, 
thence extending to the entire limb, to the trunk, and 
finally over the whole body, with only an occasional eruption 
of urticaria at distant intervals. 
Urticaria evanida (Atlas, PI. II. Fig. 3) is a chronic 
form of the disease, which not unfrequently lasts for years, 
and although unattended with fever, renders the life of the 
person who suffers from it almost intolerable, from the un- , 
ceasing painful itching b}7 which it is characterized. The 
eruption appears in small, rounded, reddish-yellow eleva- 
tions—often two, three, or more such, closely set together, 
forming a wheal like that caused by the lash of a whip— 52 
EXANTHEMATA. 
with little, if any, surrounding redness of the shin ; they 
may appear on any part of the body, but are usually de- 
veloped by scratching, or by friction of the clothes: in fe- 
males they are most frequently seated around the neck, 
where the upper part of the dress rubs the surface, and on 
the arms where they are likewise caused by the friction of 
the sleeves of the dress. The rash generally begins to 
appear towards evening, and is fully developed during the 
night, fading away before morning. The itching it occa- 
sions is most intense, causing absolute suffering, and persons 
even of the utmost fortitude cannot refrain from scratching 
violently the parts affected, by which an additional eruption 
is caused. The wheals do not remain longer on the surface 
than five or six hours, but they are renewed by the least 
local irritation, and the disease thus continues for months 
with occasional intermissions, being always most severe'dur- 
ing the summer and autumn. After it has lasted for some 
time the general health becomes more or less affected, both 
from the constant irritation it occasions and the derange- 
ment of the natural functions of the skin. 
Urticaria tuberosa (Atlas, PI. II. Fig. 4), which is a very 
rare variety of the eruption, occurs in the form of distinct, 
rounded elevations, about the size of a small walnut, hard 
and firm, extending evidently into the subcutaneous areolar 
tissue, of a livid red color, with a yellowish raised centre. 
The portion of the integuments affected is stiff, tense, and 
painful to the touch or on motion. The tumors generally 
appear on the extremities, coming out during the night with 
pain, much itching, and some fever, and nearly disappearing 
before morning, leaving the patient weak, tired, and sick. 
It is essentially chronic in its course, and very obstinate in 
its duration, sometimes extending to two or three years, or 
even longer, with short intervals of remission. 
Urticaria is of more frequent occurrence in females than 
in males, which may be accounted for by its seldom attack- 
ing any but those whose skin is fine and delicate ; for the 
same reason, while it appears not uncommonly in infants 
and children, it is not a disease of advanced life. The causes 
by which the febrile form is produced are, in most cases, 
well marked, but those on which urticaria evanida and urtica- 
ria tuberosa depend are not so manifest. A marked con- URTICARIA. 
53 
nection exists between the appearance of this eruption on 
the cutaneous surface and derangements of the digestive 
organs, or rather the irritation caused in some persons bj 
certain indigestible articles of food. Shellfish, especially 
mussels, oysters, crabs, cockles, periwinkles, and shrimps, 
have been long noted as producing urticaria in many indivi- 
duals, the eruption appearing in a few hours after any of 
them may have been eaten. Similarly it has been seen to 
arise after the ingestion of pork, veal, or goose, of salted, 
spiced, or dried meats or fish, of cheese, of honey, of many 
fruits and vegetables, particularly gooseberries, cucumbers, 
melons, mushrooms, pickles, &c. I know two persons in 
both of whom urticaria appears in half-an-hour after they! 
have eaten almonds or nuts if the brown skins had not been 
previously removed. In all these cases the occurrence of 
the eruption must be due to some individual 
with the nature of which we are unacquainted. The use of, 
certain medicines, especially of copaiba or valerian, some- 
times gives rise to this disease; in one instance which I- 
witnessed, copaiba was given to a woman who was at 
time sucking her infant, and urticaria appeared both on 
self and on her child. Frank mentions his having seen it 
occur from drinking Selters water. In the case of a boy, 
aged 15, who was admitted into Jervis-street Hospital in 
the month of December, 1851, for acute pleuritis, a copious 
eruption of urticaria appeared over the face, the upper ex-d 
tremities, and the trunk, on the third day after his admis- 
sion ; the feverish symptoms had commenced to subside, and 
his system had been brought under the influence of mercury • 
the day previously. 
Urticaria has been often noticed as occurring in connec-_ 
tion with other febrile diseases, especially with 
and Dr. Graves has pointed out the connection which exists 
between rheumatism, deranged conditions of the liver, and 
this eruption.1 In children it frequently appears at the*1 
periods of dentition, being evidently associated with the 
gastric irritation which then occurs. Many have described 
some of the forms of this disease as being caused in the 
female sex by deranged states of the menstrual function ; 
but my experience is quite opposed to this view. 
1 Clinical Medicine, Second Edition, vol. i. p. 446. 5d 
EXANTHEMATA. 
Urticaria occasionally appears as a complication of other 
cutaneous eruptions, more particularly eczema, impetigo, 
prurigo, and lichen. 
The diagnosis of urticaria cannot be attended with any 
difficulty, its local characteristics are so well marked. From 
erythema it is well distinguished by tbe absence of the dif- 
fuse redness of the cutaneous surface, and by the intense 
itching which accompanies it. Erythema nodosum might 
be mistaken for urticaria tuberosa, but the evanescent cha- 
racter of the latter, even in its most chronic form, suffices 
to diagnose it; the former also is marked by the presence 
of acute febrile symptoms. Roseola, the only other of the 
exanthemata which might be confounded with febrile urti- 
caria, is not attended with the intense itching of this disease, 
and also differs considerably in the color and appearance of 
the eruption. One of the varieties of lichen has been 
termed urticatus, in consequence of tbe troublesome sting- 
ing by which it is accompanied, owing to which symptom 
it has been occasionally mistaken for and described as a 
form of urticaria, but it is a distinctly papular eruption. 
The prognosis in any of the forms of urticaria must be 
favorable, as may be understood from what has been already 
said. A few fatal cases of the disease, it is true, have been 
recorded by some of the older writers, but that they were 
instances of this eruption uncomplicated with an internal 
organic affection may well be doubted. We have, however, 
the testimony of Willan, that a case fell under his observa- 
tion in which death occurred from the sudden retrocession 
of the eruption about the fifth day; but the patient was a 
very intemperate man, and had suffered from great pain in 
the stomach and nausea, which were much relieved when the 
cutaneous eruption came out, and delirium and high fever 
followed its sudden disappearance. 
The seat of urticaria is in the superficial layers of the 
derma and the epidermis ; as regards its pathology, it seems 
to be chiefly an affection of the nerves of the skin. From 
an analysis of the urine by Dr. Douglass Maclagan of Edin- 
burgh, he came to the conclusion that urticaria is intimately 
connected with a deficiency of the organic salts of the 
urine—urea and uric acid, and their probable retention in 
the system, and the correctness of this opinion is favored URTICARIA. 
by the connection, already adverted to, which exists between 
this disease and rheumatism. 
Treatment.—The febrile form of urticaria requires the 
employment of antiphlogistic purgatives, and diaphoretics, 
or, should the fever run very high in full habits, local or 
general bleeding may even be requisite. The best purga- 
tive is the sulphate of magnesia given in the acid infusion 
of roses, with an excess of acid; thus an ounce of the salt 
may be dissolved in twelve fluid ounces of the acid infusion, 
and to it two fluid drachms of dilute sulphuric acid be 
added ; of this the dose is a sixth part every third hour 
until the bowels are freely moved : the purgatives should 
be repeated every second day as long as the feverish symp- 
toms have not subsided. Nitre whey given at bed-time 
forms a good diaphoretic, or two drachms of the water of 
the acetate of ammonia may be added to the whey instead 
of the nitre. Acting on his view of the pathology of the 
disease, Dr. Maclagan has treated it with colchicum; and 
this medicine is certainly indicated when the eruption is 
complicated with rheumatism. 
When urticaria is produced by eating any particular 
article of food, an active and immediate emetic, such as the 
sulphate of zinc, should be at once administered, and its 
action followed by the exhibition of a mercurial cathartic ; 
if the subsequent fever be well marked, bleeding may be re- 
quired, but only a small quantity of blood should in any 
case be withdrawn, as general symptoms of pdisoning, with 
much depression, not unfrequently follow. The intermit- 
tent form of the disease requires to be treated constitu- 
tionally with tonics and antiperiodics, especially the prepa- 
rations of bark, the bowels having been first freely acted 
on by a saline cathartic; this variety of urticaria may oc- 
casionally be cut short by the administration of an emetic 
a few hours previously to the expected reappearance of the 
eruption. 
In urticaria evanida a lowering plan of treatment is de- 
cidedly contra-indicated, as the disease invariably assumes 
a chronic form. I have derived especial benefit in it from 
the use of preparations of iron, and from the administration 
of Dover’s powder ; of the former, I generally prescribe the 56 
EXANTHEMATA. 
compound iron mixture in doses of two ounces every morn- 
ing, or twenty minims of the tincture of the sesqui-chlo- 
ride three times a day in an ounce of the infusion of quassia 
or calumba, or two ounces twice daily of Bewley’s aqua 
chalybeata: of the latter, from eight to twelve grains every 
night at bed-time. Under the administration of these com- 
bined remedies, I have seen most obstinate chronic cases of 
the disease yield in a few weeks ; while administering them 
the bowels should be kept freely open by mild saline purga- 
tives. Urticaria tuberosa should be treated similarly ; but 
in cases in which the disease has been of very long stand- 
ing, it will occasionally only yield to the prolonged admini- 
stration of arsenic. When any of the forms are connected 
with or complicated by the presence of any other disease, 
the treatment ought to be modified accordingly. 
The itching and tingling of urticaria are somewhat allayed 
by the use of the warm bath, but as soon as the skin is dried 
aftemards, these painful sensations are augmented in con- 
sequence of the friction of the surface requisite to remove 
the moisture. In febrile urticaria I have employed, as a 
local application, with much effect, the following alkaline 
spirituous wTash :— 
R. Carbonatis Potassae, 3ss- 
Aquae Florum Sambuci, fl 3xiss. 
Spiritus Yini Rectificati, fl 3ss. Misco. 
Pieces of lint saturated with the lotion should he laid on 
the parts where the itching is most troublesome. In the 
chronic forms of the disease, chloroform is an excellent 
topical remedy for the same purpose; an ointment of it, 
prepared by rubbing together half a drachm of chloroform 
and an ounce of cold cream should be smeared rather thickly 
over the affected surface. Lotions and ointments, contain- 
ing prussic acid, opiates, and other narcotics, have proved 
successful in the hands of others. 
In urticaria occurring in infants and children, the state 
of the digestive organs demands especial attention, and in 
all cases whether the teeth are appearing or not, the gums 
should be lanced ; in infants at the breast, the health of the 
nurse is in particular to be attended to; the local irritation, ROSEOLA. 
57 
at this early age, may be allayed by sponging the surface of 
the body with a warm infusion of chamomile. 
Whenever the sudden retrocession of the eruption in 
urticaria is attended with evidences of derangement of any 
internal organ, the hot bath should be used, with friction 
over the surface, and blisters applied to the epigastrium 
and the nape of the neck. 
As regards the diet in urticaria, the chief point to be 
attended to is the avoidance of the use of any food which 
from individual experience, has been found to produce the 
eruption. In the acute forms of the disease the patient 
should live low ; but when it becomes chronic, the food 
should be nourishing, yet not rich or heating. 
Roseola (Rose-rash') is by many dermatologists regarded 
as being merely a variety of erythema, erysipelas, or mea- 
sles, and its existence as a distinct eruption not admitted ; 
but I fully agree with Willan, that its local characteristics 
are sufficiently well defined to separate it from any of these 
diseases, and to require a special description. The name, 
which has been applied to it in consequence of the peculiar 
rose-color which it usually presents, is to a certain extent 
objectionable, as this color varies much in the different 
stages and forms of the eruption. It consists in the appear- 
ance of very slightly elevated rose-red patches, of irregular 
shape, transient, fading at times, and again re-appearing ; 
non-contagious, and attended with some degree of fever. 
The various forms of Roseola may be classed under two 
heads: 
ROSEOLA. 
Roseola idiopathica. 
“ symptomatica. 
An attack of Roseola idiopathica (Atlas, PL II. Fig. 5) 
is usually attended with slight fever, which, however, in 
children is sometimes well marked and severe; the febrile 
symptoms subsiding to a great extent when the eruption 
appears freely on the skin. It comes out in numerous 
1 In Scotland erysipelas is commonly termed “ The Rose,” which has 
caused this eruption to be occasionally confounded with it. 58 
EXANTHEMATA. 
reddish-yellow patches, which soon assume a roseate hue, 
and are irregularly distributed over the cutaneous surface ; 
generally appearing first on the face and neck, and spread- 
ing quickly thence to the trunk and the upper and lower 
extremities; occasionally the eruption is confined to the 
face, neck, and trunk, and at times it occurs on the extremi- 
ties only. The rash is often very transient, disappearing 
completely in from twenty-four to forty-eight hours—when 
the feverish symptoms become aggravated, and re-appearing 
again within the next twelve hours; it usually runs its course 
in from five to seven days, terminating with slight epider- 
mic desquamation. When roseola occurs in infants and 
children, it is not unfrequently attended with more or less 
tumefaction of the integuments, which precedes the appear- 
ance of the eruption, being most marked in those places 
where the rash is to come out. 
Two forms of the disease have been described under the 
names sestiva and autumnalis, from their appearing at these 
seasons of the year: in the former, the feverish symptoms 
sometimes run high, and are attended with more or less 
sore throat, which, on inspection, is seen to be somewhat 
swollen and of a bright rose-red color,—the rash, too, is 
very generally distributed over the cutaneous surface; in 
the latter the eruption is of a duller hue, in smaller-sized 
patches, and attended with very slight fever or sore throat 
—this symptom, however, being often absent. When the 
disease attacks infants, it has by some dermatologists been 
described as a distinct form, and termed roseola infantilis ; 
it is in them usually very mild, and disappears in a few 
days; but in some cases is marked by itching, as would 
appear from the annoyance it seems to give the little pa- 
tient ; it is then also more prolonged. 
The eruption in idiopathic roseola not unfrequently ap- 
pears in the form of rings or circles, of a bright rosy hue, 
surrounding a healthy portion of the skin which is unaltered 
in color; it is then termed roseola annulata (Atlas, PL II. 
Pig. 6). This is a more aggravated form of the disease, 
setting in with well-marked symptoms of fever, a distinct 
shivering fit, followed by sickness of the stomach, headache, 
pains in the limbs, and hot skin, preceding the appearance EOSEOLA. 
59 
of the eruption for from twenty-four to forty-eight hours ; 
oedema of the integuments is also not uncommon in this form, 
particularly in children—in whom the disease usually occurs 
—appearing especially should the eruption suddenly retro- 
cede. In one case which I attended in 1849, that of a boy 
aged six years, the entire body became enormously swollen 
on the sudden disappearance of the rash, so much so that 
both eyes were closed, and there was great difficulty of 
breathing and of swallowing, owing to the tumefaction of 
the fauces. This variety of roseola may appear on any 
part of the cutaneous surface, but is most frequently seen 
on the lower extremities, and the trunk of the body. It 
comes out in the form of numerous small, round, reddish 
patches, which, rapidly spreading by their circumference, 
assume the character of rings, some being quite circular, 
and others irregularly so ; the central portion of healthy 
skin, which at first is only a few lines in diameter, gra- 
dually extends to half-an-inch, or even two inches, the 
surrounding rose-red eruption being from a quarter to half- 
an-inch in width : sometimes two or three of the rings, meet- 
ing, coalesce, and may thus extend beyond one of the joints, 
or nearly round a limb. Heat of the skin and itching gene- 
rally accompany this form of roseola. 
Mr. Erasmus Wilson describes a variety of roseola under 
the name of punctata, in which the eruption, attended with 
fever of a subacute type, appears on the mucous membrane 
and skin, “ on the latter, in the form of small red spots 
around the mouths of the follicles, then becoming diffused 
so as to cover the greater part of the body, reaching its 
height on the third day ; at first of a bright raspberry red 
color, afterwards acquiring a dull roseate hue, the dulness 
increasing with the progress of the decline —the disease 
lasts for ten days. He speaks of it as a rare disease, having 
seen only a few examples ; I never met with it as an idio- 
pathic affection, but I have seen syphilic roseola present 
these characteristics. 
Roseola symptomatica occurs in the course of, or as an 
accompaniment to many febrile diseases, but its charac- 
ters are so similar to those of the idiopathic form as not 
to require a distinct description. It is thus witnessed in 
small-pox—the eruption of which it usually precedes by 60 
EXANTHEMATA. 
about twenty-four hours—cow-pock, fevers, acute rheuma- 
tism, epidemic cholera, &c., and as it may attend any of 
these diseases, it has been named by dermatologists II. va- 
riolosa, R. vaccina, R. miliaria*vel febrilis, R. cholerica, 
&c. When the practice of inoculation prevailed, roseola is 
described as appearing very regularly on the second or 
third day of the fever of incubation, and was regarded as 
a favorable sign, indicating that the variolous eruption 
would be mild. In cow-pock, it occurs about the period 
of maturation of the vaccine pustule, spreading from it 
along the arm, and often appearing also on the trunk; it 
is not of very frequent occurrence, is of a very mild charac- 
ter, and fades away in two or three days. Its appearance 
during either fever or acute rheumatism is rather a favorable 
sign than otherwise; it does not require any special treat- 
ment, nor does it interfere with that of either of these dis- 
eases. The cholera exanthem has been described by Keir, 
Babington, and Rayer, all of whom witnessed it in the epi- 
demic of 1832 ; it accompanied the fever of re-action, and 
its appearance does not seem to have in any way influenced 
the progress of the disease. 
Roseola may occur at any age, but is more frequent in 
the young than in the old. It may be caused by any local 
irritation of the skin, or by any circumstance acting on the 
system generally, which gives rise to determination of blood 
to the cutaneous capillaries ; the latter is evidently the 
cause of the symptomatic form of the eruption. In sum- 
mer it is occasioned by exposure to a hot sun when the 
digestive organs are deranged, or by the perspiration be- 
ing suddenly checked ; its frequent occurrence in autumn 
is traceable to the gastric irritation which is at that sea- 
son of the year so frequently caused by the too free use 
of fruit and new vegetables. In children it commonly 
appears about the periods of first and second dentition, and 
is manifestly connected with the derangements of the 
system which then so commonly exist; and in infants it is 
usually occasioned by the nurse’s milk disagreeing with the 
child. 
With regard to diagnosis, roseola is an important dis- 
ease, as it is very liable to be mistaken for either measles 
or scarlatina. From the former it is distinguished by the ROSEOLA. 
61 
color of the eruption, so different when it is fully deve- 
loped from the dull red hue of measles, by its not assuming 
the crescentic or horseshoe shape, and by the absence of 
the catarrhal fever. From scarlatina, with which, in con- 
sequence of the sore throat, it is in its early stage apt to 
be confounded, the color of the rash, its appearing in 
patches or spots, and not being generally diffused over 
the surface, the comparatively mild character of the fever 
and of the attendant sore throat, and the absence of the 
burning heat of the skin, are sufficient to diagnose it. The 
distinguishing characteristics between roseola and erythema 
nodosum are, the elevation, the color, and the peculiar 
shape of the latter ; and the chief diagnostic features be- 
tween it and urticaria are, the absence of the intense 
itching and of the wheal-like eruption. 
The prognosis in roseola is always favorable, the eruption 
being attended with but slight annoyance, disappearing 
generally in the course of ten days, though occasionally pro- 
longed for three or four weeks ; but in all cases it is a simple 
affection, and one attended with little or no danger, and .in 
many febrile diseases its occurrence is manifestly salutary. 
The treatment of the disease is simple; rest in bed or 
even confinement to the house, with low diet, the use of 
diluent drinks, and, when the eruption is well out, mild pur- 
gatives, being sufficient in most cases to effect a cure. Mer- 
curial seem better adapted than saline purgatives for the 
treatment of roseola—with infants and children the hydrar- 
gyrum cum magnesia appears especially to agree. Should 
the fever run high, and the eruption be slow in coming out, 
the warm bath will prove of service; it should be always 
used wdth children. When there is oedema of the surface, 
small doses of the spirits of nitric ether and of the water 
of the acetate of ammonia are prescribed with benefit. In 
chronic cases, or in weakly habits of the body, should the 
disease become chronic, vegetable tonics and the mineral 
acids are indicated. If much itching or heat of surface 
attends the eruption, it will be allayed by a weak alkaline 
spirituous wash, such as the following:— 
R. Sodae Biboratis, 5ss. 
Aquae Florum Sambuci, . . . fl .Ixiss. 
Spiritus Rosmarini, fl oSS. Misce. 62 
EXANTHEMATA. 
In most cases, however, no local application, except the 
general warm bath, or sponging the skin with warm water, 
will be needed. Symptomatic roseola requires no special 
treatment apart from the disease which it accompanies, and 
the employment of any which might repel the eruption from 
the surface should be especially guarded against. ECZEMA. 
63 
CHAPTER III. 
VESICUL^E. 
The term formerly employed to designate 
any cutaneous eruption, in which matter was effused beneath 
the cuticle, was restricted by Willan to those forms in 
■which the effusion is a transparent fluid, contained in mi- 
nute, orbicular, epidermic elevations, corresponding to his 
definition of a vesicle; when these elevations were of larger 
size, the diseases in which they occurred were placed in a 
distinct class, denominated by him Bullse; but with re- 
spect to their visible phenomena, as they differ only in 
magnitude, I shall include both in one class. The Order 
Vesiculse, then, may be defined to be characterized by an 
eruption of vesicles or blebs, which consist in an elevation 
of the epidermis varying in size, sometimes minute (vesicles), 
sometimes of tolerable magnitude (bullae or blebs), contain- 
ing a transparent, serous fluid, which, with the progress 
of the disease, becomes opaque, and dries into thin scales 
or crusts. There are five genera contained in the Order: 
Eczema, Herpes, Pemphigus, Rubia, Scabies. Of these 
the first two are attended usually with acute symptoms; 
pemphigus and rubia with fever of a low type; and scabies 
with local inflammatory action, but very rarely with con- 
stitutional derangement. In all, the fluid contained in the 
vesicles becomes opaque and sero-purulent with the progress 
of the disease, and they are then often diagnosed with dif- 
ficulty from pustular eruptions. 
ECZEMA. 
Eczema (Scall or Humid Tetter) is a most important 
and interesting disease of the skin, being of extremely 
frequent occurrence, at times very difficult of diagnosis— 
particularly in its advanced stages, and usually most re- 
bellious to treatment. It is characterized by the eruption 
of numerous minute transparent vesicles, closely set and 64 
V E SIC U L jE . 
irregularly aggregated on an uncircumscribed inflamed 
surface, and attended generally with burning pain and in- 
tense itching. It is highly inflammatory, but not conta- 
gious. The vesicles, which are at first perfectly transparent, 
become opaque on the second or third day after their 
appearance,—the contained fluid assuming a semi-purulent 
character,—and either dry up with a fine furfuraceous 
desquamation, or bursting, become covered with thin, yel- 
low crusts, from beneath which an acrid, watery exudation 
takes place. Eczema differs much in appearance, as it 
occurs on the parts of the cutaneous surface which are 
ordinarily covered, or exposed, or on which hair grows, 
and therefore must be described more or less with reference 
to a regional system of classification. The forms of the 
disease, according to the course which they run, are 
naturally divided into two groups, the acute and chronic: 
and as regards external characteristics two varieties are 
well marked:— 
Eczema simplex. 
“ rubrum. 
But it is also requisite to consider it specially, as it may 
be seated on the face or on the scalp :— 
Eczema faciei. 
“ capitis. 
Eczema simplex (Atlas, PI. III. Pig. 1) is attended 
with scarcely any fever, slight nausea and headache occa- 
sionally preceding its eruption, which is accompanied by 
some heat and tingling of the surface. It consists in the 
appearance of numerous minute shining vesicles, not ex- 
ceeding in size the head of a small pin, which are closely 
aggregated, and irregularly distributed on apparently 
healthy skin of the natural color, but with a magnifying 
glass each vesicle may be seen to be surrounded by a nar- 
row red areola; in forty-eight hours the fluid contained in 
them becomes opaque, and on the third or fourth day they 
dry up and are followed by a fine mealy desquamation of 
the epidermis, and thus the disease may run its course in 
from four to six days. In most cases, however, a fresh 
crop of vesicles appears as soon as the first has maturated, ECZEMA. 
65 
and by successive crops its duration may be prolonged for 
as many weeks; under such circumstances, thin yellowish 
crusts or scabs are formed, and a serous exudation continues 
to flow from the surface while the disease lasts, often in 
large quantity. The heat and itching are then also trouble- 
some, and if the part be scratched or irritated, the eruption 
may become chronic, or may change into the second form. 
For a long time after the disappearance of the disease the 
epidermis continues to desquamate, but it leaves no stain on 
the skin or other trace of its existence. 
This form of eczema usually appears on the backs of the 
hands and arms, sometimes on the scalp, but rarely on the 
lower extremities, on the trunk, or on the face. 
Eczema rubrum (Atlas, PI. III. Fig. 2) is an acutely 
inflammatory disease, an attack of it being ushered in gene- 
rally with sharp fever, and always with much local pain, 
heat, and swelling of the portions of the integuments about 
to be affected. Numerous pellucid, small vesicles are rapidly 
developed on a highly inflamed, uncircumscribed surface, of 
a bright red color and tumefied, over which they are irregu- 
larly distributed, but crowded together in patches; the parts 
feel painfully tense, and cause a continued tingling rather 
than itching. The vesicles, becoming opaque, enlarge 
somewhat, look fuller, and bursting, form yellowish crusts; 
in a few rare cases the disease terminates in from a fortnight 
to three weeks with the falling off of these crusts and subse- 
quent epidermic desquamation. But in most instances, and 
invariably when the parts have been torn by scratching or 
otherwise irritated, a copious discharge of an acrid, thin, 
serous fluid, continues to flow from the inflamed surface, 
apparently without the formation of new vesicles; the in- 
flammation spreads to the adjoining portions of the skin, 
often seemingly caused by this discharge flowing over them; 
bright red cracks and fissures form in the integuments, which 
are excoriated, thickened, much swollen, and attended with 
intense pain and itching, and blood flows freely should they 
be scratched. The serous exudation is usually in very large 
quantity, so great as at times to require to be continually 
wiped away, that from even a limited surface wetting com- 
pletely a large handkerchief in a few moments; when it is 
not so copious it dries quickly into fine lamellar scales, a 66 
VESICUL^E. 
constant desquamation of which takes place. The aspect 
of this form of the disease, when fully developed, is highly 
characteristic ; the shining crimson or bright red surface, 
covered in parts with the ichorous discharge, and in parts 
with the thin film of desquamating epidermic secretion, the 
deeper-colored fissures and cracks, from which blood occa- 
sionally flows, and the tensely tumefied appearance of the 
whole. Eczema rubrum, when it presents the aggravated 
characters now described, seldom gets well in a shorter space 
of time than two or three months, and occasionally, becom- 
ing chronic, lasts for years. 
In some cases the local inflammation is still more acute, 
the discharge becomes sero-purulent or purulent, concreting 
into thick yellowish scabs, and scattered pustules form on 
the surface ; it is then termed eczema impetiginodes (Atlas,. 
PL III. Fig. 3), from the resemblance which it presents to 
impetigo. This variety of the eruption is generally met 
with in infants and children, is attended with well marked 
febrile symptoms, and much local pain and itching, and lasts 
for from three to six weeks, or occasionally, becoming 
chronic, for as many months ; its duration being kept up by 
the successive eruption of semi-purulent vesicles. 
When any of the forms of eczema become chronic they 
are usually described as a distinct variety, under the name 
of eczema chronicum (Atlas, PL III. Fig. 4); the disease 
then loses its vesicular character, the integuments which are 
swollen, thickened, and elevated above the surrounding por- 
tion of the skin that may remain unaffected, assume a perma- 
nently dark crimson hue, with numerous deep fissures which 
discharge a bloody ichor, and, taking on an inflammatory 
action from the least constitutional excitement or local irri- 
tation, are painful to the touch, tense, and attended with an 
acrid watery discharge and extreme itching. The constitu- 
tion also, after a time, becomes affected, the digestive organs 
being deranged and general debility ensuing. 
Eczema rubrum may be seated on any part of the body, 
but generally attacks a large extent of the cutaneous surface, 
spreading rapidly from the place where it first appears. It 
thus occurs on the face, the scalp, the trunk, the arms and 
hands, and the thighs, rarely extending to the legs or feet 
except in very extreme cases. It also not unfrequontly is ECZEMA. 
67 
local, appearing merely on the scalp, the face, the fingers, 
the backs of the hands, the ears, around the nipples in 
females, or in a single patch on the lower extremities, or in 
the pudendal region, being in all these cases very obstinate 
to treatment, and apt to become chronic. Each of these 
local forms of the disease has been constituted by some der- 
matologists into a distinct variety—an unnecessary refine- 
ment, as, with the exception of the first two, they present no 
essential differences, whether as regards diagnosis or treat- 
ment. 
The outbreak of Eczema faciei (Atlas, PI. III. Fig. 5) 
is preceded in young persons by a sharp attack of fever, at- 
tended with burning heat and soreness of the part about to 
be affected, which lasts for two or three days: in adults 
these symptoms are very trifling. Numerous minute vesicles 
then appear, closely crowded together, on a highly inflamed 
patch of the euticular surface, characterized by acute burn- 
ing pain and intense itching. These vesicles do not matu- 
rate, but burst usually on the day or day but one after their 
first appearance, giving exit to an abundant irritating serous 
fluid, which dries into soft thin scales. In some few in- 
stances the disease does not proceed beyond this stage, the 
cuticle of the part affected gradually exfoliates, and recovery 
takes place ; but more generally the inflammation of the 
surface goes on increasing, fresh crops of vesicles continu- 
ously appear, the discharge becomes more copious and of a 
more acrid character, exciting irritation of those portions of 
the neighboring healthy skin over which it may flow, and the 
itching and painful tingling are most intense,'scarcely allow- 
ing the patient a moment’s rest, night or day. The skin 
which is the seat of the eruption becomes swollen as the 
disease advances, the epidermis exfoliates with the soft 
scabs, or is torn off by scratching, and deep bright red 
cracks appear all over the surface, from which a sanious 
often bloody discharge exudes. The caused by 
eczema, when it reaches this stage, can scarcely be described; 
suffice it to say, that they totally incapacitate adults affected 
with the disease from following any trade or employment. 
Whether eczema rubrum attacks young or old persons, 
when it assumes a chronic character, it is the most intract- 68 
VESICUL.E 
able of the eruptions 'which appear on the face. It not 
unfrequently lasts for years (in one case, regarding which 
I was lately consulted, it had been of upwards of twenty-five 
years’ duration), and is rarely cured under several months’ 
treatment. 
The most usual part of the face on which it appears in 
infants and young children is the forehead, to which it or- 
dinarily spreads from the scalp, and, unlike most of the 
other eruptive diseases, is much more obstinate there than 
on its primary situation. This seems to depend on the 
greater delicacy of the skin of the face permitting those 
cracks and fissures, to which the rebellious nature of the dis- 
ease appears to be chiefly due, to form more easily. In 
adults, it occurs with greater frequency on the nose and lips, 
but in many cases spreads also to the forehead and cheeks. 
jEczema capitis (Atlas, PI. III. Fig. 6) soon loses its 
vesicular character, and in its various stages presents so 
much diversity of appearance that its diagnosis is not always 
unattended with difficulty. The eruption is preceded by 
heat, tingling, and itching, which are rapidly followed by 
the appearance of minute vesicles, crowded together in irre- 
gular-shaped patches, or scattered over a large surface. 
The interspaces between the vesicles and the whole of the 
scalp on which they are seated are red and inflamed; in most 
cases the vesicles are so minute as to be scarcely recogniz- 
able, or at least are not seen by the physician until they 
have burst and given exit to a copious exudation of a serous 
fluid, by which the roots of the hair are accreted together. 
In the acute forms of the disease, this serous exudation con- 
tinues for a long time, and is a most troublesome symptom ; 
but in the chronic forms—and some cases assume a chronic 
character almost from the first—it rapidly dries into furfura- 
ceous scales, which are pushed forward by the hair as it 
grows. 
The vesicles of eczema capitis usually appear first behind 
the ear close to the edge of the hairy scalp, from whence 
the disease spreads rapidly, very generally attacking the ear 
itself; in some cases the entire of the scalp will be covered 
with the eruption in a week or ten days, but in others the 
disease spreads very slowly. ECZEMA. 
69 
With the progress of the affection, the appearance of the 
diseased surface varies much ; sometimes it is scarcely, if at 
all, elevated above the healthy parts, and the eruption is 
only to be recognized by the watery exudation which keeps 
the hairs in a constantly moist state. In other cases the 
scalp is raw or excoriated, and secretes a thin whitish pus, 
which dries into grayish brown scabs, presenting cracks or 
fissures, through which the inflamed surface is seen. In a 
third form of the disease the serous exudation dries rapidly 
into extremely thin membranaceous scales, which are readily 
removable by the slightest friction, but cause much itching. 
And a fourth variety is characterized by a repeated eruption 
of minute patches of vesicles—the patches rarely exceeding 
the size of a small bean—all over the scalp, which pass 
through the stages of eczema as witnessed on other parts of 
the cutaneous surface, and disappear in seven or eight days, 
but to be rapidly succeeded by a fresh outbreak of the 
disease. 
The hair in eczema, no matter how long the disease may 
have existed, remains unaltered. When in the acute forms, 
attended with much inflammation, ulceration of the scalp 
occurs, the hair, of course, falls off, but in the progress of 
cure it grows again in a perfectly healthy state, except that 
in individuals past the age of puberty the new growth of 
hair is often gray. 
Eczema occurs at all ages, from the infant at the breast 
to the very aged ; in new-born children it not uncommonly 
appears on the umbilical region,—eczema umbilicale,—evi- 
dently arising from the local inflammation attendant on the 
separation of the remains of the funis, or from a want of 
due attention to cleanliness. The causes of the disease are 
often sufficiently apparent, but equally often it is not to be 
accounted for; thus, as regards the head and face, the erup- 
tion occurs on the scrofulous and non-scrofulous child, on 
the healthy and the delicate, on the ill-fed, ill-housed, defi- 
ciently-clothed children of the poor, and the highly-nurtured, 
well-housed, warmly-clad children of the rich; in short, 
frequently the only cause that can be plausiby assigned for 
its outbreak is that scarcely understood one, constitutional. 
It certainly affects females more frequently than males, for 
the same reason that those of all ages whose skin is fine and 70 
VESICUL^E. 
delicate, are more liable to the disease than those in whom 
the skin is coarse and hard ; in many families, too, a pecu- 
liar predisposition to diseases of the skin exists, and this 
predisposition, which appears to be hereditary, is well 
marked, as regards the causation of eczema. 
Exposure to the direct rays of the sun often produces the 
disease in summer, so commonly that Bateman made a dis- 
tinct variety of eczema when so caused, naming it eczema 
solare ; a numerous class of causes, amongst which this must 
be included as one, is the action of local irritants, as of 
blisters, of Burgundy pitch plasters, of croton oil and tur- 
pentine liniments, &c.; thus, too, in washer-women, the 
eruption is produced by the irritation of the alkali of the 
soda or soap which they use, and in house-scourers and char- 
women, of the potash,—in both cases the disease is termed 
washer-women's itch ; in grocers and makers of confection- 
ery, of the sugar—in them it is named grocers' itch; in 
glove and clothes-cleaners it is a very usual disease arising 
from the irritation of the oil of turpentine or resin which 
they employ; and in the higher walks of life a not unfre- 
quent cause of the eruption is the too frequent use of stimu- 
lating soaps and cosmetic washes to the face and hands, and 
also the habit of washing the face, when heated, in cold 
water, or of not drying it sufficiently after it has been 
washed. Sitting in close, heated rooms, engaged in any 
occupation in which the face is constantly kept stooped, as 
in that of writing, is also a common cause of eczema faciei. 
An eruption of eczema is of very frequent occurrence on 
the legs of old persons in whom the small superficial veins 
are in a varicose condition, and in them, if irritated, it is 
apt to degenerate into troublesome ulceration. 
The constitutional irritation caused by the action of 
mercury on the system produces in some cases—now more 
rare than formerly, when the employment of the preparation 
of this metal was so much abused—a very grave form of 
eczema; it is usually termed eczema mercuriale, but was 
described as a distinct affection, under the name of Hydrar- 
gyria,, by the late Mr. Alley of this city, in an original 
and highly valuable essay on the disease, published by 
him in the year 1810. In the majority of cases it seems 
to have occurred when only a very small quantity of a ECZEMA. 
71 
mercurial preparation had been taken. In its milder forms 
it resembles the acute stage of eczema rubrum, arising from 
other causes ; but it more frequently assumes a much more 
severe character when it is ushered in by fever, difficult re- 
spiration, dry cough and tightness across the chest, with a 
general smarting and burning feel of the skin over the whole 
body. These symptoms are soon followed by an eruption 
of minute vesicles, which break and discharge a very fetid 
fluid. As the disease increases in severity the eruption 
extends over the face and the whole of the body, which 
becomes covered with incrustations; the fever assumes a 
typhoid type, the difficulty of breathing increases and is ac- 
companied by bloody expectoration, spots of purpura appear, 
and death ensues, preceded by delirium or convulsions. On 
the first appearance of this eruption the use of mercury 
ought to be immediately relinquished, and the accompanying 
symptoms treated by the means appropriate for the indi- 
vidual case. 
The diagnosis of eczema in its advanced stages, and in 
some of its local forms, is not unattended with difficulty. 
Eczema simplex may at its origin be mistaken for herpes, 
but the vesicles in the latter are larger, more distinct from 
each other, and occur in patches always well defined, and 
often of small extent. When it appears on the fingers the 
serious mistake of confounding it with scabies is not unfre- 
quently made, and thus much mental annoyance may be 
caused not alone to individuals but to families, owing to the 
dread and anxiety with which that eruption is viewed by 
all; even at their commencement they are, however, readily 
to be distinguished, the vesicles in itch being solitary, large, 
and conical, and becoming rapidly purulent; the tingling, 
burning heat of eczema is also very different from the in- 
tense itching of scabies, and by careful examination the 
itch insect, the existence of which is an unfailing diagnostic 
sign, may be discovered in the latter. In fevers and other 
diseases, in which profuse sweating occurs, a vesicular erup- 
tion, which, from the cause by which it is produced, is 
termed sudamina, appears not unfrequently on the cuta- 
neous surface, and might be mistaken for eczema simplex ; 
but in it the vesicles, though of a small size, are few in 
number, perfectly distinct, and separated from each other, 72 
VESICULA’. 
and, drying up in a few days, disappear without any serous 
exudation or local irritation. 
Eczema impetiginodes, as its name indicates, very closely 
resembles impetigo ; in both there is a purulent discharge, 
but the crusts or scabs which form on the affected part are 
always of a greenish hue, and the discharge purulent in the 
latter, while they are yellowish or yellowish-brown, and the 
discharge sero-purulent in the former. The chronic forms 
of the disease are liable to be mistaken for chronic lichen, 
especially for lichen agrius when seated on the hands, a 
serous exudation being then usually present; but the latter 
eruption never loses its papular character, the portion of 
the integuments which is affected being raised unevenly, 
rough, and not marked by the cracks and fissures so cha- 
racteristic of chronic eczema; and the serous exudation is 
small in quantity, is evidently caused by the local irritation 
to which the eruption gives rise, and only occurs occa- 
sionally. With psoriasis, too, chronic eczema may be con- 
founded by the superficial observer, in consequence of the 
epidermic desquamation by which it is attended, but the 
formation of true scales never takes place in the latter, nor 
the copious serous exudation in the former. The diagnostic 
marks between intertrigo and eczema have been noticed 
when describing that eruption. Eczema faciei is distin- 
guished from herpes, in addition to the difference in the cha- 
racter of the eruptions already mentioned, by the latter 
affecting the mouth or lips alone, while the former is not 
confined to any special locality. 
Eczema capitis may be confounded with impetigo or 
herpes of the scalp ; it is diagnosed from either by the co- 
pious serous exudation, which dries rapidly into yellowish, 
not greenish crusts, by the rapid and excessive formation of 
soft furfuraceous scales, and by the hair not being affected. 
For porrigo capitis it can scarcely be mistaken, but the cha- 
racteristic differences between the two eruptions will be more 
easily understood by deferring the mention of them until 
describing that disease. 
In eczema the prognosis varies as regards the duration of 
the disease with the different forms, but in very few in- 
stances can the affection be said to be dangerous to life; 
yet some do occur ; these are cases of debilitated old per- ECZEMA. 
73 
sons in whom it becomes complicated with pemphigus, and 
whenever such a complication takes place the prognosis 
should be most grave. Eczema simplex, when submitted to 
treatment at an early stage of the eruption, very seldom 
becomes chronic, but it is very apt to return on exposure to 
any local cause, and especially when it has been originally 
produced by the direct action of irritant substances. Ec- 
zema rubrum is always an obstinate and severe affection of 
the skin, and most rebellious to treatment, years sometimes 
elapsing before it can be subdued ; in such cases the general 
health sympathizes more or less, from the continued annoy- 
ance caused by the local irritation, the individual affected 
being not unfrequently altogether incapacitated from mental 
or other occupation. When the disease affects the scalp or 
face, it is also one of the most obstinate of the eruptions 
which appear on these parts. The occurrence of a general 
attack of eczema in the course of some chronic constitu- 
tional affection, particularly of the nervous system, is often 
not incorrectly regarded as a favorable sign. 
With reference to the precise anatomical seat of eczema, 
dermatologists are not agreed: Cazenave adopts Biett’s 
view, that it is an inflammatory affection of the sudoripa- 
rous glands, but it is evident that other structures of the 
derma are also equally engaged. 
Treatment.—Eczema is essentially an inflammatory erup- 
tion, even in its most chronic stages, and this fact should 
always influence our choice of remedies, whether topical or 
constitutional, for its treatment. In eczema simplex occur- 
ring in adults, mild saline antiphlogistics with alkalies, as 
in the following form, are prescribed with advantage at its 
commencement:— 
R. Sodai et Potassm Tartratis,. . . 3j. 
Solutionis Alkalinse (Brandish), fi 3iv» 
Aquae destillatae, fl 3xixss. Misce. 
“A wine-glassful to be taken three times a day.” 
For children, gentle mercurial purgatives are better adapted, 
combined with antimonials, such as James’ powder, if the 
febrile symptoms are well marked. In the mild forms of 74 
VESICULJE. 
the disease, the best local treatment in the acute stage is 
the use of the general tepid bath, or of warm water spong- 
ing, the parts being thoroughly but gently dried afterwards. 
When the local affection is more severe, the weak lead-wash 
—a drachm of the solution of subacetate of lead to twelve 
fluid ounces of rose or elder-flower water—applied on old 
linen wet well with it, is an excellent application: if the 
eruption is seated on any part of the extremities, it is best 
and most efficiently applied by means of bandages evenly 
put on, and kept constantly moist with the wash. In some 
cases of eczema moisture appears to disagree singularly, 
always aggravating the local symptoms ; under such circum- 
stances an ointment containing four grains of the carbonate 
of lead, or of the acetate of zinc, to an ounce of cold cream, 
may be used, and if there is much tingling or itching in the 
part, two minims of prussic acid should be added to the 
latter, or six minims of chloroform to the former ointment. 
If simple eczema occurs, as is not unfrequently the case, in 
children of a scrofulous diathesis, it is very apt to become 
chronic; when it does so, local remedies seem to have little 
effect on the eruption, but it yields rapidly to the internal 
administration of cod-liver oil, and the daily use of the tepid 
fresh-water bath. 
In the early stages of eczema rubrum general antiphlo- 
gistic treatment, proportionately active according to the 
inflammatory character of the constitutional and local symp- 
toms, is requisite; in persons of full habit of body, bleeding 
from the arm even may be indicated, and in most cases, 
topical bleeding by leeches from the neighborhood of the 
affected parts is attended with much benefit; active saline 
cathartics should be administered and repeated at short 
intervals until the febrile symptoms are subdued. The local 
heat, swelling, and tingling are best alleviated by gelatine 
baths, and at night the application of poultices, prepared 
by first steeping the best white bread in boiling water, 
squeezing it out as dry as possible, and then moistening the 
pulp with the weak lead-wash above mentioned. 
When this form of eczema becomes chronic, it is usually 
most rebellious to treatment, and requires the employment 
of internal specific or alterative medicines to produce a ECZEMA. 
75 
change in the state of the constitution with which it is com- 
bined, or on which it may depend, and this is requisite even 
though the eruption is of small extent and local. In many 
cases the preparations of iodine prove most efficacious, but 
sometimes it is requisite to combine them with arsenic, or to 
give that medicine alone; in delicate constitutions, or if 
debility be present, the iodide of potassium is the best form ; 
it may be given in some tonic decoction, as follows:— 
R. Iodidi potassii, gr. viij. 
Decocti ulmi (corticis recentis), fl Sxij. 
Decocti dulcamarse, . . . . fl 3iv. Misce. 
“ A wine-glassful to be taken every night at bed-time.” 
When thus given it is not liable to sicken the stomach, 
and in my experience small doses of iodine or its prepara- 
tions act most efficaciously in the treatment of diseases of 
the skin. If the use of arsenic be indicated, either from 
the obstinacy of the affection or the failure of other reme- 
dies, five minims, very gradually increased to eight, of the 
liquor potassae arsenitis, or of the liquor arsenici chloridi of 
the last London Pharmacopoeia, may be added to each dose 
of the above mixture; but whether iodine or arsenic be ad- 
ministered alone or in combination, their use must be con- 
tinued for a long time, at least for two or three months, and 
beneficial results are always most effectually derived from 
the system being brought very gradually under their in- 
fluence. Numerous internal medicines, as well as local ap- 
plications, have been recommended by different writers for 
the treatment of chronic eczema; of the former the most 
generally employed are the tincture of cantharides, anti- 
monials, sulphur, especially in the form of the sulphurous 
mineral waters, mercurials, and various vegetable tonics; 
but my own experience leads me to rely on either or both of 
the powerful alteratives above recommended; even in the 
most chronic cases I have seen the sulphurous waters—so 
valuable in other diseases of the skin—prove injurious, and 
mercurials generally disagree except with children, in whom 
the green iodide of mercury combined with the hydrargyrum 
cum creta often acts as a most valuable alterative. 76 
VESICUL jE. 
The itching and copious secretion attendant on chronic 
eczema demand the employment of local sedatives and as- 
tringents. The compound lead-cerate of the London Phar- 
macopoeia, to every ounce of which two drachms of glycerine 
and eight minims of chloroform have been added, constitutes 
a most useful ointment, no matter on what part of the sur- 
face the eruption may be seated; or the carbonate of lead 
or acetate of zinc ointment already described may be substi- 
tuted for it should there be much tendency to local inflam- 
matory action. Tannic acid, in the proportion of from four 
to twelve grains to the ounce of cold cream, with or without 
the addition of chloroform, is also an excellent application. 
Some recommend highly stimulating compounds for the local 
treatment of chronic eczema, such as anthrakokali or fuli- 
gokali (forms of carburet of potassium, which, when intro- 
duced into the practice of medicine a few years since, were 
highly vaunted for their remedial powers, but have now fallen 
into disuse), tar pitch, sulphurous preparations, &c. By dis- 
tilling tar with water, a mixture of impure oil of turpentine, 
a pyrogenous oil, and some pyretine is procured; this liquid 
has been recently used and highly praised by some French 
dermatologists, under the name of Jiuile de cade, as a local 
application, inunctions being made with it twice daily; by 
the term Jiuile de cade, however, most of the French phar- 
macologists understand a tarry oil obtained by the dry dis- 
tillation of the wood of thejuniperus oxycedrus. No matter 
what local remedy is employed, it will be found of advantage 
to sponge the affected parts carefully with a weak alkaline 
wash—ten grains of the carbonate of soda to a pint of dis- 
tilled water, each time previously to its fresh application. 
When eczema occurs on the face or hands, the treatment 
as above described for its different forms is equally appli- 
cable, but in either situation, in consequence of the expo- 
sure to atmospheric vicissitudes and to various local irritants, 
it is usually more obstinate, and when the disease is general 
over the body the face is for the same reasons the last part 
to get well. The use of soap in washing should be inter- 
dicted, the wreak carbonate of soda lotion warmed to blood 
heat being substituted for it, and especial care should be 
taken not to expose the surface to the action of harsh winds, ECZEMA. 
77 
the sun, the heat of the fire, or any cause which might pro- 
duce determination of blood to the affected parts. 
In eczema capitis the hair should be cut close to the scalp 
with a sharp pair of scissors—not shaved off—and kept as 
short as possible while the disease lasts, and for a short time 
after it is apparently cured. The crusts and scabs should 
be removed by poulticing with linseed meal, and sponging 
with the weak carbonate of soda solution mixed with an 
equal quantity of new milk, the surface being carefully dried 
afterwards. When the scalp is thus cleaned, in the milder 
and less inflammatory forms of the eruption an alkaline oint- 
ment, containing twelve grains of the bicarbonate of soda to 
the ounce of cold cream, may be applied morning and evening, 
the surface having been previously sponged as above directed; 
but if there be any tendency to inflammatory action, the car- 
bonate of lead or the tannic acid ointment, and the sub- 
acetate of lead-wash, prove more beneficial. The scalp 
should be kept cool, very lightly covered or exposed to the 
air when in the house. As regards constitutional treatment, 
in scrofulous habits of body, either cod-liver oil or iodide of 
potassium, with tonics, should be administered; but the best 
alterative for children who are not scrofulous is the green 
iodide of mercury, as before mentioned. 
In all forms of eczema, when the origin of the disease can 
be traced to any local irritant, this of course should be care- 
fully guarded against, both during the progress of treatment 
and when a cure is effected; in the case of persons engaged 
in trades, and others who cannot abandon the occupation by 
which the eruption was caused, the cutaneous surface should 
be protected as much as possible by the use of wash leather 
gloves. The diet of persons affected with eczema should 
be regulated according to the constitutional circumstances, 
but in children much benefit will be derived from placing 
them on a strictly milk and farinaceous diet. In both adults 
and children the bowels require to be carefully attended to, 
the use of mild saline purgatives, if possible the natural 
mineral waters, of which probably the Pullna is the best, 
being employed with excellent effects. In children the pro- 
cess of teething must be watched and the gums lanced when 
necessary ; and the eruption on the scalp should not be dried 78 
VESIOULiE. 
up too suddenly if there exists a tendency to disease of the 
brain or of any other internal organ. 
HERPES. 
Herpes [Tetter).—This term, though very generally used 
in the nomenclature of cutaneous diseases by the older 
medical writers, had with them no special reference: it is 
now employed to designate an eruption of small globular 
vesicles clustered together, and often regularly grouped, on 
inflamed patches of the skin usually of small extent and dis- 
tinctly separated. The eruption is preceded by heat, ting- 
ling, and some degree of swelling and redness in the parts 
on which it is about to appear, but there is no antecedent 
or accompanying fever unless, which is rarely the case, it is 
developed simultaneously over an extended surface, and 
even then the febrile symptoms are but slight. It is described 
by most English dermatologists as being non-contagious, but 
an accumulation of direct evidence has convinced me that 
one form of the eruption is propagated by contagion, no 
matter on what part of the cutaneous surface it may be situ- 
ated. The vesicles, which on their first appearance are 
globular and transparent, on the second or third day become 
somewhat flattened, opaque, and semi-confluent; they then 
burst and give exit to a trifling serous discharge, which con- 
creting into a soft, thin, yellowish-brown crust, falls off and 
leaves a superficial ulceration that heals rapidly. The 
causes of herpes, when it affects the body generally, cannot 
be traced with certainty, but in some of its local varieties are 
often suflicienly manifest. 
The forms of this eruption present great variety, and have 
been differently named with reference both to their external 
phenomena and the parts on which they may appear ; this 
has led to numerous subdivisions of the disease in classifying 
it for the purposes of description, thereby tending to com- 
plicate the inquiry. I shall describe them all under the 
three following heads :— 
Herpes phlyctenodes. 
“ zoster. 
“ circinnatus. 
Herpes phlyctenodes (Nirles) (Atlas, PI. IV. Fig. 1) is HERPES. 
79 
occasionally, more particularly when it occurs in adults, 
attended with slight fever, foul tongue, loss of appetite, 
nausea, and thirst, but the pulse is rarely quickened; there 
is a deep-seated pain in the part on which the eruption 
is about to appear, and superficial heat and tingling. Small 
irregularly shaped patches of the skin become slightly 
swollen and red, and in about twenty-four hours afterwards 
an eruption of vesicles appears on them. The majority of 
these vesicles are of small size, but a few of them attain the 
magnitude of a pea; they are distinct from each other, 
rounded, and contain a transparent serous fluid : they occur 
in groups, varying in size from one to three or four inches 
in length or breadth, but rarely exceeding that of the palm 
of the hand; usually, when of large extent, constituting but 
a single group, which, however, is often made up of three 
or more smaller, by the eruption spreading over the inter- 
mediate sound skin. On the second day after their appear- 
ance the fluid in the vesicles becomes opaque or sero-puru- 
lent, and they burst on the third or fourth day—those that 
were closely aggregated together having previously become 
confluent, forming soft crust or brown scabs, from beneath 
which a thin sero-purulent matter exudes in small quantity. 
These scabs, falling off on or about the tenth day, leave 
small superficial ulcers which heal in three or four days, so 
that the disease rarely lasts longer than a fortnight. But 
it is sometimes prolonged by the eruption of a distinct patch 
of vesicles on the third or fourth day after the appearance of 
the first, and in their neighborhood; they unite with the 
former, and the entire thus cover a rather extended surface ; 
requiring, however, the same time for maturation and heal- 
ing, the duration extends to three or four days more. Should 
there be any attendant fever, it abates or disappears with 
the outbreak of the eruption, but the local symptoms increase 
until the vesicles burst, when some slight itching only re- 
mains. 
The local pain, which is often severe previously to the 
appearance of the eruption, is usually much alleviated then, 
but sometimes returns with greater intensity after the sur- 
face is healed, and, presenting somewhat of a neuralgic 
character, lasts with great obstinacy frequently for months. 80 
VESICUL^E. 
Occasionally in old persons or in bad constitutions, an her- 
petic eruption terminates in troublesome ulceration. 
The phlyctenoid form of herpes may appear on any part 
of the body; its most usual seat is on the trunk, the neck, 
and the arms, rarely occurring on the lower extremities. It 
attacks some special portions of the integuments with great 
regularity, and its occurrence there requires to be separately 
described; these are the lips and the prepuce. Herpes 
labialis is a slight form of the disease, deserving notice 
merely in consequence of the local annoyance which is occa- 
sioned by its situation; the eruption, which is preceded by 
a certain degree of tumefaction, dryness of the skin, heat, 
tingling, and redness, appears at the angles of the mouth, 
or on the upper or lower lip, more usually on the latter, 
being of small extent, rarely exceeding the size of a shilling. 
The vesicles, which are minute, closely aggregated, and 
covering the entire of the inflamed surface, are at first glo- 
bular, transparent, and shining; within forty-eight hours 
the contained serum grows turbid, the vesicles become con- 
fluent, forming bullae of the size of a pea, and on the fourth 
or fifth day, soft brownish crusts appear on their surface, 
which fall off in two or three days more, leaving a slight 
degree of redness and swelling of the part, that lasts for 
about a week. Should the crusts, however, be torn off by 
scratching, or irritated from their situation at the commis- 
sure or on the vascular portion of the lips, the surface bleeds, 
and a hard, dark brown scab is formed, which is slow in 
separation. Sometimes the herpetic eruption on the lips 
extends completely round the mouth, when it is a trouble- 
some and obstinate affection; but unless under these circum- 
stances it runs usually a rapid course, its duration seldom 
exceeding a week or ten days. A variety of herpes, similar 
in all respects to this, occasionally appears on the ears; it 
is then termed herpes auricularis. 
Herpes prceputialis has been so named from its appearing 
on the prepuce, being situated either upon the external cuti- 
cular surface or on the mucous membrane. The eruption is 
preceded by heat and tingling in the part, and some degree 
of soreness, and when it occurs on the internal aspect of 
the prepuce there is also more or less tumefaction ; the 
transparent orbicular vesicles soon appear in a small group, HERPES. 
81 
but distinct from each other, on a somewhat circular inflamed 
patch of the integument, rarely exceeding the size of a six- 
pence ; when they occur on the external surface, they matu- 
rate quickly, becoming opaque, and forming brownish crusts, 
which fall off on the fifth or sixth day, leaving the part on 
which they had been seated slightly tender and red; but 
when the eruption is situated on the mucous membrane the 
vesicles are larger, become sero-purulent, and from the con- 
fluence of two or three attain the size of a split pea; the 
scabs which form are softer, and of a yellowish color, and, 
being easily rubbed off, leave a small ulcerated surface, which, 
from the swelling of the surrounding mucous membrane, 
occasionally presents a slightly excavated character, in con- 
sequence of which it is likely to be mistaken for a chancre. 
Herpes prseputialis sometimes becomes chronic Avhen the 
disease spreads, by the appearance of successive crops of 
the eruption, over the entire of the prepuce, especially 
affecting the part where the mucous membrane and skin 
meet; there is much thickening from the effusion into the 
sub-mucous areolar tissues, caused by the repeated attacks 
of inflammation ; the surface becomes hard, rugose, fissured 
in parts, and in parts covered with brownish crusts, from 
between and beneath which an unhealthy, fetid, sero-puru- 
lent discharge takes place, and as the glans penis cannot 
be uncovered, foul ulceration of it not unfrequently occurs 
to complicate the original disease. When the eruption is 
of this chronic character, it often lasts for months, and the 
general health becomes affected in consequence of the anx- 
iety and distress of mind it occasions. 
In females herpes phlyctenodes sometimes appears on the 
pudendal region, being situated at the vaginal orifice on both 
the skin and mucous membrane ; its characters correspond 
precisely with those of the disease of the prepuce in males, 
but in consequence of the parts being more exposed to the 
irritation arising from local discharges and from the urine, 
it is generally more chronic and rebellious to treatment. 
By some writers it is made a distinct variety, and termed 
herpes pudendalis. 
Herpes zoster [Shingles; Ignis sacer) (Atlas, PI. IV. Fig. 
2) has derived its specific name from the peculiar form which 
the eruption assumes, resembling, as it were, a girdle or 82 
yesicul^:. 
sword-belt. The constitutional and local symptoms are more 
severe than in the variety last described, the former often 
amounting to well-marked fever preceding the outbreak of 
the disease, attended with a distinct shivering fit and vomit- 
ing. Locally there are sharp stinging pain, burning heat, 
redness, and some tumefaction of the integuments in the 
part on which the vesicles are about to appear ; these occur 
of tolerable magnitude, and closely grouped together in 
three or four distinct but neighboring patches, each sur- 
rounded by an inflammatory areola, which gradually spreads, 
new vesicles appearing on it, and the entire constitutes a 
crescentic or oblique demi-zone from half-an-inch to one or 
two inches in breadth, seated on one side of the neck or 
trunk, often extending from mesial line to mesial line, by 
which it seems to be distinctly bounded, very rarely passing 
its limits. The eruption runs the same course as in herpes 
phlyctenodes, but the vesicles become more confluent, thus 
often attaining the magnitude of bullae, those which first ap- 
pear being always the largest; and it is somewhat more 
chronic in all its stages, thes cabs being often particularly 
slow in separating. 
The local pain which precedes the appearance of the 
eruption in herpes zoster is not unfrequently very severe, 
and apparently deep-seated, seeming to shoot through the 
chest or abdomen if the disease is about to occur on the in- 
teguments of either of these regions. This pain, which to 
a great extent disappears when the vesicles are developed, 
usually returns with greater or less intensity, especially in 
adults or old people, when the crusts fall off, sometimes 
lasting even for years, and causing great suffering. At 
times chronic ulceration succeeds this form of herpes in bad 
constitutions, and this may terminate even in gangrene, and 
thus prove fatal. 
The usual seat of herpes zoster is on the thorax or ab- 
domen ; it also appears occasionally on the neck; when the 
eruption commences over the scapula, or in the neighbor- 
hood of the hip, it may extend to the shoulder or thigh, 
including either in the semicircle which it forms, but it very 
rarely originates on the extremities. By Franck and Ca- 
zenave the disease is stated to appear more frequently on 
the right side of the body, but my experience agrees with HERPES. 
83 
that of Reil and Wilson, that it is situated on the left 
in a greater number of cases. It is so extremely rare for 
the demi-zone of herpes to pass the median line, that 
amongst the ancients it was popularly believed, and the 
fact is mentioned by Pliny, that if the eruption surrounded 
the body it should prove necessarily fatal ; yet cases are 
recorded by modern writers,—Franck and others,—in which 
such took place by the simultaneous development of the 
eruption on both sides and their extremities meeting, yet the 
patients recovered. 
Herpes circinnatus {Ringworm) (Atlas, PI. IV. Fig. 3), 
like the last described variety, derives its name from the 
shape of the groups in which the eruption appears, namely, 
distinct rings or circles, inclosing healthy skin in the centre. 
Slight pricking sensation or tingling accompanies the out- 
break of the disease, but it is not attended with any consti- 
tutional symptoms. At first, one or more small, red, circular 
patches, from half an inch to an inch in diameter, appear 
apart from each other on some portion of the integuments, 
on the outer border of which numerous minute, globular, 
transparent vesicles are developed on the second or third 
day; the redness then fades from the centre of each circle, 
which remains unaffected afterwards during the progress of 
the disease, but the ring of vesicles has an inflammatory 
border both external and internal. The vesicles, which are 
closely aggregated, become more or less confluent within 
forty-eight hours after their appearance, assume a pearly 
aspect, and then bursting discharge a small quantity of a 
serous fluid, which dries into thin brownish crusts that fall 
off on the eighth or ninth day, to be succeeded by a fine 
epidermic desquamation that lasts for some time. The dis- 
ease, however, rarely terminates thus, but is prolonged by 
the repeated eruption of fresh crops of vesicles on the outer 
inflammatory border, each set running in an independent 
course, but one similar to the first; spreading in this man- 
ner from the circumference, the rings at times attain the 
size of the palm of the hand, which they rarely exceed. 
The circles may be few or many in number, rarely, however, 
more than four or five, and when of larger size, there is 
usually but one; they may appear simultaneously on the 
surface or in succession: in the latter case the disease often 
becomes chronic, lasting for months. 84 
VESICUL^E. 
Occasionally it occurs that the vesicles, instead of burst- 
ing and forming crusts, dry up, and are succeeded by a 
secretion of fine, soft scales, which continue to be exfoliated, 
not alone from the circumference, but from the centre of the 
circles. This form has been specially described by Caze- 
nave, who denominates it herpes squamosus (Atlas, PI. IV. 
Fig. 5); it is always chronic, and very obstinate to treat- 
ment. 
Herpes circinnatus occurs with greatest frequency on the 
face, neck, and scalp, being, however, occasionally situated 
on the chest, the shoulders, the arms, and the hands. When 
it appears on the face, its most usual situations are the 
cheeks and the forehead; as the circles spread from their 
circumference they often extend from the former to the 
nose, but do not pass the mesial line, and from the latter 
into the scalp. In its milder forms, ringworm disappears 
in eight or ten days, but its duration is more usually pro- 
longed for three or four weeks, either by the spreading of 
the circles or by the successive development of fresh patches 
of the eruption ; occasionally, as above remarked, it becomes 
chronic, and lasts for months, producing annoyance more 
from the unsightliness of its appearance, when it is situated 
on any of the exposed regions of the skin, than from any 
local uneasiness. 
This form of herpes, when it occurs on the scalp, requires 
to be specially described, as it constitutes almost a distinct 
variety, which might be termed herpes capitis; it resembles 
in many of its characteristics the herpes squamosus of Caze- 
nave, but that distinguished dermatologist, in consequence 
of the effect its presence exerts on the hair, proposes to 
term it herpes tonsurans. Its occurrence on the scalp at 
all is denied by many of the celebrated English writers on 
diseases of the skin, who regard the eruption about to be 
described as a species of porrigo; but prolonged clinical 
observation, independent of their corroboration by so deserv- 
edly high an authority as M. Cazenave, has tended but to 
convince me of the correctness of the views I propounded 
some years since.1 
Herpes capitis (Atlas, PI. IY. Fig. 6) usually attacks 
children from the age of 3 to 12. It is very rare in early 
1 Dublin Quarterly Journal of Medical Science, New Series, yoI. vi. p. 33. HERPES. 
85 
infancy, and I have never met with it after the age of 
puberty, except in one instance, in which it had commenced 
at the age of 13, and had lasted for more than five }rears 
before I saw the case. It is very rarely witnessed in its first 
stage—that of vesicle—as it then produces but little annoy- 
ance, and advice is, consequently, not sought for until it 
becomes more developed. When seen, however, at its com- 
mencement, it presents the appearance of a small ring of 
minute vesicles, not more than an eighth of an inch in dia- 
meter, without any redness or other marks of inflammation 
beyond a slight tingling—not itching. These vesicles are 
attended with scarcely any discharge, soon drying up and 
desquamating ; but as they dry up in the centre, they spread 
from the circumference, and the diseased spots, in the course 
of a few days, attain the size of a shilling. When we exa- 
mine them in this stage, the centre, the part where the erup- 
tion first appeared, is thickened, elevated above the surface 
of the surrounding scalp, and covered with fine scales, which 
are renewed rapidly on being removed. As the disease pro- 
ceeds, the patches extend from their periphery, still retain- 
ing a perfectly circular shape, and finally, after some weeks, 
attain the size of a crown-piece, which they rarely exceed, 
no matter how chronic the case may have been. Having 
attained this size, and ceased to spread, the entire of the 
diseased surface is thickened, elevated, and covered with 
fine, soft scales, which the least touch removes; this, the 
advanced stage of the disease, is usually attended with itch- 
ing. Sometimes but one patch of herpes is found on the 
scalp, but more generally there are three, four, or more cir- 
cles, distinct, and at some distance from each other. 
As the disease advances, the hair assumes a very pecu- 
liar appearance, almost pathognomonic of this form of 
eruption of the scalp. In the early stage each hair appears 
to be slightly bent on itself, and turned against the grain, 
obstinately refusing to lie smooth ; the roots are also some- 
what matted together by the scaly crusts of the eruption. 
After some time it presents a diseased appearance, being 
twisted, broken, of a whitish color, and readily falling 
out; so that bald patches begin to appear, over which are 
scattered small bundles of the altered hair, which has been 
described, not inaptly, as resembling tow. This condition 86 
VESICULAR. 
of the hair has induced some writers to describe the affec- 
tion as a disease not of the scalp, but of the hair itself. 
The eruption does not always present the exact charac- 
ter now described. In the early stage—when, however, 
it is rarely witnessed by the medical practitioner—its ap- 
pearance always agrees with the description given, except 
that in some cases there is more inflammation than in 
others ; but in the advanced stages it varies much, both as 
regards the amount of desquamation and the appearance 
of the elevated patches : it is this fact which has led to so 
much confusion in the diagnosis and nomenclature of the 
disease. Yet in the most chronic or complicated cases, 
the circular form of the eruption, and the peculiar condition 
of the hair, render its diagnosis easy to even the tolerably 
experienced eye. 
Herpes capitis does not cause baldness: the altered hair 
falls off the diseased patches, which, when the scales dis- 
appear in the progress of cure, are thus left in a bald state ; 
but the hair eventually grows on them again, thereby con- 
stituting an essential difference between this affection and 
alopecia. The disease, unless when seen and properly 
treated in its early stages, soon becomes chronic and obsti- 
nate, and loses its inflammatory character. No constitu- 
tional symptoms either precede or accompany herpes of the 
scalp. 
In some very rare cases the eruption in herpes circinna- 
tus assumes a singular arrangement, which, in the opinion 
of some dermatologists, entitles it to be considered as a 
distinct variety, receiving the appellation of herpes iris, 
or rainbow ringworm (Atlas, PI. IY. Fig. 4). A small, 
round, inflammatory patch appears on some part of the cu- 
taneous surface, and around it, but separated by a narrow 
band of healthy integument of the natural color, is a red, 
slightly elevated circle, which in its turn is again surrounded 
by two or three other similar rings of inflamed skin : on the 
centre a few minute herpetic vesicles are developed in 
about twenty-four hours after its appearance, as also on 
each of the rings, but they are more numerous and more 
closely aggregated on them. The rings, which are usually 
four in number, differ in color, the inner one being of a 
darker red than the central patch, that next to it of a HERPES. 
87 
lighter shade, the third darker even than the first, and the 
outer ring paler than the second, being of a yellowish-red 
hue, fading at its outer border into the color of the sur- 
rounding skin. The vesicles run the same course as in the 
milder form of herpes phlyctenodes, the crusts, which are 
small and thin, falling off on the eighth oV ninth day, to be 
followed by slight furfuraceous desquamation, which lasts 
for a few days longer. Herpes iris seldom occurs except 
in very young children and in females ; it usually appears 
on the backs of the fingers or of the hands, on the temples 
and on the prominent parts of the joints, being sometimes 
associated with other forms of the eruption. It may occur 
singly, or several patches may appear simultaneously on 
different parts of the body ; the only local symptoms are 
some trifling heat and itching, and it has no tendency to 
become chronic. 
Causes.—Herpes is a disease almost entirely confined to 
young persons and to those in the prime of life, very rarely 
appearing in the old ; among adults it affects females more 
commonly than males, but in children sex seems to have 
no influence in the frequency of its occurrence, those of a 
sanguine and lymphatic temperament, and in whom the 
skin is fine and soft, being most liable to it. Of the excit- 
ing causes of herpes phlyctenodes but little is known; it 
seems to be occasionally developed under the influence of 
strong mental emotions, and it is often connected with de- 
ranged conditions of the digestive and biliary organs. The 
season of the year, too, appears to have some influence on 
its occurrence, for it is most frequently met with in the 
spring and autumn. The connection of herpes labialis with 
febrile states of the system is usually very evident, and 
especially with those which affect the respiratory organs: 
thus it is an almost invariable accompaniment of catarrh, 
influenza, bronchitis, and pneumonia, in all of which its 
occurrence is a favorable symptom, whence has arisen the 
popular expression that the cold goes off in this way. It 
is also occasioned very frequently in travelling by the direct 
effect of a harsh cold wind on the lips, or of the sun’s 
rays; the action of local irritants, too, may produce herpes 
here, as is often witnessed in its being caused on the upper 
lip by the acrid secretion from the nostrils in coryza; this 88 
VESICULAR. 
discharge, however, more frequently produces an eruption of 
eczema. 
Herpes praeputialis occurs only in adults, and most fre- 
quently in those in whom the skin of the prepuce is very 
sensitive; it is often caused there by the friction of the 
clothes; and when it appears on the mucous membrane, or 
on the glans penis where I have occasionally seen it, by the 
irritation of the natural sebaceous secretion of the part, 
allowed to accumulate from want of attention to cleanliness. 
The connection between the occurrence of herpes on the pre- 
puce and stricture of the urethra is very generally admitted, 
but many observers believe it to be only an accidental coin- 
cidence; others, with whom I agree, consider the existence 
of stricture to be a cause of this eruption, and the manner 
in which it acts may, I think, be easily explained. In 
persons affected with stricture, the last drops of urine are 
retained for some time in the urethra, the shirt is thus con- 
stantly wet, and the prepuce is irritated by the acrid moist- 
ure to which it is thereby so constantly exposed; hence 
also, in these cases, the eruption is usually seated on the 
verge of this fold of integument. In females herpes of the 
pudendum may occur at any age; it is invariably caused by 
local irritation. 
Herpes zoster appears in adults more frequently than any 
of the other varieties, occurring also occasionally in old 
persons, in whom it sometimes becomes chronic, and termi- 
nates in troublesome ulceration: it seems to be generally 
occasioned by cold, acting on individuals suffering from 
hepatic derangements. In the summer and autumn of some 
years it would appear to be epidemic among children, and in 
them it is very frequently produced by sudden suppression 
of the perspiration. 
Herpes circinnatus is a disease of youth, being very rare 
amongst adults, and occurs with equal frequency in both 
sexes; it is very common in schools, or wherever many 
children are congregated together, amongst whom it spreads 
rapidly. The popular idea that ringworm is contagious is 
opposed by most English dermatologists on the grounds that 
no other form of herpes is so, and that the disease cannot 
be produced by inoculation. Now, neither of these reasons 
is sufficient to counteract, in my mind, the amount of direct IIERPES. 
89 
evidence which an experience of some years in the treat- 
ment of diseases of the skin has afforded me of the propa- 
gation of this form of herpes by contagion, no matter on 
what part of the body it may be situated. I have else- 
where1 published cases illustrative of the development of 
the eruption on the hands of adults engaged in the applica- 
tion of local remedies to the scalp of children who were 
affected with it, and to these I could now add several others ; 
and I have seen too many instances of its direct communi- 
cation from child to child of different families, when the 
argument of similarity of constitution and of dietetic ar- 
rangements could not avail, to have any doubt on the matter; 
but it must be remembered that, like all other contagious 
diseases, some families and some children are more prone to 
its attacks than others. My own opinion, too, is confirmed 
by that of M. Cazenave, who, in his Legons sur les Mala- 
dies de la Peau, and in his more recently published Traite 
des Maladies du Quir Ohevelu2 adduces several cases from 
his own practice, which exhibit in a marked degree the con- 
tagious nature of herpes circinnatus. 
Diagnosis.—The characters of the eruption in herpes 
are so well defined that, unless when it occurs on the scalp, 
it can scarcely be confounded with any other cutaneous 
disease. It differs from eczema in the vesicles being 
larger, more globular, and distributed in patches; its erup- 
tion is unattended with constitutional symptoms, and in its 
advanced stages it is not accompanied by the copious serous 
exudation of that disease. When the vesicles are very 
confluent it may be mistaken for pemphigus, but in that 
affection the eruption consists of bullae, which do not in any 
of their stages present the pearly aspect of herpes, and are 
succeeded by hard, dark-brown crusts; the bullae of pem- 
phigus, moreover, are usually solitary and scattered over 
the cutaneous surface, not distributed in groups. Herpes 
labialis is diagnosed by the characteristic vesicles, and by 
their local situation. As already remarked, the serious 
1 Dublin Quarterly Journal of Medical Science, New Series, vol. viii. p. 
164, Note. 
2 Paris, 1850, p. 197. See also Annales des Maladies de la Peau et de la 
Syphilis, tom. i. p. 37, et seq. 90 
VESICULJ2. 
error may be committed of confounding herpes praeputialis 
with chancre ; if the eruption is seen on its first appearance 
it is readily diagnosed by its vesicular character, but when 
the scab is formed, or ulceration caused by irritation, the 
diagnosis is often not unattended with difficulty. The ul- 
ceration in herpes, however, is always superficial, never 
deep, and presents a smooth surface without raised edges, 
and not coated with a white, filmy membrane, appearances 
peculiar to chancre; in very doubtful cases the question 
may with certainty be decided, by inoculating the integu- 
ments of the thigh of the patient with some of the matter 
from the diseased surface. The same remarks as regards 
diagnosis, apply equally to herpes of the pudendum in 
females. Erythema circinnatum, or lichen circumscriptus, 
in their advanced stages, present some resemblance to herpes 
circinnatus, but neither of these are vesicular during any 
period of their presence on the skin, nor do they spread 
from their circumference in the manner that disease does; 
they are, too, attended with more thickening and elevation 
of the integuments on which they are situated. 
Herpes capitis, which corresponds with the herpes ton- 
surans of Cazenave, is, as I have already remarked, described 
by many English writers as a variety of porrigo, the yellow, 
cup-shaped, favus crusts so characteristic of which it, how- 
ever, never presents. It is diagnosed from the other erup- 
tive disease of the scalp by its occurring in distinct circular 
patches, the slight serous discharge from which dries into 
fine, soft scales, that are readily detached by the slightest 
touch, but are again very quickly renewed, and especially 
by the peculiar change, before described, which it produces 
on the hair. 
The prognosis in any form of herpes is favorable, as the 
eruption may be said almost never to endanger life, and 
is but very rarely productive of any injury to the general 
health; it is also not so liable as many other eruptions to 
become chronic, unless when it occurs on the scalp. The 
local neuralgic pain, which not unfrequently is consequent 
on herpes phlyctenodes and herpes zoster, is at times both 
severe and obstinate, often lasting for many months. 
Treatment.—The phlyctenoid form of the disease very 
rarely requires any active constitutional remedies; in a HERPES. 
91 
few cases, when it occurs in young persons of a full habit of 
body, bleeding from the arm, or the application of leeches 
in the neighborhood of the eruption, is attended with 
benefit, but neither should be had recourse to until the 
eruption is fully developed: saline purgatives,—preceded, 
if there is any biliary derangement, by a mild mercurial, 
five grains of blue pill, or two of calomel combined with a 
grain of extract of hyoscyamus,—will, however, in nearly 
all cases sufficiently meet the constitutional symptoms. In 
weakly individuals, tonics with antacids,—as bark with 
the carbonate of ammonia,—are indicated. With refer- 
ence to local treatment, all that is requisite during the 
first two or three days after the formation of the vesicles 
is to protect them from being irritated by rubbing or 
scratching; unless there is much tingling and pain of the 
part, which will be relieved by smearing them over with 
a cerate consisting of two grains of acetate of zinc, an 
ounce of cold cream, and four minims of chloroform. 
Should there be any tendency to a copious discharge, 
finely powdered lapis calaminaris or starch, will be dusted 
over the surface with benefit. As soon as the brown scabs 
form, a spirituous lotion, such as the following, should be 
substituted for the ointment: 
R. Olei Limonum, m. vj. 
Olei Corticis Aurantii, . . . fl 3ss. 
Spiritus Yini rectificati, . . fl 3iv. 
Misturee Camphorm, . . . fl 3viij. Misce. 
The local pain consequent on this form of herpes, or on 
herpes zoster, is as far as my experience enables me to come 
to a conclusion, but little relieved by external applications ; 
those usually ordered for it are narcotics and sedatives, such 
as preparations of opium, of aconite, of belladonna, of 
arnica, &c. Regarding it as being chiefly neuralgic, I have 
prescribed with much benefit a combination of bark with 
hemlock, as thus: 
R. Tincture© Cinchonse composite, fl 3ij* 
Succi Conii, fl 3vj- 
Infusi Cinchonse, fl .Ivij. Misce. 
“ A tablespoonful to be taken four times a day.” 92 
VESICULJ!:. 
In herpes labialis, if a strong spirituous lotion—I have 
found none answer so well as Eau de Cologne—be con- 
stantly applied to the part on which it is about to appear, 
as indicated by dryness, heat, swelling, and tingling, before 
the vesicles are formed, the further progress of the eruption 
may in most cases be arrested. The only local application 
requisite, where the disease is fully developed, is some mild 
oleaginous ointment, such as the cucumber cerate ; should 
it, however, become chronic, an ointment composed of ten 
grains of calomel to an ounce of simple cerate will be found 
useful. Persons who have once had an attack of herpes 
praeputialis are fully aware of the premonitory local symp- 
toms by which it is ushered in ; the development of the 
eruption may then be stayed by the continued employment 
of cold water, the colder the better, which can be applied 
by plunging the penis several times in the day into ice-cold 
water, and retaining it there for a minute or two; when 
the vesicles are formed, no caustics or irritants should be 
employed, as their use is apt to be followed by troublesome 
ulceration ; the best local application is the black wash, or 
Turner’s cerate, if there is much discharge when the vesicles 
have burst. 
The same treatment is adapted for herpes zoster as for 
the phlyctenoid form of the disease. M. Cazenave, with 
the view of preventing the premature rupture of the vesi- 
cles, recommends that the surface should be smeared with 
oil, and then dusted with starch. The ectrotic plan of 
treatment, that is to say, opening each of the vesicles with 
a needle, and introducing into them a finely-pointed pencil 
of nitrate of silver, has been recommended in both these 
varieties of the eruption. If they are situated on an unex- 
posed part of the body, and not in any way connected with 
visceral derangements, it may be had recourse to, but it 
should be remembered that an indelible mark sometimes 
follows the application of caustic to herpes. 
Most cases of ringworm require no treatment in the com- 
mencement except the use of mild mercurial purgatives, 
and protection of the eruption from local irritation; if, 
howTever, there is much heat or tingling in the part, poul- 
tices prepared with bread and the wreak lead-wash (see page 
77) are productive of much benefit; when the scales have HERPES. 
93 
formed, the ointment of cold cream and acetate of zinc 
(see page 30) will be found an excellent application. If 
the disease becomes chronic, constitutional treatment is 
generally required for its removal,* and preparations of 
iodine, with or without tonics, according to individual cir- 
cumstances, are usually the most efficacious; as regards 
local applications, astringent ointments and alkaline lotions 
prove in most cases successful; thus an ointment consisting 
of four grains of the dried sulphate of iron, an ounce of 
■white wax ointment, and a drachm of glycerine, should be 
smeared over the eruption three times a day, it having been 
previously sponged well each time with a lotion containing 
ten grains of the carbonate of potash in twelve fluid ounces 
of rose-water ; or, in very chronic cases, a dilute citrine 
ointment; containing from one to two drachms of brown citrine 
ointment to the ounce of prepared lead, may be substituted 
for that of sulphate of iron. When herpes circinnatus is 
inclined to spread rapidly, the progress of the eruption may 
be sometimes stayed by the application of strips of blis- 
tering plaster around the outer border of the rings, at a 
short distance from the inflamed surface ; their effect seems 
to depend on a new action being excited in the part. In 
herpes of the scalp the same local applications will be re- 
quisite as when it occurs on other parts of the body, but 
the hair should be kept cut close with a pair of scissors 
during the entire progress of the treatment, and for at least 
three or four weeks afterwards ; nor is it sufficient to cut 
the hair on the diseased part solely, but it must be removed 
from the entire scalp, as otherwise the eruption is apt to 
appear in other patches on it. In herpes capitis in chil- 
dren, the green iodide of mercury, prescribed as recom- 
mended for eczema of the scalp, has proved in my experience 
the best alterative remedy. Milk diet, as an important 
aid to treatment, should be enforced in this variety of the 
eruption. 
Herpes iris is to be treated on the same principles as the 
milder forms of herpes circinnatus. 94 
VESICUL^E. 
PEMPHIGUS.. 
Pemphigus (Water-blebs).—Willan described three forms 
of diseases of the skin which were characterized by the 
elevation of the epidermis into bullae, namely, erysipelas, 
pemphigus, and pompholyx; that the first of these was 
incorrectly classed by him with the others is now admitted 
by all dermatologists for the reasons given when describing 
erysipelas ; and the distinction he made between pemphigus 
and pompholyx—that the one is attended with constitu- 
tional fever and local inflammation, and the other is not 
—does not sufficiently separate them to constitute distinct 
diseases ; the latter term therefore is now very generally 
abandoned, and when used is considered as being synony- 
mous with the former. Pemphigus may be defined to con- 
sist in the development of oval or rounded elevations of 
the epidermis, containing a transparent serous fluid, which 
vary in size from that of a pea to that of a large nut (bullse), 
—at times they attain the size of an egg—each being 
surrounded by an inflamed areola. The contained fluid 
rapidly becomes opaque, and of a yellowish color, the 
epidermic covering, which is extremely thin, then bursts 
spontaneously, or is easily torn, and the eruption results in 
the formation of fine foliaceous crusts, or superficial excori- 
ations from which a slight serous discharge flows. The 
bullse come out generally singly or in crops of from two 
to five or six, each crop disappearing in a few days with 
some trifling epidermic desquamation, but the duration of 
the disease is often indefinitely prolonged by successive 
eruptions. In a few cases all the bullse appear simulta- 
neously, when it runs its course in about a week. By some 
writers pemphigus has from this circumstance been classified 
into Pemphigus simultaneus and Pemphigus successivus; 
others arrange it in groups according to the number of the 
bullae, and others again with reference to the age of the 
person on whom the eruption appears. The division, I 
think, least open to objection, and most convenient for the 
purpose of description, is into acute and chronic:— 
Pemphigus acutus. 
“ chronicus. PEMPHIGUS. 
95 
Acute 'pemphigus (Atlas, PL Y. Fig. 1) is ushered in 
with well marked febrile symptoms, being preceded by shiver- 
ing, heat of skin, general malaise, and loss of appetite ; as 
well remarked by Dr. Corrigan, there are sometimes two or 
more shivering fits so distinct that the attack at first sight 
appears to be intermittent fever.1 The feverish symptoms 
are succeeded on the second or third day by the appearance 
of a few or many bright red spots, scattered generally over 
the thighs and lower part of the abdomen, which are attended 
with heat and itching; these spots rapidly enlarge, and a 
minute, transparent vesicle is developed in their centre, 
which in a few hours extends so as nearly to cover the pre- 
viously inflamed patch of integument, a border being left 
which forms an areola to each. The bullae thus constituted 
are round or oval, somewhat flattened at the summit, of a 
shining brilliancy, and, being irregularly distributed, resem- 
ble the effect which would be produced if boiling water was 
dashed on the skin ; on the day after their appearance the 
contained fluid assumes a yellowish, opaque aspect, and 
within forty-eight hours the bullae usually break, giving exit 
to a thin, serous discharge, which continues to be secreted 
for a few days longer, the surface thus exposed being red 
and excoriated ; the discharge then accretes into a thin scab, 
of a yellowish color, and a foliaceous aspect, which, falling 
off on the sixth or seventh day from the first appearance of 
the eruption, is succeeded by a slight epidermic desquama- 
tion and yellowish stain of the surface; the former ceases 
from the tenth to the fourteenth day, but the latter often 
lasts for an indefinite period. In the acute form of pem- 
phigus the eruption may occur in a single crop, but 
there are more usually two or three in succession, an in- 
terval of from twenty-four to forty-eight hours existing be- 
tween them, and as each set of bullae runs a similar course, 
the duration of the disease is then prolonged for about three 
weeks. Two or more bullae being occasionally developed 
close to each other become confluent, and thus a very large 
vesication is often formed. On some of the inflammatory 
patches, on the other hand, no elevation of the epidermis 
1 Cyclopaedia of Practical Medicine, vol. iii. p. 263. 96 
VESICUL.E. 
occurs; when, however, there is more swelling of the part, 
and a serous exudation takes place from its surface. 
The feverish symptoms always abate on the development 
of the eruption, and the local heat and itching are much 
diminished, but the appearance of each successive crop of 
bullae is marked by their return. In some cases the fluid 
contained in the bullae is absorbed when they do not break, 
and the disease terminates with epidermic desquamation, 
while in others superficial ulceration occurs, and then its 
duration is more prolonged, and indelible marks are often 
left on the skin. 
Willan termed the disease Pompholyx benignus, when the 
premonitory fever was very mild, and the local inflammation 
trifling. He also described a very rare form of the eruption 
under the name, Pompholyx solitarius; in it “ large vesica- 
tions arise on some part of the body, one after another, at 
nearly equal intervals of time; a disagreeable tingling is 
felt for several hours before the vesication arises, which is 
usually in the night. It enlarges rapidly, so as sometimes 
to contain on the following day a tea-cupful of lymph. 
Within forty-eight hours the cuticle breaks, the lymph is 
discharged, and a superficial ulceration remains. Near this 
another vesication arises in a day or two, and goes through 
the same process as the first. A third, fourth, fifth and 
sixth vesication will sometimes appear and proceed in like 
manner.” This singular variety of pemphigus seems to 
affect women solely ; it is extremely rare, yet Willan men- 
tions that he witnessed three cases of it; Cazenave states 
that he saw one remarkable instance; and Copland records 
its occurrence under his observation in a man. 
The most usual site of acute pemphigus has been already 
indicated, namely, on the thighs and lower part of the ab- 
domen, but it may affect the arms, the backs of the hands, 
the legs, and the thorax; it has been also witnessed on the 
mucous membrane of the mouth and tongue. It most 
usually occurs in adult life, but infants and children are not 
unfrequently attacked, and a variety has been specially de- 
scribed by some dermatologists under the denomination of 
pemphigus infantilis. 
This corresponds with the form so admirably depicted by PEMPHIGUS. 
97 
the late Dr. Whitley Stokes,1 as being not uncommon in 
Ireland, and which he termed Pemphigus gangroenosus 
(popularly known as burnt-holes or eating-hive) (Atlas, PI. 
V. Fig. 3). By some recent writers, however, it has been 
regarded as a species of Rupia, but to any one who has wit- 
nessed it in our country districts, where it is even in the 
present day of not unfrequent occurrence, its agreement 
with the characteristic phenomena of pemphigus must be 
sufficiently evident.2 The eruption generally appears on a 
child in apparently good health, but occasionally a livid suf- 
fusion of the surface of the body precedes its outbreak ; one 
or more bulloe appear on the surface, and increase in size 
for a few days, when they burst and discharge a thin fluid, 
having a disagreeable smell; “ before or after breaking, the 
vesicles run together, the sore becomes painful with loss of 
substance, and a thin, fetid, ichorous discharge; the edges 
of the ulcer are undermined, and it spreads quickly.” The 
discharge daily increases in quantity, and becomes more and 
more fetid, the ulcers spreading rapidly, probably from its 
acridity, and the constitutional fever, which is evidently 
caused by the local irritation, is extreme; emaciation and 
great debility quickly ensue, and the child dies on the tenth 
or twelfth day, death being often preceded by convulsions. 
Should recovery take place, the progress to convalescence is 
very tedious, and relapses not unfrequently occur, even 
when the ulcers are skinned over. A deep pit, like that re- 
sulting from smallpox, but much more extensive, is always 
left. The eruption appears usually very generally over the 
body, sometimes spreading to the meatus auditorius, when 
deafness follows, and to the eyes so as to destroy the sight. 
Pemphigus chronicus (Atlas, PI. V. Fig. 2) is of more 
frequent occurrence than the acute form of the eruption, 
and sometimes appears as an epidemic; of this a remark- 
able example is recorded by Dr. Macbride, who witnessed 
it in the county of Wicklow in 1766. The disease which 
corresponds with the Pompholyx diutinus of Willan is not 
attended with any febrile symptoms, yet the outbreak of the 
1 Dublin Medical and Physical Essays, vol. i. p. 146; Dublin, 1808. 
2 In the following account of the disease, Dr. Stokes’ faithful and original 
observations are freely made use of. 98 
VESICUL^. 
eruption is preceded for some days by sickness, debility, and 
muscular pains. Red spots, as in the acute form, appear 
scattered over the skin, but the redness is of a livid color, 
and is not accompanied by heat or itching ; on these spots 
the bullae are rapidly developed, each bulla covering com- 
pletely the reddened surface, so that to the naked eye they 
appear to have no areola, but when examined with a lens, 
a narrow red line will be seen to surround each. The vesi- 
cations, which generally attain their maximum size in a 
single night, are much larger than in the acute form, and 
rarely become confluent; they come out almost invariably 
in successive eruptions, a second crop sometimes not appear- 
ing until the one which preceded it has completely disap- 
peared from the surface, and thus the disease may be in- 
definitely prolonged. 
The bullae are irregularly globular, somewhat flattened 
at the summit, and contain a citrine-yellow, semi-transpa- 
rent, serous fluid,—in old persons, or in broken-down con- 
stitutions, the fluid is generally sanguinolent in some of the 
bullae ; in eight or ten hours they burst, and are succeeded 
by the formation of thin, blackish crusts, beneath which the 
surface of the skin is excoriated ; when these crusts fall off-, 
small, unhealthy ulcers, with a foul ichorous discharge, not 
unfrequently succeed. 
If the disease is not prolonged by the development of 
successive crops of bullae, which, however, is rarely the case, 
it may not last longer than for a month or six weeks, and 
the general health is but little affected ; more usually, how- 
ever, a relapse takes place, the eruption seeming to lie 
dormant during the winter, returning again in the spring 
and summer, and thus, or by fresh sets of the bullae con- 
tinuing to be developed, its duration is prolonged for months 
or even years, very frequently proving fatal. In the latter 
case there may be seen on the cutaneous surface, at the 
same time, recent bullae and black crusts and atonic ulcers, 
the result of previous eruptions. The constitution then 
sympathizes, extreme debility, with low fever, ensues on 
the loss of rest caused by the local irritation, pain, and foul 
discharge ; the appetite fails, and the patient dies quite 
worn out. 
In one very chronic variety of pemphigus which attacks PEMPHIGUS. 
99 
old persons, the bullse form with extreme rapidity, no dis- 
tinct interval elapsing between the development of the suc- 
cessive crops ; they become confluent, burst almost as quickly 
as they appear, and spread so as to engage the cutaneous 
surface over the greater part of the body, the face in 
especial being affected. The bullae are succeeded by epi- 
dermic desquamation in large, yellowish, foliaceous scales, 
which partly adhering to and partly peeling from the sub- 
jacent integument, gives a singular aspect to the disease ; 
these scabs are aptly compared by Cazenave to the layers 
of puff-paste, and he terms the eruption in which they 
occur, pemphigus Chroiiicus foliaceus. It is generally a 
very fatal form, death being preceded by dropsical effusion 
and diarrhoea. 
Chronic pemphigus may occur on any region of the body, 
except those parts on which hair grows; it is more diffused 
than when the disease is acute, and appears more frequently 
on the upper extremities, the face and the thorax. It not 
uncommonly is complicated with other cutaneous diseases, 
especially with prurigo or scabies, in either of which cases 
the sufferings it occasions almost baffle description. 
The causes of pemphigus are more or less connected with 
constitutional derangements ; the chronic form in particular 
rarely occurring except in persons who have been debilitated 
by distress, and by insufficient or bad diet, or in those who 
suffer from some chronic visceral disease, of which it seems 
at times to be symptomatic. Acute pemphigus is most fre- 
quent in children and young persons, infants even not being 
exempt from it, appearing rarely in adults or in the old ; 
while chronic pemphigus is a disease of advanced life. The 
eruption is occasionally developed in children after a con- 
tinued exposure to the heat of the sun; but it much more 
frequently seems to depend on the effects of moisture, most 
of those at any age who are attacked with it being persons 
who have lived in damp situations ; this fact is well estab- 
lished in the country districts of Ireland, where it is most 
prevalent among the peasantry who dwell in mountainous 
districts, much rain falling there, and the hills being con- 
stantly enveloped in mists. The occurrence of the disease 
as an epidemic has been already adverted to; some of the 100 
VESICUL2E. 
ancient medical writers regarded it as being contagious, and 
Willan, by describing a variety of it under the name Pem- 
phigus contagiosus, tended to perpetuate this erroneous 
view, one, too, which was contrary to his own opinion. 
The diagnosis of pemphigus, whether acute or chronic, 
is, in most cases, unattended with difficulty. Although the 
bullae resemble somewhat the vesications which occasionally 
accompany erysipelas, they are never situated on a diffusely 
inflamed portion of the skin, as occurs in that disease, nor 
are they attended with the constitutional fever. The diag- 
nostic marks between pemphigus and herpes have been 
given in the description of that eruption. Rupia differs 
from pemphigus in there being in it a broad inflammatory 
areola to each bulla when it is first developed, and in the 
peculiar appearance of the resulting scab or crust. The 
foliaceous form of chronic pemphigus might be mistaken 
for psoriasis, but the scales in the latter desquamate more 
freely, are smaller, of a silvery whiteness, and are never 
preceded by an eruption of bullae, nor attended with a serous 
discharge. 
Prognosis.—Pemphigus in any of its forms is not un- 
attended with danger, notwithstanding Willan termed one 
variety of it Pompholyx benignus. The chief apprehensions 
in the acute form are, the liability to relapse when it appears 
in children, or about the age of puberty; and, at an earlier 
age, that it may assume the characters of the pemphigus 
gangraenosus of Stokes. The chronic form is always a 
most dangerous disease, few old persons recovering from 
an attack of it. The more acute the symptoms, and the 
more inflammatory the constitutional disturbance, the more 
favorable the prognosis. 
As regards the pathology of pemphigus, it is manifestly 
an atonic inflammation of the superficial layers of the derma, 
which terminates in serous effusion : the fluid contained in 
the bullae is highly albuminous, becoming nearly solid when 
exposed to heat. 
Treatment.—The acute forms of this eruption demand 
but little medical interference, the accompanying fever 
being rarely such as to require any active antiphlogistics; 
should it, however, continue after the bullae are fully de- 10 L 
PEMPHIGUS. 
veloped, or inflammatory symptoms then appear, a small 
abstraction of blood from the arm may be requisite ; but 
in the majority of cases, rest in bed, diluent drinks, reduced 
diet, and mild saline purgatives will suffice. The vesica- 
tions should be as much as possible protected from local 
irritation, and, above all, from being prematurely ruptured; 
with this view they may be dusted over with flour or starch ; 
as soon as they have burst they may be dressed with some 
simple ointment, such as the cucumber or acetate of zinc 
cerate, or collodion may be applied over them. When acute 
pemphigus presents the characters described by Dr. Whitley 
Stokes, all debilitating plans of treatment must be carefully 
avoided, good nourishing diet should be given in abundant 
quantity, the air be at once changed, and powdered bark, 
with minute doses of pulvis cretae opiatus apd of the hydrar- 
gyrum cum creta, administered internally. On the sugges- 
tion of Dr. Stokes, an ointment prepared with lard and the 
leaves of the common figwort, Scrophularia nodosa, was 
used as a local application in this form of pemphigus ; he 
states that he derived his knowledge of its beneficial action 
from an inquiry into the applications which were popularly 
employed with success in the country districts of Ireland, in 
all of which he found that the leaves of this indigenous 
plant formed a principal ingredient; at his recommendation 
it was originally introduced into the Dublin Pharmacopoeia, 
from the last edition of which, however, it has been omitted. 
It was, in fact, but a mild astringent ointment, and its chief 
efficacy probably depended on the protection from the action 
of the air which it afforded; a weak cerate of tannic acid 
—two grains to the ounce of white wax ointment—melted, 
and applied to the surface with a camel’s-hair pencil, just 
as it is again about to become concrete, will be beneficially 
substituted for it. 
In chronic pemphigus the chief indications are to allay 
both the local and constitutional irritation, and to support 
the strength ; attention must also be directed to any 
visceral disease of which it may be symptomatic, or with 
which it may be complicated. I have experienced very 
great benefit in its treatment from the free use of opiates, 102 
VESICULAR 
which may be given, combined with bark, as in the follow- 
ing form :— 
R. Liquoris Opii Sedativi, . . . . m. x. 
Tincturae Cinchonae Compositae, ra. xv. 
Misturae Camphorae, fl3j. Misce; fiathaustus. 
“ One such to be taken every sixth hour.” 
To allay the local irritation, the parts may be covered 
with raw cotton or dusted with starch, or, if the itching 
and pain are very severe, they may be dressed with lint on 
which has been spread the compound lead cerate, to every 
ounce of which a fluid drachm of glycerine has been added. 
By some it has been proposed to open the bullse as soon as 
they appear, and to apply to the surface thus exposed a 
solution of nitrate of silver, containing a scruple of the salt 
to an ounce of distilled water; instead of the solution, Dr. 
Graves proposes to employ the solid nitrate for this pur- 
pose, and mentions a case in which its use was attended 
with complete success the practice, however, is only ad- 
missible when the eruption is of small extent, and not 
connected with constitutional derangement. In very ob- 
stinate cases arsenical preparations and iodide of potassium 
are occasionally employed with benefit. Wine and generous 
diet should be allowed in all cases of chronic pemphigus, 
and change of air to a drier locality enforced, if possible. 
When diarrhoea or dropsical symptoms occur in the course 
of the disease, they are to be treated on the ordinary prin- 
ciples. 
RUPIA. 
Rupia is characterized by the eruption of distinctly- 
separated and dispersed, flattened bull®, of the size of a 
small nut, on an inflamed base, terminating in elevated, 
dark brown crusts, which, falling off, are succeeded by 
atonic ulcers. The bull®, which in most cases are not 
preceded by either local or constitutional inflammation, 
1 Clinical Medicine, Second Edition, vol. ii. p. 354. RUPIA 
103 
contain from the first a semi-opaque or ichorous fluid, 
which appears not to distend them completely ; this fluid 
rapidly becomes sero-purulent and more consistent, and 
the epidermic covering of the bullae, giving way usually on 
the second or third day, accretes into a wrinkled scab, more 
prominent in the centre than at the circumference. Three 
varieties of rupia are in general described by dermatologists, 
but the third of these, rupia escharotica, as has been already 
mentioned when describing pemphigus, is a form of that 
eruption, being the pemphigus gangraenosus of Dr. Whitley 
Stokes—two forms, therefore, only remain to be considered 
here:— 
Rupia simplex. 
“ prominens. 
In Rupia simplex (Atlas, PI. Y. Fig. 4) the bullae are but 
few in number, often not more than two or three, and situ- 
ated remotely from each other; the inflammatory areola is 
narrow, and scarcely raised above the level of the surround- 
ing integument, and the crusts, which are of a dark-brown 
color, only slightly elevated in the centre. The resulting 
ulceration is superficial, and scabs cover it in a few days ; 
these scabs, which are wrinkled and raised at the edges, fall 
off and are renewed several times for from one to two or 
three weeks, when the surface heals, a livid stain, which 
does not disappear for some time, remaining on the part. 
The duration of the disease until the falling off of the scabs 
is, as above remarked, from two to three weeks, unless, as 
occasionally occurs, it is prolonged by the formation of new 
bullae at the time those first developed are about to disap- 
pear. In some rare cases a slight degree of fever precedes 
the appearance of the eruption, and superficial redness, as 
in pemphigus, marks the spot on which each bulla is about 
to form. 
Rupia prominens (Atlas, PI. Y. Fig. 5) is so named from 
the characteristic appearance of the crusts or scabs which 
are formed in it. The bullae are of larger size than in rupia 
simplex, the patches of the cutaneous surface on which they 
occur are previously swollen and of a dark-red color, and the 
contained fluid, which is often ichorous or sanguinolent, 104 
VESICUL M. 
sometimes as dark as chocolate, rapidly thickens and dries 
into a hard, wrinkled, blackish crust, surrounded by a swol- 
len, inflamed border. From the inner edge of this inflamed 
areola, unhealthy pus is secreted, which, concreting, forms 
additional crusts; these, pressing on the original scabs, 
already somewhat raised in the centre and corrugated, force 
them still more forwards until they eventually attain such 
a prominence that they bear an extraordinary resemblance 
to the shell of a limpet, or, in some cases, spreading from 
their circumference until they cover the entire of the in- 
flamed border by which they were surrounded, to the shell 
of an oyster. These crusts, which are firmly adherent and 
slow in falling off, in a few days become somewhat raised at 
their outer border, and permit the discharge of unhealthy 
pus from the excoriated surface beneath; in the course of a 
week or ten days they may be readily detached, or they fall 
off spontaneously, when an excavated atonic ulcer, the depth 
of which is usually proportioned to the thickness of the scab, 
is seen to occupy the site of the original bulla. These ulcers 
are extremely indolent, pale, and bleeding on the slightest 
touch, and either become covered anew with the character- 
istic crust, which, however, does not attain the same degree 
or prominence as in the first instance, or, discharging an un- 
healthy, ichorous pus, heal slowly, leaving dark, livid stains 
on the skin. Rupia prominens is always a chronic disease, 
lasting generally for months, and its duration is often pro- 
longed by successive eruptions of bullae. 
The usual site of either form of rupia is on the lower 
extremities, sometimes on the abdomen, the loins, or the 
thorax; but, unless when occurring as a syphilitic eruption, 
it is very rarely witnessed on the upper extremities or the 
face. The disease may occur at any age, but it most usually 
affects children and old persons, being uncommon in adults. 
The causes by which it is produced are sufficiently obscure, 
but it appears to be connected with a debilitated state of the 
constitution, and especially in children with the scrofulous 
diathesis. It is also one of the sequelae of the eruptive 
fevers in young persons, and in the old it not uncommonly 
occurs at the termination of some prolonged illness, such as 
fever or dysentery. Rupia is sometimes complicated with RUPIA 
105 
other cutaneous diseases, more particularly scabies, ecthyma, 
and purpura; in the last case the bullae usually contain 
blood. 
Diagnosis.—Rupia may he confounded with either pem- 
phigus or ecthyma. From the former it is distinguished, 
even in its vesicular stage, by the bullae being solitary, 
never confluent, and by the raised inflammatory border 
which surrounds them ; when the scab is formed, its charac- 
teristic prominence serves to render the diagnosis easy. 
Ecthyma is an inflammatory pustular eruption, and the 
resulting scabs are small and flat, while rupia is distinctly 
vesicular at its origin, and the scabs are large and promi- 
nent. The more serious mistake may be made of mistaking 
idiopathic for syphilitic rupia, which is a much more severe 
disease, and one requiring different treatment; the latter is 
distinguished by the areola surrounding the bullae being of a 
dull, coppery hue ; by the bullae being much more numerous, 
often covering nearly the entire body, and appearing very 
frequently on the face; by there being generally present at 
the same time syphilitic sore throat; and by the antecedent 
history of the case. 
The prognosis in rupia is always favorable; it is often an 
obstinate, but never a dangerous disease, and rarely injures 
the general health, unless the resulting ulcers are very 
numerous, and attended with much discharge, when a degree 
of low, irritative fever is developed by their presence. 
Treatment.—Constitutional remedies are chiefly to he 
relied on in the treatment of rupia, and these should be 
adapted to the indications in individual cases. Tonics, 
especially preparations of bark and of iron, good food, and 
nourishing diet, are most usually demanded. When the 
disease becomes chronic, hydriodate of potash will be 
given with benefit in equal parts of the decoctions of elm- 
bark, of dulcamara, and of mezereon; and in the case of 
scrofulous children, cod-liver oil should be prescribed. As 
regards local treatment, it is generally recommended to 
open the bullae at the earliest opportunity, so as to prevent, 
if possible, the formation of the crust; they should then be 
covered with pledgets of lint, and slight pressure made on 
them, or they may be dusted with starch, or, what is still 
preferable, as the chief object is to exclude the air, collodion 106 
VESICUL^E. 
maybe applied. When the crusts have formed they should 
be removed as quickly as possible, having been previously 
softened by the application of bread and water, or of linseed- 
meal poultices; the ulcers, for the first few days, should be 
treated with water-dressing, over which oiled silk is placed, 
but if they do not show a disposition to heal, stimulating 
ointments or lotions become requisite; of the former, the 
brown citrine ointment, or one composed of equal parts of 
oil of turpentine and of white wax ointment, may be used ; 
or of the latter, if it be found, as is often the case, that 
greasy applications disagree, solutions of the sulphate of 
copper or of sulphate of iron, from six to twelve grains of 
ether to the ounce of distilled water, may be employed, lint 
soaked in them being laid on the ulcerated surface. Some 
of the French dermatologists report that they have derived 
excellent results from ointments of the iodides of mercury, 
—a drachm of the green or twelve grains of the yellow 
iodide, to the ounce of lard. By some practitioners it is 
recommended to touch the ulcer every second or third day 
with the solid nitrate of silver, but the nitrate of copper, 
allowed to deliquesce, and then applied by means of a 
camel’s hair brush, will in very obstinate cases, be found 
more beneficial. It must not be omitted to mention that 
Rayer states he found the simple practice of dusting the 
ulcers with finely-powdered cream of tartar very successful. 
SCABIES. 
Scabies (Itch) (Atlas, PI. YI. Figs. 1 & 2).—No little 
difficulty has been at all times experienced in classifying 
scabies; by some it is regarded as being papular, by others 
pustular, and by many modern dermatologists it has been 
made to constitute a division of cutaneous diseases of which 
it is the type,—the presence of parasitic animalcules beneath 
the epidermis being considered by them as a necessary cha- 
racteristic of the eruption. There can be no doubt but that 
during the course of the disease pimples and pustules con- 
stantly occur on the skin, mingled with the vesicles, and the 
vesicles themselves assume a purulent aspect in a few days 
after they are developed, yet on careful observation it will 
be found that the eruption is at first always distinctly vesi- SCABIES. 
107 
cular, and that this character is never completely lost in any 
stage of the affection. The occurrence of the peculiar itch 
animalcule is very constant in scabies, and its existence 
easily demonstrable, but as cases do occur in which even 
the most experienced observers are unable to detect it, I 
cannot admit that its presence is necessary to and pathog- 
nomonic of the disease. For these reasons, then, and also 
because the peculiar vesicle of scabies is highly character- 
istic, I shall retain it amongst the vesiculse. It has always 
been an eruption of much interest to the physician in con- 
sequence of its great prevalence, the rapidity with which it 
spreads by contagion, and the severity of the local symptoms 
with which it is attended. 
The eruption in scabies, the development of which is 
unaccompanied by constitutional symptoms, is preceded 
by itching and tingling of the parts on which it is about 
to appear, usually the backs of the hands, the angles be- 
tween the fingers, and the flexures of their joints ; in about 
twelve hours afterwards there may be seen developed on 
them one or more conical vesicles, which rapidly enlarge 
until they not unfrequently attain the size of a small pea, 
being more or less solid at the base, and transparent at the 
apex, which is acuminate. The majority of these vesicles 
soon become opaque and sero-purulent, and, bursting, 
form yellowish scabs ; but in some of them the serous effu- 
sion is absorbed, and they then present a papular appear- 
ance, a thin, epidermic scale forming on the top of each 
papule. In the neighborhood of some of the vesicles may 
be seen, in most cases of itch, a narrow line or superficial 
fissure of a few lines in length, such as would be made 
with the point of a needle—the sillon, which terminates in 
a small, rounded, elevated point, of a reddish color—the 
cuniculus, or burrow of the itch animalcule, and from which, 
with a little care, it may in general be extracted. 
This insect—the Acarus scabiei, or, as it has been also 
termed, Sarcoptes hominis, being constituted into a new 
genus by Latreille—was discovered and described as ex- 
isting in scabies in the twelfth century by Avenzoar; but 
although its presence was evidently known to the Greek 
and Homan physicians, little notice of it occurs afterwards 108 
VESICULJi. 
in medical writings until the middle of the seventeenth 
century, when an Englishman, Mouffet, left in a posthu- 
mous work a singularly full and accurate description of 
the animalcule, especially as regards its anatomical cha- 
racters, and in which many of the so-called discoveries of 
modern days are anticipated. In our own times the na- 
tural history of the itch animalcule has been especially 
investigated by the French and German dermatologists, 
particularly by Renucci, Raspail, Albin-Gras, Hebra, and 
Bourguignon; amongst English writers Mr. Erasmus Wil- 
son gives the fullest account of its habits and structure, 
and from his observations the following description is con- 
densed. 
Examined with the naked eye, the acarus scabiei (Atlas, 
PI. XYI. Fig. 1) looks white, shining, and globular in form. 
“ There is no difficulty in extracting the little animal; the 
cuniculus is seen without difficulty ; the end of the cunicu- 
lus is perceived to be a little raised, while a grayish speck is 
seen beneath it; as soon as this little eminence of epiderma 
is lifted, if the end of the needle or pin with which the ope- 
ration is performed be examined, the minute, white, and 
shining globe will probably be observed attached to the in- 
strument. If there be no such object, the point of the 
needle, placed again beneath the raised capsule of epiderma, 
will pretty certainly draw it forth. This facility of extract- 
ing the little creature is due to its great power of clinging 
to any object with which it comes in contact. When the 
acarus is seen running upon the surface of a plate of glass 
it may be perceived that its anterior margin presents a dusky 
tint of color, and the examination of this part of the crea- 
ture with the microscope brings into view a head not unlike 
that of a tortoise, and a pair of large and strong legs on 
each side of the head. These organs are encased in a mo- 
derately thick layer of chityne, and have consequently the 
reddish-brown tint of the cases of certain insects, or of the 
bright part of a thin layer of tortoise shell.”1 The general 
outline is sub-rotound, it being a very little longer than 
broad; the ventral surface is flat, and upon it may be seen 
the head and eight legs ; the dorsal aspect is arched and 
1 Erasmus Wilson on Diseases of the Skin. Third Edition, p. 499. SCABIES. 
109 
uneven, and covered by numerous spines; and twelve hair- 
like filaments, some long and others short, project backwards 
from the posterior segment of the animalcule. Mr. Wilson, 
from a comparison of the measurements in ten specimens, 
found them to vary between T{?th and of an inch in 
length, and 5d and in breadth. 
This account refers to the female acarus, and with it are 
generally found some of the ova; the male insect (Atlas, 
PI. XYI. Fig. 2) seems to have eluded the research of most 
investigators ; M. Bourguignon, writing so lately as 1847, 
says, “ that he has never found male sexual organs in the 
acarus, but in every specimen he examined has seen ovaries 
with the ova, it appearing that connexion with a male is not 
requisite for the reproduction of the animalcule.”1 Gustav 
Simon, Physician to the Charity Hospital at Berlin, de- 
scribed the male acarus in the first edition of his Anatomical 
Description of Diseases of the Skin, published in 1848 ; and 
in 1851, it was also discovered and described by M. Lan- 
quetin, a pupil of M. Cazenave. It is much more minute 
than the female, and being always situated on the free sur- 
face of the skin, not taking up its abode in a cuniculus, ac- 
counts for its existence being overlooked by so many careful 
investigators. 
The eruption in scabies is invariably attended with severe 
itching—whence the name by -which the disease is com- 
monly known,—this, causing the sufferer from it to scratch 
and tear the skin with the nails, increases the local inflam- 
mation, which already is considerable ; fresh vesicles appear, 
often thickly set on the surface, and mixed with them large 
papulae and pustules ; a bloody serous and sero-purulent dis- 
charge flows from the torn integuments, in which deep 
fissures are also formed, and the eruption spreads rapidly, 
in severe cases attacking the lower extremities, the abdo- 
men, and the trunk, as well as the hands and arms, but 
being very rarely, if ever, witnessed on the face. The suffer- 
ings occasioned by the disease are then extreme, sleepless 
nights are passed often for weeks together, the itching being 
always much augmented by the warmth of the bed ; the con- 
stitution, consequently, sympathizes more or less, and in the 
1 Recherches Entomologiques et Pathologiques sur la Gale de l’Homme. 
Paris, 1847, p. 8. 110 
V ESICUL-iE. 
old or the debilitated, prurigo, ecthyma, or pemphigus, com- 
plicates the original eruption, rendering it more intractable, 
and in very aged persons even fatal. 
In some cases of scabies the eruption is apparently alto- 
gether papular, but on examination with a lens it will be 
found that a minute vesicle surmounts each papule ; from 
mistaking its true character, Willan and Bateman termed 
this form of scabies papuliformis; when the vesicles are 
perfectly transparent, and with little or no inflamed base, 
they denominated the disease, scabies lymphatica ; and when 
the pustular character predominated, they constituted it a 
distinct variety, under the name scabies purulenta. The 
occurrence of the eruption in broken down constitutions is 
not unfrequent, and its aspects being then influenced by the 
physical condition of the individuals attacked, the same 
dermatologists arranged it in a distinct species, which they 
called scabies cachectica. 
Causes.—Scabies occurs at all ages, in individuals of 
every rank of life, and in all climates, being even more 
prevalent in hot countries than in cold, and there it is also 
a more severe disease ; it is of much more common occur- 
rence among the poor than amongst the higher orders, in 
consequence evidently of the less frequent ablutions to which 
their bodies are subjected, and the longer period during 
which their clothes are worn without being changed, for the 
eruption is especially a concomitant of filthy habits. That 
the spread of the disease from individual to individual takes 
place by contagion is undoubted, but that this is the only 
cause some have questioned, believing that it may be self- 
generated in the system; however, such a doctrine is now 
nearly obsolete, and the sole difference of opinion existing 
on the matter at present may be said to be as to which is 
the contagious principle in scabies, the acarus, or the matter 
of the eruption. Mr. Erasmus Wilson asserts his belief, 
that “ the vesicle is a provision of nature to protect the 
derma from the nearer approach of the arator, and the 
vesicle is formed with the judgment which usually marks 
nature’s operations—namely, before a defensive operation 
would be too late.” Now how the approach of the insect 
is to be prevented by the formation of the vesicle, I must 
confess 1 cannot understand; the sillon, or tract from the SCABIES. 
cuniculus, always terminates in a vesicle, and observation 
shows that the development of the vesicle precedes the ap- 
pearance of the animalcule; I therefore think that the con- 
nection between them may be more simply explained by re- 
garding the sillon as being the track of the acarus in making 
its way from the vesicle—which has been caused by the 
irritative inflammation occasioned by its deposition from the 
skin of another person, no matter how conveyed, or in the 
fluid of which it has been hatched—to the cuniculus or 
burrow for the purpose of depositing its ova. The belief 
of those, then, who think with that dermatologist is, that 
scabies, being in all cases dependent on and caused by the 
acarus, can alone be propagated by the deposition of this 
insect, or of its ova on the epidermis, and that the secre- 
tion from the vesicles will not of itself reproduce the disease. 
Direct experiment, however, proves that it may be thus 
propagated, but to this they answer, that when it is so, the 
inoculating matter employed must contain some of the ova ; 
but a similar argument is equally applicable to their view, 
namely, that when the disease has been produced in indi- 
viduals by the acarus being placed on the skin, it cannot be 
denied that the animalcule conveyed with it some of the cha- 
racteristic secretion. 
For my own part, I am of opinion that scabies will be 
developed in a person whose skin has been previously free 
from the disease by the contact of either the itch-insect or 
the secretion from the eruption, but I believe the latter to 
be the most frequent cause of the contagion, and in this 
way only can we account for the many cases that occur 
in which the disease has been produced by contact with 
clothes, with gloves, &c., which have lain by for some 
time; in one instance wrhich I saw, a lady was attacked 
with scabies on the palm of her hands, and as far as obser- 
vation, which I freely admit is not indisputable evidence 
here, enabled me to judge, the contagion was conveyed to 
her from her servant-man, who was affected with the disease, 
by means of the handles of the knives which he was in the 
habit of cleaning. 
From experiments which have been made it appears that 
scabies is more quickly developed in the young and in indi- 
viduals of a full and robust habit of body than in the old, 112 
VESICUL^!. 
or those who are of a weak constitution; the period of 
incubation in the former being about four days, while in 
the latter it may extend to ten days or a fortnight, or even 
longer. 
The diagnosis is, in some cases of scabies, extremely 
difficult, and in no other cutaneous eruption is it more 
important that a mistake should not be made, especially as 
the plan of treatment adapted for it is not at all suited for 
those diseases with which it is likely to be confounded; 
moreover, an opinion given with regard to contagion, if 
it prove to be incorrect, may seriously injure a physician’s 
character. When eczema appears on the fingers or hands 
it is very often mistaken for scabies; in its early stages 
the minuteness and number of the vesicles generally suffice 
to render the diagnosis facile, but when it becomes chronic, 
the itching with which it is attended not unfrequently may 
lead to error. Eczema, however, never presents the conical- 
shaped vesicles of scabies, the discharge from the parts 
affected with it is more watery,—being rarely sero-purulent 
except in eczema impetiginodes,—is accompanied by a 
mealy, epidermic desquamation, and it is rather a sensation 
of smarting and stinging than of true itching that attends 
it. The papular form of scabies may be mistaken for lichen, 
more particularly when the latter affects the backs of the 
hands; but the complete absence of vesicles and of a sero- 
purulent discharge in the latter, generally suffices to prevent 
the mistake from being made; the eruption, too, does not 
spread to the flexures between the fingers, the most usual 
seat of itch. Prurigo, which, like lichen, is a papular 
eruption, is liable to be confounded with scabies, chiefly in 
consequence of the severe itching with which it is attended; 
but it rarely affects the hands unless when it appears as a 
complication of that disease, its usual seat being the trunk 
of the body, the shoulders, and the thighs; and the small 
black crusts on the summits of the papulae produced by 
scratching are highly characteristic; it is moreover, very 
rarely accompanied by any discharge. When scabies 
assumes the pustular character, and the individual pustules 
attain a large size, it might be mistaken for ecthyma, but 
the latter is characterized by not being attended with itch- 
ing, by its mode of development, and by the pustules being SCABIES. 
113 
usually isolated. In fine, from all the cutaneous diseases 
now enumerated, scabies is especially distinguished by its 
contagious nature, and by the presence of the acarus; but 
it should be remembered that it may be complicated with 
any of them. 
Prognosis.—As this eruption can scarcely be said to prove 
dangerous to life, except in the rare instances already re- 
ferred to, the prognosis refers only to its probable duration, 
and this, when effective treatment is adopted, is always very 
short; but if scabies be left to itself, uninterfered with by 
the application of remedies, it may be indefinitely prolonged, 
as it never seems to exhibit a tendency to wear out, or to 
undergo a spontaneous cure. 
Treatment.—If there be any well-established example of 
a specific in the whole Materia Medica, it is that of the 
action of sulphur in the treatment of scabies, and as this 
medicine never fails to cure the disease, it is the universally 
admitted remedy for it; none other indeed would require to 
be alluded to, were it not that the unpleasant odor of sulphur 
renders its employment in some instances inadmissible. The 
general method of using this substance for the treatment of 
scabies is by the local inunction of ointments containing it, 
either alone or combined with alkalies; in the latter form it 
is generally employed in the present day in France, and 
found to be more efficacious than when used alone; the com- 
bination was first introduced by M. Helmerich, and the oint- 
ment, which is called after him, Pommade d' Helmerich, is 
composed of two parts of sulphur, one of carbonate of potash, 
and eight of lard. The surface of the entire body, but 
more particularly of the affected parts, should be first washed 
well with a strong solution of soap, the patient then placed 
for a quarter of an hour in an alkaline bath, containing a 
pound of the carbonate of potash to twenty gallons of water, 
at the temperature of 92°, the skin well dried, and this sul- 
phuro-alkaline ointment afterwards thoroughly rubbed in; 
the disease may thus be effectually cured in two or three 
days, a single friction, preceded by the alkaline and sapona- 
ceous bath, being used daily. Out of upwards of TOO per- 
sons treated on a plan nearly similar to this at the Hopital 
St. Louis, in Paris, M. Bazin only met with six unsuccessful 114 
VESICUL^. 
cases, all the rest being cured on the third day.1 M. Ilardi, 
who succeeded M. Bazin in the charge of the itch wards in 
this Hospital, has introduced a plan of using the sulphuro- 
alkaline ointment there, by which the period required for a 
complete cure is reduced to two hours. His method is as 
follows: “ On the admission of the patient, the entire sur- 
face of the body is rubbed for half an hour with soft soap— 
savon noir; he is then placed in a bath for an hour, and the 
body well rubbed while in it, and at the end of that time 
general frictions made and continued for half an hour with 
Helmerich’s ointment. The acarus,” adds M. Hardi, “is 
thus killed, and the patient consequently cured.” Of 400 
patients thus treated, it is said that 4 only required to re- 
turn for further advice, and of these 2 had recontracted the 
disease. 
A question arises as to whether it is advisable to cure 
thus suddenly a vesicular eruption, which in some cases is 
attended with a rather copious discharge; M. Devergie, a 
celebrated dermatologist, and one of the senior physicians 
to this hospital, thinks it may be dangerous to do so, but I 
cannot agree with him, for as scabies is not attended with 
any constitutional disturbance, and is never symptomatic of 
an internal disease, the same causes do not operate against 
the sudden cure of it as against that of cutaneous diseases, 
the discharge in which is evidently dependent on some 
deranged condition of the system generally. M. Devergie, 
however, asserts that although the contagious nature of sca- 
bies is destroyed by this plan of treatment, a troublesome 
cutaneous eruption still remains—one, too, attended with 
much annoyance to the patient, and often difficult of cure. 
When any insuperable objection exists to the employment 
of sulphur for the cure of scabies, other applications may 
be had recourse to, which, although more tedious in their 
action, are equally efficacious; the use of any of them will 
invariably be beneficially preceded by the employment of 
frictions with soft soap, and of the alkaline bath. Oil of 
turpentine made into an ointment with eight times its weight 
of prepared lard, is a very certain application, but its odor 
to many persons is more objectionable even than that of sul- 
1 Journal de Modecine et de Cliirurgie Pratiques, December, 1851, p. 520. SCABIES. 
115 
phur; this may to a great extent be removed, and its efficacy 
rather increased, by the addition of eight minims of oil of 
hitter almonds to each ounce of the lard combined with it. 
The ointment of sulphuric acid, of the former Dublin Phar- 
macopoeia, which is free from any unpleasant odor, rarely 
fails to cure the disease; stavesacre and white hellebore 
ointments, also, have been used with success ; the former is 
prepared by mixing with prolonged trituration one part of 
the powdered seeds of the Delphinium staphisagria with 
four times its weight of white wax ointment and one part of 
glycerine, and the latter by combining two ounces of pow- 
dered root with half a pound of prepared lard, and adding 
twenty minims of oil of lemons. Inunction with simple 
fatty matters even, such as olive oil or lard, has been found 
sufficient to cure scabies, but the duration of the disease is 
more prolonged than when any of the above-mentioned 
remedies has been had recourse to. 
A strong objection often existing with some persons to 
the use of greasy applications, lotions of the sulphuret of 
potassium, or of chlorinated lime or soda, may be substituted 
for them ; of the former twenty grains, and of either of the 
latter a drachm to the ounce of distilled water, should be 
employed. 
With reference to internal treatment nothing more is 
usually requisite than the administration of saline or sul- 
phurous cathartics, and the use of the former should never 
be omitted; in very obstinate cases the combined employ- 
ment of sulphur as an internal remedy and an external 
application is not alone attended with benefit, but often 
absolutely demanded. Should the local inflammation run 
high in young persons of robust constitution, bleeding 
from the arm even may be indicated, but this is very rarely 
requisite. 
In all cases of scabies constant ablutions with soap and 
water constitute an essential part of the treatment, and 
the clothes which had been worn previously should be 
laid aside, as from their retaining the contagious matter, 
the disease may be reproduced after a cure has been 
effected. 116 
PUSTULE. 
CHAPTER IY. 
PUSTUUE. 
The Order Pustule includes those cutaneous diseases 
that are characterized by the eruption of circumscribed, 
rounded elevations of the epidermis, which contain pus, and 
are situated on an inflamed base—pustules; the pustules 
which may be either psydracious or phlyzacious (see page 
26), burst and form scabs or thick crusts, on the falling off 
of which a slight, not permanent, depression or stain is left. 
Pustular eruptions are non-contagious, attended with more 
or less inflammation, usually of a sub-acute or chronic cha- 
racter, and their duration may be either very short or much 
prolonged. The local inflammatory action by which a 
pustule is produced affects the deeper structures of the 
derma as well as the epidermis, in consequence of which 
the sub-epidermic effusion is purulent, while in vesicular 
eruptions the superficial layer only of the derma being in- 
flamed, the effusion is serous. In its early stage a pustule 
can scarcely be distinguished from a papule, inasmuch as the 
pus on which its specific character depends does not usually 
appear at the apex until the second or third day ; the puru- 
lent secretion then gradually increases, distending the epi- 
dermic covering more and more, until, finally, it gives way, 
when the matter is effused on the cutaneous surface, and a 
scab is formed; of this process an excellent example is 
afforded in the case of the pustular eruption artificially pro- 
duced by the local application of tartar emetic in the form 
of ointment or solution. While undergoing these changes, 
the pustule is said, in popular language, to be ripening. 
Some of the diseases included by Willan and Bateman in 
this order were so classed by them from an incorrect idea 
of their true characters ; thus scabies, for the reasons given 
in the last Chapter, is more properly placed among the 
vesiculm; variola is one of the eruptive fevers ; and porrigo ACNE 
117 
is not pustular in any of its stages. Acne, included by them 
in the division which they termed Tubercula, presents the 
aspects of a true pustule, according to the foregoing defini- 
tion. The group then comprehended three forms of cuta- 
neous eruptions, Acne, Impetigo, Ecthyma. 
ACNE. 
Acne consists in the eruption of psydraeious pustules, 
with a hardened base, distinct from each other, but usually 
aggregated in small patches on a circumscribed inflamed 
portion of the skin ; when they maturate, bursting and 
giving exit to purulent matter, which dries into thin, brown- 
ish crusts. The pus first appears as a minute dot at the 
apex of each pimple, which is somewhat acuminate, then, 
gradually increasing in quantity, the pustule becomes glo- 
bular, and of a straw-yellow color, its base still remaining 
hard, red, and painful, and surrounded with an inflamed 
areola. At times some of the pustules, taking on an in- 
dolent action, little or no matter forms in them, when they 
present the appearance of hard, inflamed, minute tumors, 
about the size of a small pea and exquisitely painful to the 
touch, and are slow in disappearing. The seat of the 
inflammatory action in acne is chiefly in the sebaceous 
glands, and the disease is not unfrequently produced by 
obstruction at their orifices causing an accumulation of the 
natural secretion and consequent irritation. By some 
modern dermatologists it has, therefore, been made to con- 
stitute a distinct class of cutaneous eruptions, defined by 
Cazenave as consisting in “ a diseased condition of the 
follicular secretion,” and by Erasmus Wilson as “an in- 
flammation of the sebiparous glands and adjacent tissues, 
with or without alteration of secretion. Acne is a disease 
chiefly of youth and of adult life, occurring with greatest 
frequency about the age of puberty, whence its name, 
derived from the Greek word, vigor. The several 
varieties of the eruption which have been described may, I 
think, be reduced to two forms:— 
Acne simplex. 
“ rosacea. 118 
PUSTULE. 
Biett was the first to describe a rather rare cutaneous 
eruption as a variety of acne, terminating in acne sebacea, 
in which the sebaceous follicles become hypertrophied and 
their secretion diseased, and nearly every dermatologist 
since his time has adopted his views, and retained the name 
proposed by him ; as, however, it does not in any respect 
resemble acne, except in being an affection of the sebaceous 
follicles, it will be more correctly classed in the group of 
cutaneous eruptions, which I propose to term Hypertrophim. 
Acne simplex (Atlas, PI. YI. Fig. 3) is a very frequent 
disease in young persons, especially in those in whom the 
cutaneous capillary circulation is active, appearing generally 
in the spring and autumn, and disappearing partially in 
summer and completely in winter ; it may consist in the 
eruption of only a few scattered pustules on the face, or may 
occur in small patches or pretty thickly disseminated over 
a large portion of the cutaneous surface, especially affecting 
those regions where the sebaceous follicles are most nume- 
rous. The pustules, whether few or many, are developed 
individually, and do not coalesce ; each of them appears first 
as a small, red, acuminated elevation, hard, and somewhat 
painful, particularly so if the skin where it occurs is thick; 
within twenty-four or thirty-six hours the pustule, which 
has continued to enlarge, presents at its apex a yellowish 
point, which increases for a day or two, when the epidermis 
gives way or is ruptured, and pus, mixed with the curdy 
sebaceous secretion of the follicle which may have been 
involved in the local inflammation, is discharged : although 
each pustule has an inflamed base, there is no diffuse sur- 
rounding redness of the skin. Many of the pustules do not 
maturate, but, remaining indolent for a few days, terminate 
by resolution, the lymphy effusion contained in them being 
re-absorbed; some slight hardness and redness, however, are 
left, which gradually disappear. 
In some persons, who are characterized for the most part 
by having a coarse, greasy skin, the sebaceous and hair 
follicles are particularly developed, and secrete copiously 
the thick curd-like matter which naturally exists in them; 
individual follicles often become obstructed at the orifice, 
somewhat distended, and present a black point at their 
apex ; they then exhibit the appearance described by some ACNE 
119 
dermatologists as a distinct variety of acne, under the name 
acne punctata (Atlas, PI. VI. Fig. 4). The curd-like 
matter, when pressed out by the fingers, forms a round cast 
of the follicle in which it existed, and owing to its size and 
shape, and the black point at its extremity where it had 
been exposed to the action of the atmosphere, bears much 
resemblance to a small maggot, and which it is commonly 
believed to be. Although this popular notion is, it need 
scarcely be said, erroneous, Dr. Gustav Simon has discovered 
in the natural sebaceous secretion a minute animalcule, 
from the 0.085th to the 0.125th of a line (German measure- 
ment) in length, and about the 0.020th of a line in breadth ; 
it was named by him Acarus folliculorum, but has more 
recently been shown by Einsicht not to be an acarus, and 
is therefore termed by the latter Steatozoon folliculorum 
(Atlas, PL XVI. Fig. 3). 
The eruption in acne simplex is thus usually composed of 
maturating and non-maturating pustules, and of enlarged 
obstructed follicles characterized by black points,—the latter 
are constantly present on the cutaneous surface in some 
individuals; it may consist in a single outbreak affecting a 
more or less extended surface, or it may appear in successive 
crops, being consequently then of more prolonged duration. 
No constitutional fever or other disturbance attends the dis- 
ease, even when it attacks many regions of the skin simul- 
taneously, nor, although some pustules may be attended 
with pain, are the local symptoms troublesome, being chiefly 
annoying in consequence of their being situated on the face, 
and therefore causing a temporary disfigurement. The du- 
ration of individual pustules, when they run an acute course, 
is from five to eight or ten days, but when they are indolent, 
or appear in successive crops, the disease may be prolonged 
for as many weeks; in the latter case the marks left on the 
skin are slow in fading away. Appearing and disappearing 
with the seasons, being developed in spring and autumn, and 
receding in summer and winter, acne simplex becomes less 
frequent as youth changes into puberty, and with adult life 
either ceases altogether, or, becoming nearly permanent, is 
converted into the next variety to be described. 
The usual seat of the simple form of acne is on the face, 
the neck, the shoulders, and the chest; it occasionally occurs 120 
PUSTULE. 
on the scalp, where it is exquisitely painful, although the 
pustules are few in number, and very scattered; but it is 
very rare on the extremities. 
Acne rosacea (G-utta rosacea; Rosy-drop ; Oarbuncled 
face: Brandy face) (Atlas, PL VI. Fig. 5) is a disease of 
more mature life than the preceding variety; it has espe- 
cially attracted the attention of the French dermatologists, 
by many of whom it is described as a special disease under 
the name of Couperose. The eruption, which is invariably 
seated on the face, usually becomes chronic, but in all its 
stages is attended with more local inflammation than acne 
simplex; it generally commences in the form of a red patch 
on the skin, on which is rapidly developed a cluster of mi- 
nute pustules, or rather pimples, hard, and but little ele- 
vated ; these enlarge gradually, but are slow to maturate, 
and their base becomes harder, often painful, and much in- 
flamed. Eventually giving way at their apex, a serous 
exudation, mixed with blood, oozes forth, which concretes 
into a hard, dry scab, and from beneath it a small quantity 
of a curdy pus escapes in a few days after. The hardness 
at the base of each pustule, however, still remains, and the 
rosy or crimson-violet patch of the skin, on which a varicose 
condition of tho superficial veins is sooner or later devel- 
oped, is often persistent on the face for months or even 
years, spreading gradually over the nose, cheeks, forehead, 
and chin, fresh crops of similar pustules constantly appear- 
ing on it. 
When this form of acne is chronic, it assumes a very ag- 
gravated character, and from its unsightly appearance causes 
great mental annoyance ; the skin of those parts of the face 
on which it is situated becomes thickened and elevated, from 
effusion into the subcutaneous areolar tissue, caused by the 
repeated fresh attacks of inflammation consequent on the 
development of each successive crop of pustules; it pre- 
sents a permanent roseate hue, which is deepened on every 
exciting cause,—exposure of the face to heat, indulgence in 
the pleasures of the table, or mental emotions; and the sur- 
face is hypertrophied, rugose, and seamed with the cicatrices 
from pustules of previous eruptions. 
In its most chronic form it constitutes what has been 
termed acne indurata (Atlas, PI. VI. Fig. 6), but I have ACNE 
121 
seen this variety of the disease not unfrequently succeed 
acne simplex, and even sometimes appear as an indurated 
and tuberculated eruption from the first; it might, there- 
fore, probably be made to constitute a distinct form of the 
eruption, but it has so many features similar to those of acne 
rosacea, and so commonly occurs apparently as an advanced 
stage of it, that I have thought it better to describe it as 
such. Acne indurata is characterized by the eruption being 
much elevated over the surface of the skin which is of a 
violaceous-crimson hue, and consists in conoidal pustules, 
about the size of a pea, extremely hard and tuberculated, 
and presenting minute points of suppuration at their apex. 
These pustules are not very painful to the touch; they do 
not scab over, but whenever they maturate and burst, they 
leave a bluish cicatrix or pit resembling that of small-pox. 
Those that may be set closely together usually coalesce, and 
present then the appearance of boils, but the contained mat- 
ter is small in quantity, the aggregated bases extremely hard 
and minute, and superficial ulcers, covered with a yellowish, 
soft scab, form on their apex. Acne indurata, when it is 
an advanced stage of acne rosacea, or when it occurs as an 
independent disease, is invariably situated on the face, affect- 
ing especially the aloe of the nostrils, and the most promi- 
nent portions of the cheeks; when it is consequent on acne 
simplex it may appear on any of the regions of the body 
mentioned as being liable to be affected by that form of the 
eruption. 
Causes.—Acne simplex being, as already remarked, a 
cutaneous eruption of the period of puberty and of the 
prime of life, appears to be connected with the full develop- 
ment of the capillary circulation of the surface of the 
body, which at these ages usually prevails; it is also pro- 
bably for the same reasons most frequently witnessed in 
individuals of the sanguine temperament, and when it 
occurs in others it is seemingly dependent on a naturally 
enlarged condition of the sebaceous follicles, the skin being 
then usually coarse, sallow, greasy, and shining. It is 
manifestly hereditary, and local heat, or anything which 
may determine to the surface, is a frequent exciting cause 
of the eruption in those constitutionally predisposed to it. 122 
PUSTULJ3. 
Acne rosacea is frequently connected with the state of the 
uterine function in the female, in many cases appearing 
for the first time at the turn of life ; it also occasionally, 
hut much more rarely, attacks the face of young girls 
about the period of first menstruation ; and when it does 
so, they are very liable to frequent returns of the eruption 
on the least exciting cause. It is also a constant accom- 
paniment of a deranged condition of the digestive organs, 
especially when attended with constipation; and in many 
persons is evidently caused by indulgence in the pleasures 
of the table, particularly a too free use of rich wines or of 
spirituous liquors. Prolonged or extreme mental excite- 
ment is also a frequent exciting cause of acne rosacea. An 
attack of either form may be suddenly produced by the sup- 
pression of any accustomed evacuation, such as that arising 
from bleeding hemorrhoids ; and they are very common at- 
tendants on pregnancy. 
Diagnosis.—The various forms of acne are in general re- 
cognizable without difficulty ; the parts of the cutaneous 
surface which they affect, the conoidal shape of the pustules 
with their hardened bases, and the accompanying altered 
condition of the sebaceous follicles, being sufficiently cha- 
racteristic of the disease. Secondary syphilitic eruptions 
may be confounded with acne indurata and acne rosacea, 
from which they are distinguished by their appearing on 
the extremities, where acne does not occur, at the same 
time that they affect the face and trunk ; by their present- 
ing a tubercular rather than a pustular character; and by 
the diseased surface being of a dull coppery color : the se- 
baceous follicles, too, are unaffected. The pustules of ec- 
thyma differ from those of acne in being larger and flatter, 
scattered over the cutaneous surface generally, especially 
that of the extremities, and in not having any hardened 
base. Acne indurata in some cases bears much resemblance 
to lupus, but the latter disease presents more of a tubercu- 
lar character, and is always attended with destructive ulcer- 
ation, either superficial, or attacking the deeper structures; 
in acne indurata, also, the rich crimson hue of the hyper- 
trophied skin, with the varicose condition of the superficial 
veins, and the spots of acne punctata scattered over the sur- 
rounding integument, arc highly characteristic. ACNE 
123 
Prognosis.—Acne simplex, though readily removable by 
treatment, unless when the pustules assume an indolent 
character, is very apt to return annually until after the age 
of 25 or 30, and persons who in their youth suffer from it 
are more liable than others to be affected in after-life with 
either of the other forms of the disease. Both acne rosacea 
and acne indurata are very obstinate and rebellious to treat- 
ment, in some cases seeming for years to defy all remedial 
measures. None of the forms tend in any way to shorten 
life, or to injure the general health. 
Treatment.—When acne simplex occurs on those parts 
of the body which are not ordinarily exposed, medical in- 
terference is scarcely needed; in persons of a sanguineous 
temperament and an active cutaneous circulation, saline 
cathartics, more especially the saline mineral waters—as 
those of Cheltenham, Leamington, Epsom, and Scarborough, 
in England; and of Seidlitz, Marienbad, Carlsbad, and 
Pullna, on the Continent—will be used with benefit; or, 
should the disease return in a very active form every spring, 
a general bleeding, practised just before the period of the 
expected appearance of the eruption, will, in strong young 
persons, of either sex, sometimes prevent its outbreak. 
When pustules of acne simplex form on the face, the sooner 
they are opened, and the curdy matter they contain pressed 
out of them, the more rapidly they disappear. In persons 
predisposed to the disease, the best preventive treatment 
consists in the use of carbonate of soda—twenty grains to 
the quart of soft water—instead of soap to wash the face, 
and in the application of a spirituous lotion, consisting of 
two drachms of oil of lemon and half a drachm of oil of 
rosemary in a pint of rectified spirit, immediately after the 
face is washed. In cases where there is much tendency to 
local inflammatory action, this lotion should be reduced in 
strength, by diluting it with twice or four times the quantity 
of elder-flower water. Should the eruption accompany or 
appear to depend on derangement of the menstrual function, 
the treatment should be directed to restore it to a healthy 
condition, either by the use of evacuants or of tonics, accord- 
ing to the indications in each case. When acne simplex is 
general over the regions of the body which it affects, warm 
baths every second or third day, accompanied by friction 124 
PUSTULJ3. 
with a flesh-brush, should there be obstruction of the seba- 
ceous follicles, will be found of much service; in chronic 
cases, when the pustules are indolent, and there is rather 
deficient than increased cutaneous capillary circulation, the 
use of sulphurous baths—more particularly those of the 
natural sulphurous waters, as of Lucan, near this city, of 
Ilarrowgate in England, of Moffat in Scotland, and of Eng- 
hien, of Aix-la-Chapelle, of Bareges, and of the Pyrenees, 
on the Continent—usually constitutes the most efficient plan 
of treatment. If it be possible to obtain the natural mine- 
ral waters for the baths, they may be artificially prepared 
by dissolving four ounces of sulphuret of potassium in thirty 
gallons of water. 
No remedial measures can possibly prove of service in the 
treatment of acne rosacea until the habits by which the dis- 
ease may have been occasioned are corrected, and in every 
case especial attention must be paid to the avoidance of all 
stimulating articles, both of food and drink, which occasion 
determination of blood to the face, such as rich meats, spices, 
spirituous and vinous drinks, &c., from the use of which the 
eruption is invariably augmented, if it had not been origin- 
ally produced thereby; heated rooms, exposure of the face 
to the fire, continued stooping of the head, and mental ex- 
citement or anxiety, must be equally guarded against. When 
acne rosacea is seen in its early stages, or where there is 
much inflammatory action present, the application of from 
four to six leeches behind the ears, twice or three times a 
week at bed-time, will be found of much service, and at the 
same time saline cathartics should be used daily, preceded 
by mild mercurials, if there be any biliary derangement. 
The saline cathartic mineral waters are here, as in acne sim- 
plex, of especial service; and of them all I have found the 
Pullna water—which is now very generally imported—the 
most beneficial ; it may be given in the dose of from one to 
two wine-glassfuls, mixed with an equal quantity of tepid 
water, every morning. When they cannot be procured, one 
drachm of the compound saline powder, prepared as I have 
directed in my work on Medicines,1 dissolved in half a pint 
of tepid water, may be substituted. The tendency to local 
1 Third edition, p. 107. ACNE 
125 
inflammation being thus subdued, slightly stimulating appli- 
cations may then be used, such as ointments of the ammonio- 
chloride or of the nitrate of mercury, of dried sulphate of 
iron, of the acetate of copper, &c. ; the employment of the 
first of these will be found equally beneficial; it may be 
prepared as follows :— 
R. Hydrargyri Ammonio-chloridi, . gr. xij.—3ss* 
Cerati Simplicis, ,?j. 
Glycerin®, fl 3j. 
Olei Amygdalae Amarse, . . . m. iij. Misce. 
The ointment should be smeared thickly over the affected part 
at night, and washed off in the morning with a weak spiritu- 
ous alkaline wash, containing not more than twelve grains 
of the carbonate of soda to the pint of liquid, to which from 
half an ounce to an ounce of glycerine should be added, if 
the skin be hard and dry and inclined to bleed. In every 
stage of acne rosacea the use of soaps should be carefully 
eschewed, as they are all more or less irritating; the bicar- 
bonate of soda may be substituted for them, and in the case of 
men who are compelled to shave, a saturated solution of it, 
mixed with an equal part of olive-oil, may be used. In chronic 
cases of the disease, preparations of iodine must be given 
internally ; two grains of the iodide of potassium, dissolved 
in two ounces of the decoction of fresh elm-bark, with the 
addition of a quarter of a grain of iodine when the disease is 
very obstinate, taken at bedtime, will be found perhaps the 
most efficacious form of administering this remedy. 
Should acne rosacea prove rebellious to these plans of 
treatment, the more active local medication proposed by some 
dermatologists may be tried; such as the application daily 
to each inflamed follicle of a small pledget of lint dipped in 
a concentrated solution of sulphuret of potassium, as pro- 
posed by M. Duchesne-Duparc,1 the contact being continued 
for from fifteen to twenty seconds : of a concentrated solu- 
tion of acetate of lead in white-wine vinegar, as recom- 
mended by M. Bretonneau ;2 or of a solution of two grains 
of the bicyanide of mercury in an ounce of distilled water, 
1 Nouvelle Prosop.algie: Paris, 1847, p. 69. 
2 Bulletin do Therapeutique, tome xxxi. p. 285. 126 
PUSTULE. 
washed off in a few moments after with cold water ; an appli- 
cation highly spoken of by Dr. Burgess.1 
When acne assumes the indurated character which has 
acquired for it that special denomination, it requires active 
treatment, both constitutionally and locally; blood may be 
removed by cupping from the nape of the neck to the extent 
of from two to four ounces once or twice a week, according 
to the youth and constitution of the patient, and daily pur- 
gation by active saline cathartics had recourse to; unless, 
which rarely occurs, the disease appears in an individual of 
a weak constitution, when preparations of iodine with iron 
will be found more beneficial. The best local application is 
the iodide of sulphur in the form of ointment, the strength of 
which may be gradually increased from fifteen grains to half 
a drachm to the ounce of lard. Alkaline washes should also 
be used as in acne rosacea, and change of air, with the inter- 
nal use of the sulphurous mineral waters, will be found of 
especial benefit. Blistering the face has been sometimes had 
recourse to, and it is said with success, in cases of acne in- 
durata which had resisted all other methods of treatment. 
Most of the lotions which are empirically employed in 
acne of the face consist of corrosive sublimate dissolved in 
bitter almond emulsion, in the proportion of from one to 
two grains to the ounce; their use for a short time is not 
unfrequently attended with benefit, but if continued long 
they cause the skin to become hard and scaly. 
IMPETIGO. 
Impetigo (Crusted tetter).—This term, like so many others 
applied to designate diseases of the skin, had no determinate 
signification previously to the time of Willan. It is now 
understood to indicate a cutaneous affection, characterized 
by the eruption of numerous psydracious pustules, occurring 
singly and distinct from each other, or in groups and con- 
fluent, with but little surrounding inflammation ; they matu- 
rate rapidly, and discharge a thick purulent matter, which 
dries into a semi-transparent, greenish-yellow, irregularly 
shaped, persistent, solid crust. From beneath this crust, 
1 Eruptions of the Face, Head, and Hands: London, 1849, p. 55. IMPETIGO. 
127 
■when formed, purulent matter continues to be secreted, often 
in considerable quantity, and the duration of the disease is 
thus usually prolonged for some time ; the crusts are slow in 
separating, and when they at length fall off, a red mark or 
stain is left on the integuments, which, however, gradually 
wears away. Fresh pustules are developed in successive 
crops around the region of the skin originally affected, and 
the disease thus spreads, until it not unfrequently involves 
an extended surface of the body, which becomes covered 
with the characteristic, pellucid, soft, greenish crust, and 
from beneath which purulent matter oozes; when the erup- 
tion has existed for some time, cracks and fissures form as 
in eczema, but they do not present the red color of that dis- 
ease, nor are they accompanied by the serous exudation so 
characteristic of it. Impetigo is a highly inflammatory erup- 
tion, and may run either an acute or chronic course: it is 
not contagious. 
M. Gendrin has carefully described the anatomical cha- 
racters of impetigo and its seat, having had an opportunity 
of examining it after death,—an opportunity which occurs 
with extreme rarity, as the disease does not prove fatal, and 
as inflammatory cutaneous eruptions generally disappear in 
the course of mortal diseases. The following is the account 
which he gives of the result of his observations: “ At the 
parts corresponding to the eruption, the skin was more ad- 
herent to the areolar tissue than elsewhere, nevertheless, 
there existed on the external surface of the derma but a 
slight degree of capillary injection. The cutaneous tissue 
was more dense than natural, and was of a reddish-yellow 
hue, but this morbid color only extended for a short way 
into the chorion. On the edges of a section made through 
the diseased skin, it could be observed that the small, red- 
dish, closely aggregated, but only slightly prominent granu- 
lations, which were situated beneath the crusts, were made 
up of minute grains about the size of the head of a pin, of a 
liquid and greenish-yellow, cheesy-like substance ; the sur- 
rounding cutaneous tissue was red, and matter similar to 
that which was secreted by the pustules of the eruption, and 
which, by drying, formed the crusts of the disease, oozed 
out of it when pressed between the fingers.”1 
1 Traits des Inflammations, tom. i. 128 
PUSTULE. 
The various forms of impetigo which have been described 
by dermatologists may, I think, be conveniently considered 
in two groups, named from the mode of development of the 
eruption. But as it presents certain peculiarities when it 
occurs on the scalp, which require to be specially noticed, I 
shall describe it under three heads:— 
Impetigo figurata. 
“ sparsa. 
“ capitis. 
Impetigo figurata (Atlas, PL VII. Fig. 1) is so named 
from the disease appearing in patches of a circular or ovoid 
shape. It usually sets in with feverish symptoms, which 
both precede and accompany the eruption, never severe, but 
generally well-marked, consisting in malaise, headache, loss 
of appetite, and occasionally slight shivering ; in children 
the symptoms amount only to some heat of the surface, and 
general uneasiness; but at times there are no premonitory 
signs noticeable, when the disease usually assumes rather a 
chronic character from the first. Small, rounded, slightly- 
elevated, red patches appear on the skin of the face,—where 
the disease is of most frequent occurrence,—of the trunk, 
the shoulders, the arms, the hands, or the thighs ; and on 
them psydracious pustules, closely set together, and more or 
less confluent, are rapidly developed, their appearance being 
preceded by much local heat and itching. The pustules 
attain their full magnitude, which rarely exceeds that of the 
head of a pin, in about forty-eight hours, when they burst 
and give exit to the contained purulent matter ; this, which 
is very liquid, dries quickly into a pale, greenish-yellow or 
citrine-colored, soft crust, of a pellucid aspect, and bearing 
much resemblance to candied honey, so much so that 
Alibert, from this characteristic, named the disease melitagra. 
The crust generally covers completely the original red patch ; 
it is very friable, and through cracks which form from the 
motion of the part on which it may be seated, an ichorous 
pus oozes; this, drying rapidly, adds to the volume of the 
first crust, until it often acquires a considerable thickness, 
still, however, retaining its semi-transparency, and kept 
constantly moist by the discharge from beneath. Should 
the crusts be removed or fall off, the surface on which they IMPETIGO. 
129 
were seated is seen to be raw, inflamed, and secreting pus, 
by which they are rapidly renewed. 
The original patches of the eruption, should there be more 
than one, may remain distinct from each other, separated 
by healthy integument during the whole progress of the 
disease, but more usually those which are near become con- 
fluent, the eruption spreading by the development of isolated 
pustules or of successive crops on the intervening sound 
skin. The crusts in the more acute cases remain attached 
to the surface for three or four weeks, during which time 
the discharge continues; they then gradually become drier, 
the secretion diminishes in quantity, and, unless successive 
crops of pustules appear, the disease terminates by their 
becoming detached in separate pieces as it were, a reddish- 
brown stain being left which is slow in disappearing ; and 
from which for some time an epidermic desquamation, ac- 
companied occasionally by a slight serous oozing, takes 
place, causing the eruption, as well remarked by Cazenave, 
to resemble somewhat eczema. Until the crusts commence 
to dry up and fall off, a constant heat and painful tingling 
in the affected parts attend the disease; these cause children 
and sometimes even adults, to tear the surface with their 
nails, and thereby aggravate the malady. 
In some cases of impetigo figurata the symptoms, both 
local and constitutional, are of a much more severe charac- 
ter than those now described. High fever marks the out- 
break of the eruption, which is characterized by active in- 
flammation that extends to the subcutaneous areolar tissue, 
and affects a considerable surface of the integument, which 
is red and much tumefied. In its commencement it can 
scarcely be distinguished from an attack of erysipelas,—and 
was therefore named by Willan and Bateman impetigo ery- 
sipelatodes (Atlas, PL VII. Fig. 3),—but on the second day 
the characteristic psydracious pustules appear on the in- 
flamed surface, when the disease runs the course above de- 
scribed, except that the local symptoms are throughout of 
much greater severity, the discharge especially being much 
more copious, and so acrid as to irritate, and cause the de- 
velopment of pustules on those parts of the unaffected skin 
over which it may flow; there is also more or less fever 
present to the end, and its duration is very prolonged. 130 
PUSTULES. 
Impetigo sparsa (Atlas, PI. VII. Fig. 2) differs, as its 
name indicates, from the preceding form in the arrangement 
of the pustules, which are developed individually, and scat- 
tered or dispersed over the cutaneous surface, sometimes 
pretty thickly on the legs, where it is of most frequent oc- 
currence ; but it may affect any part of the body, in chil- 
dren being often seen on the ears, the face and the neck. 
When the pustules in impetigo sparsa are numerous and 
closely set together, as usually happens on the folds of in- 
tegument in the neighborhood of the joints, although they 
may not coalesce, which they very rarely do, the intervening 
skin is inflamed, red, and slightly tumid, hot, painful, and 
tingling. The crusts which form present the same appear- 
ance as in impetigo figurata, but they are distinct on each 
pustule, or cover the site of two or three, rarely more, and 
are much thinner, softer and more easily detached. The 
development of the eruption is attended generally with some 
fever, and always with an extreme degree of burning heat, 
sometimes almost insupportable, which remains, but in a 
less degree, until the crusts are about to fall off; then it re- 
turns, if possible, even with greater intensity, and a second 
crop of pustules is developed in the neighborhood of and in 
the intervening spaces between the first. This is in like 
manner followed by a third or fourth crop, and thus the dis- 
ease becomes often very chronic, when the skin is hyper- 
trophied, fissured with red cracks caused by tearing with the 
nails, of a crimson tint, and discharging a thin, unhealthy, 
bloody pus, which dries into dark greenish-brown crusts, that 
at times envelope an entire limb like the bark of a tree ; 
when impetigo sparsa assumes this aggravated character it 
corresponds with the form described by Willan as impetigo 
scabida (Atlas, PI. VII. Fig. 4). The duration of this 
variety of the eruption is always much prolonged—acrid, 
ichorous matter, of a heavy, disagreeable odor being secreted 
from the surface beneath the crusts, which are very per- 
manent, and scattered pustules continuing to be developed 
in the neighborhood, often without any apparent fresh at- 
tack of local inflammation ; superficial ulcerations also form, 
and if the limbs are the parts affected they become more or 
less oedematous. 
Impetigo of either of the forms now described is very fre- IMPETIGO. 
131 
quenton the face of infants and young children, andbecoming 
chronic there presents these characteristics in their most ag- 
gravated form ; the features are completely changed, and 
the eruption covering them, as it were, with a mask, the dis- 
ease has been termed impetigo larvalis (Atlas, PI. VII. 
Fig- 5)* . 
Impetigo capitis (Atlas, PI. VII. Fig. 6) is the only pus- 
tular disease which appears exclusively on the scalp. Its 
occurrence in children is preceded for a few days by feverish 
symptoms frequently attended with vomiting; the surface 
of the scalp is hot and painful, and the part about to be 
affected presents an erythematous blush. The eruption 
makes its appearance either in distinct pustules of a psydra- 
cious character, scattered over the head, or in groups thickly 
set on an inflamed base. In the former case they are about 
the size of small peas both in circumference and elevation, 
and are attended with but little surrounding inflammation. 
On the second day of their appearance each pustule contains 
thick, yellow matter at the summit, but it is soon matured, 
when it bursts and gives exit to the contained pus, which 
rapidly dries into a greenish-yellow scab. This form, which 
to a certain extent corresponds with impetigo sparsa, termed 
by some dermatologists impetigo granulata, rarely assumes 
a chronic character, its continuance, when it has lasted for 
any time, being kept up by an eruption of fresh pustules on 
other parts of the scalp. It not unfrequently passes into 
the second form, which is characterized by the eruption 
occurring in groups of pustules. Their appearance is at- 
tended with more decided symptoms of inflammation both 
general and local, and the heat and itching are in many 
cases so severe that children tear the scalp and prevent the 
disease from presenting the truly pustular character of the 
first stage. The eruption usually commences on the fore- 
head, involving at the same time some of the hairy scalp; 
the inflamed patches vary in size and form in different cases; 
in some extending in their longest measurement not more 
than from half an inch to one or two inches, while in others 
the greatest part of the scalp is involved from the very 
commencement; in nearly every instance the skin bordering 
on the scalp is more or less engaged in the disease, and it 
often appears at the same time on the ears or on some part 132 
PUSTULE. 
of the face. The pustules are not so large as when they 
occur singly; their coats are apparently thinner, and the 
pus which they contain is not so consistent, and is of a 
richer yellow color. They usually become confluent before 
they burst, and the resulting greenish-yellow—if chronic, 
greenish-brown—scab is consequently much more extensive. 
When the eruption has continued for any length of time, 
large quantities of bright yellow pus are secreted beneath 
the greenish crust, which separate in cracks to give exit to 
the matter, exhibiting beneath the highly inflamed raw sur- 
face of the scalp from which the pus is secreted. 
In either form of impetigo the hair is unaltered; it is 
usually matted together by the purulent secretion and the 
scabs, but it does not fall off or become changed in appear- 
ance, even in the most chronic cases. 
Impetigo capitis is not contagious ; it is met with at all 
ages, but most generally in early infancy, lasting for several 
years if not properly treated ; it very rarely appears for the 
first time after the age of 9 or 10, but I have seen some 
instances in which the eruption occurred in advanced life ; 
in them the disease was of the form first described. 
In the chronic stage of the eruption small abscesses very 
frequently form at the nape of the neck, close to the roots 
of the hair; and some of the chain of lymphatic glands, 
which lies behind the sterno-mastoid muscle, become en- 
larged, swollen, and tender, but they very rarely suppurate. 
Bateman described a form of cutaneous eruption as a 
species of impetigo, terming it impetigo rodens, and in this 
he has been followed by Biett and Rayer; but the disease 
is evidently a lupoid ulceration of the scalp, and as such 
will consequently be considered in the group Cancrodes. 
Two other forms of the disease have been characterized by 
M. Devergie, as impetigo purifluens, and impetigo pilaris; 
the former is attended with profuse purulent secretion, and 
the latter affects those parts of the skin on which the hair 
grows, the pustules being frequently developed around indi- 
vidual hairs, which thus seem to penetrate them; these, 
however, are merely accidental circumstances, and neither 
can be admitted as sufficient to constitute a special variety 
of the eruption. The impetigo sycosiformis and impetigo IMPETIGO. 
133 
lupiformis of the same dermatologist are identical, the for- 
mer with sycosis and the latter with impetigo rodens. 
Causes.—Impetigo is of most frequent occurrence in 
infants and children; when it affects adults, appearing 
only in those who have a fine transparent skin, being there- 
fore more common in women than in men. In old persons 
it is usually seated on the lower extremities, especially the 
thighs; in them it is developed in the form of impetigo 
sparsa, and assumes a very obstinate character. The con- 
stitutional causes of the disease are more or less connected 
with the scrofulous diathesis, and in children of this 
temperament it commonly appears about the periods of 
first and second dentition, its eruption being excited then by 
the general perturbation of the system thereby occasioned. 
Anything which produces cutaneous capillary determination 
of blood acts as a cause of impetigo in those predisposed 
to it; thus its origin may be determined by irritants 
applied to the surface, such as washing in very hot water— 
a frequent cause in infants and children—the use of hard 
brushes or fine tooth-combs to the hair, stimulating soaps 
and cosmetics, and solar heat or that from a fire—the 
former accounts for the frequently witnessed recurrence of 
the disease in summer and autumn, and the latter for its 
appearance on the lower extremities of old persons. Pro- 
longed constipation and menstrual irregularities are both 
frequent exciting causes of impetigo in females. 
Diagnosis.—Impetigo is well characterized in all its 
forms by its truly pustular character, and by the peculiar 
semi-transparent, soft, greenish-yellow, honey-like appear- 
ance of its crusts. From eczema impetiginodes it is often 
with difficulty diagnosed, and both diseases seem frequently 
in their advanced stages to be precisely similar; yet the 
copious ichorous exudation—so well described by the French 
term, suintement—and the epidermic desquamation, are 
present usually in all forms of eczema, and in impetigo 
fresh psydracious pustules are in general being constantly 
developed in the neighborhood of the eruption. From 
ecthyma the disease is diagnosed by the small size of the 
pustules, those of ecthyma being phlyzacious, and for the 
most part scattered singly, or in twos or threes, over the 134 
PUSTULE. 
cutaneous surface, and the scab resulting from them is of a 
dull brownish yellow color: the parts usually affected are 
also different in the two eruptions. When pustules occur 
in scabies they are of a large size, and a conoidal shape, 
but that disease is especially distinguished from impetigo 
by the itching which accompanies it, burning heat, tingling 
and smarting, not itching, being present in the latter; the 
detection of the acarus scabiei, of course, renders the diag- 
nosis more precise, but it should be remembered that in 
some cases both diseases exist together on the same person. 
Sycosis, from its occurrence on the face, has been at times 
confounded with impetigo; but it invariably affects that 
part on which the beard grows and its immediate neigh- 
borhood, is not truly pustular, and the crusts which form 
in it are hard, dry, and of a brown color, and, if examined 
under a microscope, exhibit the characters of a vegetable 
parasite. 
As impetigo is the only pustular eruption which specially 
affects the scalp, it can scarcely be mistaken for any other 
eruptive disease that appears on this part of the cutaneous 
surface; the chronic form of eczema is that with which it 
is most likely to be confounded; in it the discharge, which 
is either serous or sero-purulent, dries into brownish-yellow 
scabs, through which the ichorous liquid forces its way, or 
into furfuraceous scales, while in impetigo the purulent dis- 
charge accretes into large, greenish-yellow crusts, by which 
the whole head, and even sometimes the forehead and part 
of the face, is in many cases covered as with a mask. 
Prognosis.—The only question here to be considered is 
the probable duration of the disease, as its existence, when 
uncomplicated, does not either injure the health or endanger 
life. In children, although apt to become chronic and 
obstinate if neglected, it usually yields quickly to judicious 
treatment, and when situated on the scalp is, in my experi- 
ence, more readily cured than any of the other eruptions 
peculiar to that region, if their relative duration previously 
to the employment of remedies be taken into account. It 
is in general more rebellious in adults, and when it affects 
the lower extremities in old persons is a most troublesome 
and obstinate disease, the form termed scabida by Willan 
not unfrequently lasting for years, notwithstanding the IMPETIGO. 
185 
most careful treatment, at one time showing signs of amend- 
ment, but to break out with increased severity again and 
again. In young persons even the eruption is very apt to 
return in the summer and autumn months after it has been 
apparently cured. At all ages the obstinacy of impetigo 
is in proportion to its previous duration. 
Treatment.—The acute stages of impetigo occurring in 
young persons of robust constitution require rather active 
antiphlogistic treatment, the daily use of saline cathartics, 
and local, or even in some cases general bleeding; the local 
abstraction of blood should be by leeches applied in the 
neighborhood of the eruption, or behind the ears when it 
is situated on the face or scalp. When the disease, how- 
ever, attacks the old or debilitated, bleeding is very rarely 
admissible, but should it be requisite in consequence of the 
inflammatory symptoms running high with much heat and 
tumefaction of the part affected, a few leeches only should 
be applied, and the after-bleeding from the bites not allowed 
to continue ; tonics are here more generally indicated, and 
the use of preparations of iron, combined with vegetable 
tonics and saline purgatives, as somewhat in the following 
form, will be found highly beneficial:— 
R. Tincturse Ferri Sesquichloridi . . fl 3ss. 
Infusi Quassiae fl Ixviij. 
Tincturse Calumbae 11 
Magnesite Sulphatis 3ij. Misce. 
“A wine-glassful to be taken every morning.” 
In children or adults of the scrofulous diathesis, cod-liver 
oil is the best tonic, and if the eruption is attended with 
scrofulous enlargement of the glands of the neck, from a 
sixteenth to a fourth of a grain of iodine may be dissolved 
in each dose of the oil, which should not exceed a dessert- 
spoonful three times a day for children, or a table-spoonful 
for adults; as when given in large doses the local disease is 
apt to be aggravated, apparently from its over-stimulating 
action on the system. 
In the chronic stages of the eruption, the administration 
of more decidedly alterative medicines is requisite, and a 
mild mercurial course is often singularly efficacious, especially 136 
PUSTULE. 
when the mercury is combined with iodine and alkalies. 
With this view the green iodide of mercury may be given 
in the following form for adults, a proportionately smaller 
dose being prescribed for children:— 
R. Iodidi Hydrargyri Yiridis . . . . gr. iv. 
Hydrargyri cum Creta gr. xij. 
Carbonatis Sod® Siccati . . . . gr. xij. 
Pulveris Myrrh® gr. vj. 
Mucilaginis, quantum sufficit, ut fiant pilulae duodecim. 
“ One to be taken three times daily.” 
In the more obstinate cases, some practitioners recom- 
mend the employment of sulphurous preparations, espe- 
cially in the form of the sulphur mineral waters; and others 
have recourse to the use of arsenic; of the latter, the pre- 
parations most suited for this disease are the arseniates of 
ammonia and of soda, the dose of either is from the twen- 
tieth to the tenth of a grain ; they may be given in decoction 
of dulcamara. 
In the impetigo of infants and of very young children, 
hut little constitutional treatment is necessary: for infants 
at the breast, should the eruption exhibit a tendency to 
assume a chronic character, it will he advisable to change 
the nurse ; and when the disease appears at the periods of 
dentition, the gums should be freely lanced. The state of 
the digestive organs must in all cases be strictly attended 
to, and mild purgatives, combined with alkalies, adminis- 
tered according to circumstances. The alkaline treatment 
is at this age of especial service: for children of a full habit 
of body the bicarbonate of soda may be prescribed in doses 
of from three to five grains, three times daily, in half a 
drachm of syrup of orange-peel and two drachms of orange- 
flower water, and for those of a weak or debilitated con- 
stitution, from one to three grains of the bicarbonate of 
ammonia in the same menstruum. Should diarrhoea, or 
symptoms of any derangement of the brain accompany the 
eruption of impetigo, we should be most careful not to check 
the disease too suddenly, more especially if it is attended 
with much discharge. IMPETIGO. 
137 
The local treatment of impetigo is of even more import- 
ance than the constitutional, for upon its judicious appli- 
cation, in the first instance, most frequently depends the 
duration of the disease. It is especially necessary to keep 
constantly in view that the eruption is of an inflammatory 
nature, and that even in its most chronic stages a fresh out- 
break of inflammation, attended with the development of a 
new crop of pustules, may be readily excited. The very 
production of the disease in so many cases by the direct in- 
fluence of irritants sufficiently proves this, and should warn 
against the use of irritating applications, which have been 
often too indiscriminately recommended. In the acute 
stages, no matter on what part of the cutaneous surface 
the eruption may occur, alkaline ointments are of especial 
service; and should there be much local tingling and irri- 
tation, chloroform will be beneficially combined with them, as 
in the following form :— 
R. Sodse Bicarbonatis, gr. xx. 
Adipis praeparati, 3j* 
Chloroformi, m. iv. Misce. 
This ointment should be smeared pretty thickly over the 
pustules night and morning, the surface having been pre- 
viously washed with equal parts of new milk and tepid water. 
To allay the irritation, unguents and washes, containing 
various preparations of lead, oxide of zinc, and of prussic 
acid, are recommended by different dermatologists, but I 
have found none of them so useful as the above. Owing to 
the moisture from the purulent discharge which is so con- 
stantly present in impetigo, the addition of glycerine to the 
local applications, so far from being attended with benefit, 
usually proves injurious. 
In the chronic forms of the eruption, the crusts or scabs 
should be always removed carefully before the use of medi- 
cated applications; this is done most effectually by the em- 
ployment of linseed-meal poultices,—wet with the weak lead- 
wash (see page 74) wThen any tendency to local inflammation 
is present,—changed twice in the twenty-four hours; the 
parts being sponged with a warmed solution of half-a-drachm 
of carbonate of soda in a pint of distilled water each time 138 
PUSTULE. 
the poultice is changed. The alkaline ointment above de- 
scribed may then be used; or, should the disease be very 
chronic, an ointment of the dried sulphate of iron, in the 
proportion of from two to five grains to the ounce of cerate, 
employed; this preparation even occasionally proves too 
stimulant, when the acetate of zinc cerate should be em- 
ployed instead of it. In some cases of impetigo greasy 
applications are found to aggravate the local symptoms, and 
then lotions should be substituted for them, such as twelve 
grains of the acetate of zinc, or six grains of the acetate of 
lead, or four grains of either the sulphate of copper or the 
sulphate of iron, dissolved in eight fluid ounces of elder- 
flower or of rose-water. 
To the use of more active local stimulants, as ointments, 
baths or washes of the sulphuret of potassium, of tar, of 
anthrakokali, of fuligokali of the huile de cade, or of caus- 
tics as the nitrate of silver, my experience is decidedly op- 
posed ; as I have generally seen their application excite an 
outbreak of inflammation, and the consequent spread of the 
disease by the development of additional pustules. 
When impetigo affects the scalp, the hair should always 
be carefully cut close, and the crusts removed by the appli- 
cation of poultices and the use of alkaline washes, as above 
directed ; afterwards the ointment of the bicarbonate of soda, 
and a lotion of milk and tepid water, will be employed with 
benefit; the green iodide of mercury, with the hydrargyrum 
cum creta, and the dried carbonate of soda, should be given 
internally. This plan of treatment seldom fails to cure the 
disease, even in the most chronic forms, in from six weeks 
to three months, provided there is a careful attendant to 
carry out strictly the employment of the local remedies. 
In any case the hair should not be permitted to grow for 
some time after all traces of the eruption have disappeared. 
Dietetic and hygienic regulations are of much importance 
in the treatment of impetigo, particularly of its chronic 
forms ; all heating and stimulating articles of food ought to 
be strictly prohibited, and everything which could cause de- 
termination of blood to the surface of the body carefully 
avoided. In children, the use of a purely milk and fari- 
naceous diet will be found to expedite the cure much. ECTHYMA. 
139 
ECTHYMA. 
Ecthyma (Papulous scall) consists in the eruption of 
phlyzacious pustules, on a hardened, more or less inflamed 
base, usually isolated, but occasionally in small patches, 
terminating in yellowish-brown scabs or crusts—in very 
chronic cases, of a livid hue—which, as they fall off, leave 
small ulcers that heal with superficial cicatrices. When 
this cutaneous disease attacks the young and the robust, it 
is of an inflammatory character, but in the old and debili- 
tated it assumes from the first an asthenic type : in both it 
is non-contagious. In children it is rarely met with, still 
more rarely in infants, occurring most frequently in old per- 
sons and in adults. The pustules may appear on any part 
of the cutaneous surface, but they chiefly affect the extre- 
mities, especially the thighs; they appear with the next 
degree of frequency on the skin of the trunk of the body or 
on the neck, being but seldom witnessed on the face or the 
hairy scalp. 
The division of ecthymain to varieties, as made by Willan, 
and those dermatologists who have adopted his views, de- 
pended either upon the age of the patient or upon accidental 
phenomena, having their origin in the constitution of the 
individual attacked. This being manifestly a bad founda- 
tion for a classification, though one not uncommonly fol- 
lowed as regards cutaneous eruptions, is now almost univer- 
sally abandoned, and but two forms of the disease are de- 
scribed by most modern writers : these I shall adopt:— 
Ecthyma acutum. 
“ chronicum. 
The eruption of Acute ecthyma (Atlas, PL VIII. Fig. 1) 
is preceded by some degree of fever, usually very slight, 
amounting merely to heat of the surface, thirst, and head- 
ache ; in about thirty-six hours afterwards, small, rounded, 
slightly elevated red spots appear on the skin, generally of 
one or both of the lower extremities, their appearance being 
preceded and accompanied by heat and sharp tingling of the 
parts about to be affected, the constitutional symptoms at 
the same time subsiding. These spots, which are nearly the 140 
PUSTULE. 
size of a large pea, and few in number, are scattered over 
the cutaneous surface distinct from each other, the interven- 
ing skin being healthy ; on the second day of their develop- 
ment the centres are raised by purulent effusion, which, 
increasing rapidly, covers within twelve hours the entire of 
each inflamed spot, thus forming the characteristic phlyza- 
cious pustule of the disease, surrounded by a narrow, in- 
flamed areola, and situated on a hardened base; occasionally 
two or three of the pustules, from being developed close to 
each other become confluent, and not unfrequently a few 
psydracious pustules form in the neighborhood, being evi- 
dently produced bjr an intensity of the local inflammation. 
This stage of the eruption is attended almost invariably 
with severe lancinating pain and a burning sensation, both 
of which are much diminished, sometimes cease completely, 
on the maturation of the pustules. The maturation takes 
place from the fourth to the sixth day, the epidermic cover- 
ing giving way and the contained pus being effused; a 
brownish-yellow crust or scab, occupying the site of the pus- 
tule, then forms rapidly, and if it be removed, a cup-shaped 
ulcer, with hard edges, will be brought into view. The 
scabs, if not interfered with, fall off sometimes in a few days, 
but they often do not separate for two or three weeks, and 
a small depression, like the pit resulting from small-pox, 
marks the site of each pustule. It occasionally happens 
that purulent matter does not form in some of the red spots, 
and they terminate in resolution, a reddish-brown stain, 
accompanied by epidermic desquamation, remaining for some 
time afterwards. 
The acute form of the disease thus terminates usually in 
from a fortnight to three weeks, but its duration is not un- 
frequently prolonged for five or six weeks by the develop- 
ment of successive crops of pustules, each crop running an 
independent course. The usual seat of this form of the 
eruption, as already remarked, is on the lower extremities, 
but it also appears on the shoulders, the chest, the neck, 
the arms, and the palms of the hands, and in a few rare 
cases on the face and scalp. 
Ecthyma chronicum (Atlas, PL VIII. Fig. 2) is a not 
uncommon eruptive disease in debilitated constitutions at 
every age, occurring much more frequently than the acute ECTHYMA. 
141 
form ; it often attacks unhealthy infants and young chil- 
dren, and from its frequency at the very early periods of 
life, it was described by Willan as then constituting a dis- 
tinct variety, and termed by him ecthyma infantile. The 
eruption appears as in the acute form, but there are no pre- 
ceding or accompanying febrile symptoms, and the local 
suffering is much less—diminished, not increased, vital ac- 
tion characterizing it. The pustules are generally diffused 
over the surface, being rarely confined to any special region, 
and occur isolated, or in patches of two or three ; they ex- 
hibit a very indolent progress, maturate slowly, and form 
hard, dry, brownish crusts, which either adhere firmly, or, 
falling off in a few days, leave a superficially excavated 
unhealthy ulcer, that discharges a bloody purulent secretion. 
The matter by which some or all of the pustules are dis- 
tended in old persons is often sanguinolent, and the subcu- 
taneous areolar tissue infiltrated so as to constitute a promi- 
nent, hardened base, of a lurid or dingy-violet aspect, to 
each pustule ; these characters induced Willan to regard 
the eruption then as a distinct variety, and to name it ec- 
thyma luridum. The chronic character of the disease, as 
regards duration, is due to the continued development, in 
constant succession, of the pustules, until at length the in- 
teguments of almost the entire body are involved in the 
eruption ; the cutaneous surface then presents a most un- 
healthy aspect, large portions of it being covered with phly- 
zacious pustules in their various stages of development, hard, 
dark-browm scabs, superficial ulcers discharging unhealthy 
matter, and livid stains, the marks of spots that had healed. 
The constitution now, in most cases, sympathizes; in old 
persons extreme debility occurs, and dropsical effusion takes 
place; and the disease in this, its most aggravated form, 
well deserves the name applied to it by Willan—ecthyma 
caehecticum. 
Ecthyma chronicum lasts generally for four, five, or six 
months, or even longer, being often complicated in its ad- 
vanced stages with prurigo, scabies, or chronic lichen, and 
being a frequent attendant on chronic organic diseases in 
old persons ; although it spreads to all parts of the cutaneous 
surface, it is most thickly disseminated over the limbs, and 
least so on the face or scalp. 142 
PUSTULE. 
Either form may appear at any age, hut the acute is most 
common in adults, the chronic affecting chiefly the very 
young and the aged ; it attacks both sexes, but after the age 
of puberty males are more liable to the disease than females. 
The causes of ecthyma are both constitutional and topical. 
The former are usually what may be termed hygienic and 
dietetic; thus residents in damp, ill-ventilated habitations, 
insufficient clothing, want of due attention to cleanliness, 
unwholesome food, habits of dissipation, &c., produce a state 
of the system in which the disease is often developed ; and 
the direct action of substances which irritate the skin con- 
stitute the latter. Its association with chronic visceral 
disease has been noticed above ; it is also a not uncommon 
sequela of acute febrile disease, more particularly typhus 
fever and dysentery. 
Diagnosis.—Ecthyma is in general readily recognizable by 
the phlgzacious character of the pustules, and the isolated 
manner in which they are developed. It might be con- 
founded with either acne or impetigo, but the characters by 
which it is distinguished from these eruptions have been 
already described when treating of them. The smaller-sized 
pustules bear some resemblance to those of modified small- 
pox, but the mode of eruption of that disease, its appear- 
ance first on the face and upper part of the body, and the 
accompanying fever, are sufficiently diagnostic marks. The 
pustules of secondary syphilis are, in many cases, very 
similar to those of ecthyma, and are with much difficulty 
diagnosed from the lurid form of the disease; the latter, 
however, occurs seldom except in very old persons, and the 
presence of the usual concomitant affections of the throat 
and of the bones in secondary syphilis, together with the 
antecedent history of the case, marks the cutaneous affec- 
tions produced by the venereal poison. 
Prognosis.—When uncomplicated, ecthyma is not a disease 
dangerous to life, the chronic form of the eruption is always 
of prolonged duration, and by its continuance the general 
health is more or less injured. 
Treatment.—In the acute stages of this eruption any in- 
flammatory symptoms that may exist should be subdued by 
the use of diluents and diaphoretics ; minute doses of tartar 
emetic dissolved in whey, in the proportion of half-a-grain ECTHYMA. 
143 
to the pint, will be found a useful form, and the solution 
may be made to constitute the ordinary drink of the patient; 
or the water of the acetate of ammonia may be given in de- 
coction of barley sweetened with sugar, and flavored with 
lemon-juice. The state of the bowels requires careful at- 
tention, and the secretions, if unhealthy, should be regulated 
by the administration of mild mercurial purgatives, com- 
bined with the extract of taraxacum and of colchicum, but 
active purgation is contra-indicated. The only topical 
remedy requisite is the tepid hath, and from half-a-pound to 
a pound of gelatine should be dissolved in each bath if there 
is much local irritation ; occasionally, in persons of a full 
habit of body, a few leeches will be applied with benefit in 
the neighborhood of the eruption. 
The first requisite in the treatment of chronic ecthyma 
is to remove those causes by which the state of the system 
with which it is so frequently connected has been produced. 
In infants, the nurse should if possible be changed, or, if 
this cannot be done, the child ought to be weaned, and fed 
chiefly on asses’ or goats’ milk, mild alteratives, as the hy- 
drargyrum cum creta, combined with myrrh and dried car- 
bonate of soda, given, and the body warmly clad, but woollen 
clothing, as being apt to irritate, should not be worn next 
the skin. The best local application is calamine ointment, 
or the affected parts may be dusted with finely-powdered 
lapis calaminaris; emollient cataplasms or lotions generally 
aggravate the disease. When the eruption appears in old 
persons, the first and most important point is to change the 
air, or at least the locality in which the patient may have 
been residing: good and nourishing food should be given, 
and if there is much debility, wine or porter allowed. 
Should there exist any visceral organic disease, the line of 
treatment must be directed principally to its alleviation if 
possible, and topical applications employed with caution, as 
the sudden repulsion of the eruption would be likely not 
alone to aggravate it, but might be dangerous to life. 
Tonics, combined with alkalies and sedatives, as in the fol- 
lowing form, will in general be found useful :— 144 
PUSTULE. 
R. Infusi Cinchonse, fl svj. 
Aquoe Calcis, fl Sixss. 
Tincturse Lupulime, 
Succi Conii, aa, fl 3\j* Misce. 
“ A wine-glassful to be taken three times a day.” 
When, however, there is much debility present, alkalies 
should not be given, but the mineral acids, either the nitric 
or hydrochloric, will then be advantageously prescribed in 
combination with vegetable tonics ; in the lurid form of the 
eruption, preparations of iron, more particularly the com- 
pound or aromatic iron mixture, generally prove most effica- 
cious. For local applications many astringent and mildly 
stimulating ointments may be employed ; a form that I have 
seen productive of excellent effect consists in the addition of 
half a drachm of oil of turpentine to the compound lead- 
cerate. This should be wTarmed and applied in the semi- 
fluid state, being gently smeared over the surface with a 
feather. The ulcers which form may be touched daily with 
the solution of nitrate of silver—a scruple to the ounce, or 
dressed with lotions of sulphate of copper or sulphate of iron 
—from two to five grains to the ounce of distilled water. 
In all forms of ecthyma the patient should be kept in the 
open air as much as possible, if extreme debility or accom- 
panying organic disease does not prevent it. During con- 
valescence, exposure to the sea air, and the use of the 
chalybeate mineral water for adults, will be found of especial 
service in promoting the restoration of health, and prevent- 
ing a relapse ; and for scrofulous children, the employment 
of cod-liver oil should not be omitted. a PAPULAE. 
145 
CHAPTER Y. 
PAPULJ3. 
This group of cutaneous diseases is characterized by the 
eruption of minute solid elevations of the skin,—papulse or 
pimples,—generally reddish, but sometimes of the natural 
color of the part or even paler, which contain neither serum 
nor pus, terminate in the desquamation of fine scales, and 
are almost invariably attended with intolerable itching. The 
latter symptom is so markedly a characteristic of papular 
eruption that it has induced Cazenave to place them in a sub- 
division of his sixth group, the definition of which that he 
gives being “ general or local hypersesthesia.” By Erasmus 
Wilson they are made to constitute a group, “styled de- 
positive inflammation of the dermabut inasmuch as some 
forms of papular diseases are not in any of their stages ac- 
companied or marked by inflammatory action, and their 
treatment is based on indications directly opposed to the 
idea of inflammation having any share in their production, 
his definition is not, I think, sufficiently precise for a natural 
system of classification. 
Papular eruptions are non-contagious, occur at all ages 
and in both sexes, and affect males more frequently than 
females. The papulae, which are either disseminated and 
distinct from each other, or aggregated in patches so as to 
form groups, may appear on a single region of the body 
only, or may be diffused generally over the skin; they vary 
in size from that of the head of a small pin to that of a pea, 
and are usually developed rapidly, generally coming out in 
successive crops. They terminate in resolution, with des- 
quamation of the epidermis in fine minute scales, which 
continue for some time; but occasionally superficial ulcera- 
tion of the integuments occurs. 
By most dermatologists three forms of cutaneous disease, 
characterized by papular eruptions, are described as origi- 
nally arranged by Willan, namely, Lichen, Strophulus, and 
Prurigo: but the first two are manifestly merely varieties 146 
PAPULA3. 
of the same affection, their characteristic phenomena are 
precisely similar, and the only difference between them is 
that the former occurs in infancy and childhood, and the 
latter at a more advanced age; I shall, therefore, follow the 
example of Ilayer, Gilbert, Cazenave, &c., and speaking of 
strophulus as a species of lichen, reduce the number of 
papular diseases to two, namely, Lichen and Prurigo. 
LICHEN. 
Lichen—including strophulus—may be defined to consist 
in the development of numerous minute papulae of the color 
of the skin or of a reddish hue, aggregated in patches or 
disseminated over the cutaneous surface, attended with heat, 
tingling, or even severe itching, and terminating in super- 
ficial ulceration or in epidermic desquamation. A great 
number of forms, both of lichen and of strophulus, have 
been described by Willan and other writers on diseases of 
the skin, and named by them either from the shape, as re- 
gards distribution, which the eruption assumes, from the 
color of the papulae, from some of the attendant symptoms, 
from the particular structure of the portion of the integu- 
ment, anatomically considered, that may be affected, and 
from the mildness or severity of the disease. Thus there 
have been constituted no less than nine varieties of lichen, 
and five of strophulus ; they may, however, I consider, be 
all conveniently considered in three divisions :— 
Lichen simplex. 
“ strophulus. 
“ agrius. 
Lichen simplex (Atlas, PI. VIII. Fig. 3) is at its out- 
break very rarely attended with any constitutional disturb- 
ance, in some cases slight febrile symptoms for a few days 
precede the eruption, especially in females, but they seldom 
amount to more than a feeling of malaise, which disappears 
immediately on the development of the papulae. These are 
minute, very numerous, not exceeding in size rape-seed, of 
a bright red color, and irregularly scattered in patches 
closely set together over the cutaneous surface ; they usually LICHEN. 
147 
appear first on the upper extremities, and extend thence to 
the trunk and lower extremities, being preceded by formica- 
tion of the part on which they are about to occur. The 
eruption is attended with heat and sharp tingling, which 
lasts until all trace of the papulae has disappeared ; in some 
cases, especially in young plethoric persons, the local in- 
flammation runs high, when the whole of the integuments 
of the affected parts present a bright scarlet color, accom- 
panied by a sense of tension and an extreme degree of 
itching. Lichen simplex may be either acute or chronic ; 
in the former case the duration of the disease is for about a 
fortnight, the individual papulae are resolved in seven or 
eight days, but as from forty-eight to seventy-two hours 
elapse between their development on the different regions of 
the body which they attack, it is prolonged for this time. 
In the chronic form successive crops of papulae make their 
appearance as quickly as those which preceded them fade 
away, and thus the disease may be continued for months, or 
even years. The papulae in either case run the same course, 
attaining their greatest size on the third day, at which time 
they are markedly acuminate; they then seem to remain 
stationary for two or three days more, when they fade some- 
what, are less prominent, and a minute scale appears on the 
apex of each; this desquamates, and a general epidermic 
desquamation from the affected surface continues for three 
or four days in the acute, and for a longer period in the 
more chronic cases. In the latter, the skin after a short 
time becomes thickened, evidently from depositive inflamma- 
tion, and the diseased integument is then elevated above the 
level of the surrounding skin. 
In lichen simplex the papulae differ in size according to 
the region of the body on which they may occur, being 
always larger on those parts where the skin is softest, as 
on the face, the shoulders, and the anterior surface of the 
trunk. In the debilitated, in the aged, and in those whose 
skin is naturally of a dark or unhealthy aspect, the eruption 
is usually of a dull, livid hue, and in the former is not un- 
frequently complicated with crimson blotches, or stains of 
the integument; this form was distinctly described by Willan 
under the appellation of lichen lividus. In another variety, 148 
PAPULA3. 
which occurs usually in persons of dissipated habits, as 
noticed by this dermatologist, each papula in its origin en- 
velopes a hair, so that when arrived at its full maturation it 
presents a singular appearance, seeming to be pierced there- 
by ; he consequently termed the eruption, under the circum- 
stances, lichen pilaris ; it is always a very obstinate form, 
assuming from the first a chronic character. 
Occasionally in lichen simplex the papulae, instead of 
being dispersed over the cutaneous surface, are developed 
in regularly-shaped patches ; when these are circular or oval 
the circumference is constituted of much larger papulae than 
the centre, so that a distinct border to each patch is thereby 
formed ; this variety has been termed lichen circumscriptus 
(Atlas, PL VIII. Fig. 4); it is of a chronic character ; the 
rings enlarge somewhat by the eruption of new papulae at 
their circumference, but its duration is rather prolonged by 
the development of successive patches in their neighbor- 
hood, as those which first appeared commence to fade. The 
usual seat of lichen circumscriptus is on the backs of the 
hands,the fore-arms, the cheeks, and the trunk of the body; 
when but one patch of it exists at a time on the surface, it 
has been termed lichen solitarius (Atlas, PI. VIII. Fig. 5). 
In a few rare cases, as first noticed by Biett, the eruption 
of papulae assumes the appearance, as it were, of a piece of 
ribbon stretched on the skin, generally commencing on the 
chest, and passing around the arm; he named this form, 
lichen gyratus (Atlas, PL VIII. Fig. 6). I do not know 
that it has been observed by any British or German physi- 
cian, but it is noticed as having been witnessed by several 
French dermatologists. 
In children and young persons, especially of the female 
sex, the itching is at times most extreme, and the papulae 
are of a much larger size than usual; they are, moreover, 
occasionally to a certain degree evanescent—thus in most of 
their phenomena resembling urticaria, and the eruption, too, 
appears, as in that disease, in small patches. It is, how- 
ever, distinctly papular, and has been well denominated 
lichen urticatus. It usually occurs on the neck and side of 
the face, spreading in a few cases to the chest and abdomen; 
is of an acute character, seldom lasting longer than a few LICHEN". 
149 
weeks, and is in general witnessed only in spring and sum- 
mer. 
Lichen strophulus (Gfum).—This is a papular eruption 
peculiar to the early periods of life, being rarely seen ex- 
cept in infants at the breast, and occurring most frequently 
a few days after birth. The papulae are of the natural 
color of the skin, of a reddish or crimson hue, or white ; 
they appear most frequently on the face and upper extrem- 
ities, but they also in some cases affect the body and the 
lower extremities. In one form, which has been termed 
strophulus intertinctus (Atlas, PI. IX. Fig. 1), popularly 
known as red gum, an eruption of very minute red papulae 
appears, generally a few days after birth, on the face and 
the backs of the hands and arms; they are scattered over 
the surface, and intermingled with them are small erythema- 
tous patches ; for two or three days their color becomes 
more vivid, they then gradually fade away and disappear in 
from a week to ten days, with some slight epidermic desqua- 
mation. Smart itching would seem to accompany the erup- 
tion from the uneasiness the infant exhibits. 
When lichen strophulus appears on the skin at the time 
the child is commencing to suffer from the irritation atten- 
dant on teething, the papulae, being still of a red color, are 
much smaller and of a duller hue than in the last-described 
variety, but more numerous, and aggregated together in 
semi-confluent patches on the face, the chest, the upper 
extremities, and often also on the abdomen and legs. The 
eruption is then denominated strophulus confertus, and popu- 
larly known as tooth-rash ; it runs a somewhat similar course, 
though a little more prolonged than strophulus intertinctus, 
and not unfrequently, more especially if the child suffers 
much from teething, a fresh outbreak of the rash takes place 
as the first is fading away. In some cases, the local and 
constitutional inflammatory symptoms are tolerably intense, 
when the patches of papulae are of a bright red color, and 
less disseminated, occurring in clusters, of not more than 
from five to ten or twelve, developed successively on various 
regions of the body, as they fade from one, appear on ano- 
ther. This variety of the disease, which is rather uncom- 150 
PAPULjE. 
mon, has been termed strophulus volaticus—wild-fire rasli; 
it is often of tolerably long duration. 
The papulae in lichen strophulus are, as has been before 
mentioned, occasionally of the color of the skin, or even 
whiter, and under such circumstances have been regarded as 
characterizing a distinct variety of the disease—white gum ; 
of it two forms have been noticed: one,—strophulus Can- 
didas (Atlas, PI. IX. Fig 2)—in which the papulae are of 
tolerable magnitude, not surrounded by a red areola, and 
generally disseminated over the cutaneous surface, but at a 
distance from each other; and the other—strophulus albi- 
dus—in which they are of small size, and occur in a few 
patches, each patch having a red border; in the former case 
they are usually distributed on the neck, the shoulders, the 
arms, and the lumbar region; in the latter, on the face, the 
neck, and the chest. Both are attended, apparently, with 
much itching, but no constitutional disturbance, and seldom 
last longer than for a few weeks. 
Lichen agrius (Atlas, PI. IX. Fig. 3) is occasionally a 
sequence of lichen simplex, but more frequently presents its 
peculiar phenomena from the first. In the latter case its 
occurrence is preceded for two or three days by smart febrile 
symptoms, and a remarkable burning heat and redness of the 
skin, so much so as at times to lead to the apprehension 
that scarlatina is about to set in; the fever abates consid- 
erably, or altogether subsides on the appearance of the rash, 
which is developed in the form of numerous bright red, mi- 
nute, acuminated, shining papules, clustered together on an 
uncircumscribed inflamed patch of the skin, often of con- 
siderable extent. The papules do not enlarge in size, but 
become more elevated from lymph being effused at their 
base into the subcutaneous areolar tissue, which is in conse- 
quence swollen and hard. An extreme degree of painful 
pruritus attends the development of the eruption, and is con- 
stantly present during the entire of its course, compelling 
the patient to rub and tear the skin; the itching, which is 
incessant, is much augmented by anything which increases 
the heat of the surface, especially the warmth of the bed, 
and thus renders rest or sleep in bed almost impossible. As 
the disease advances, the papules ulcerate at their apex, and LICHEN. 
151 
give exit to a sanious ichor, which concretes into thin, fria- 
ble, yellowish scabs: the skin becomes more and more in- 
flamed, thicker, dry, and rugose, and eczematous vesicles 
and pustules of acne or impetigo appear, mingled with the 
lichenous eruption, or, owing to the intense degree of local 
inflammation, are developed on the surrounding integument. 
In this extreme form of the eruption, the skin presents an 
hypertrophied aspect, is of a dark livid color, uneven on 
the surface, rugose, and fissured, and discharges a copious 
serosity. 
In the comparatively milder cases of lichen agrius, the 
eruption commences to fade about the tenth or twelfth day, 
the subcutaneous effusion is absorbed, the local irritation 
diminishes, and the disease terminates in from a fortnight 
to three weeks with epidermic desquamation. More usually, 
however, its duration is prolonged for six weeks or three 
months, even in cases not at all aggravated, and it not 
unfrequently lasts four years, with occasional remissions 
during cold weather. 
This form of lichen especially affects certain regions of 
the body, more particularly the face, where its most usual 
seat is on the forehead, and the backs of the hands and 
fingers (Atlas, PI. IX. Fig. 4); when it occurs on the face, 
the swelling of the integuments is usually much greater than 
when it attacks other regions of the body; the features, 
presenting a tuberculated aspect, are completely altered in 
expression, and the eyes are sometimes almost entirely 
closed from the thickening of the upper eyelid. On the 
backs of the hands and fingers the eruption is in general 
attended with much discharge, and in some cases complicates 
scabies, when it causes an extreme degree of suffering. 
Heat seems to have a peculiar influence both in producing 
and aggravating lichen agrius ; it is thus not unfrequently 
developed in hot summer weather in this country in persons 
predisposed to skin diseases; but it is in warm climates 
that this influence is especially witnessed, and the eruption 
is consequently so frequent there that it has been regarded 
as constituting a distinct variety, termed lichen tropicus— 
the prickly-heat of the East Indies. The following graphic 
description of the eruption, which is especially interesting 
as embodying his personal experience of it, is from the pen 152 
PAPULAE. 
of the late Dr. James Johnson. “ Among the primary 
effects of a hot climate may he noticed the prickly-heat, a 
very troublesome visitor, which few Europeans escape. It 
is one of the miseries of a tropical life, and a most un- 
manageable one it is. From mosquitoes, cock-roaches, ants, 
and the numerous other tribes of depredators on our per- 
sonal property, we have some defence by night, and in 
general a respite by day; but this unwelcome guest assails 
us at all, and particularly the most unseasonable hours. 
Many a time I have been forced to spring from table, and 
abandon the repast which I had scarcely touched, to writhe 
about in the open air for a quarter of an hour: and often 
have I returned to the charge with no better success against 
my ignoble opponent! The night affords no asylum. For 
some weeks after arriving in India I seldom could obtain 
more than an hour’s sleep at one time before I was com- 
pelled to quit my couch with no small precipitation, and if 
there were any water at hand to sluice it over me, for the 
purpose of allaying the inexpressible irritation! But this 
was productive of temporary relief only, and what was 
worse, a more violent paroxysm frequently succeeded. The 
sensations arising from prickly-heat are perfectly indescriba- 
ble, being compounded of pricking, itching, tingling, and 
many other feelings for which I have no appropriate appel- 
lation. It is usually but not invariably, accompanied by 
an eruption of vivid red pimples, not larger in general than 
a pin’s head, which spread over the breast, arms, thighs, 
neck, and occasionally along the forehead close to the hair. 
This eruption often disappears in a great measure when we 
are sitting quiet, and the skin is cool; but no sooner do we 
use any exercise that brings out a perspiration, or swallow 
any warm or stimulating fluid, such as tea, soup, or wine, 
than the pimples become elevated, so as to be distinctly 
seen and but too sensibly felt.” 
Causes.—Lichen occurs at any age, but its different forms 
seem to prevail at different periods of life; thus, as has 
been already remarked, lichen strophulus is a disease of 
early infancy, very seldom appearing after the process of 
first dentition is completed, and being most frequent for a 
month after birth, in fact few infants then escape it; lichen 
agrius is most usually an eruption of adult life and of old LICHEN. 
153 
age ; and lichen simplex affects young persons and those in 
the prime of life. The predisposing and often also the 
exciting causes of this eruption are very obscure; it is 
certainly witnessed most frequently in persons of a nervous 
temperament, with a fine, easily irritated skin, and in whom 
the cutaneous capillary circulation is very active, but with 
deficient perspiration. The occurrence of lichen strophulus 
in infants immediately after birth may he accounted for by 
the numerous local irritants to which their fine, delicate 
skin is then necessarily exposed, such as the effect of sudden 
changes of temperature, of the water and soap used in 
washing, of the friction employed in drying the surface 
afterwards, of the clothing, &c. The action of the local 
irritants has a decided effect in the production of lichen at 
all ages and in most cases; thus it is caused on the forehead 
in men by the pressure of a tight hat, on the face and hands 
by harsh dry winds, and by solar heat or that arising from 
a very hot fire; the latter is not an unfrequent cause of the 
eruption in some trades, such as blacksmiths, furnace-men, 
&c., and on the legs by the friction of worsted stockings, 
particularly when the veins are in a varicose condition. In 
certain occupations lichen is developed on the backs of the 
bands and on the fingers—in the same manner as other 
eruptions are—from the irritation of certain substances; 
thus it is witnessed in grocers, bakers, washerwomen, &c., 
when it is described as constituting one of the forms of the 
so called grocer’s, baker’s, or washerwoman’s itch. In many 
cases lichen seems to be connected with derangement of the 
digestive organs, and its appearance on the skin in persons 
who had long suffered from painful affections of the stomach 
or head was noticed by Bateman and Biett as a favorable 
circumstance. The use of stimulating drinks, or of heating 
articles of food and of spices will, in some individuals, be 
followed by a lichenous eruption. 
Diagnosis.—Lichen simplex is in general easy of recog- 
nition, in consequence of its distinctly papular character ; 
the disease with which it is most likely to be confounded is 
prurigo, the elementary character of the eruption in both 
being the same ; but in the latter the papulae are larger and 
more globular—their apex being rather flattened than acu- 
minate, and they are generally of the same color as the 154 
PAPULA. 
part of the skin on which they appear ; the itching, also, 
which accompanies lichen simplex is not of the same acrid, 
burning nature as that which is so characteristic of pruri- 
go. When the papulae begin to fade and to desquamate at 
their apex, the eruption might be mistaken for psoriasis 
guttata, from wrhich it is distinguished by the scales being 
much thinner, more minute and branlike, and by the 
papular elevation of the surface from which they separate, 
as may be recognized with the aid of a lens, or felt by 
passing the finger over the part. From scabies and ecze- 
ma, lichen simplex is diagnosed by the vesicular character 
of both these eruptions, and the copious discharge with 
which they are attended. Lichen circumscriptus is liable 
to be confounded with herpes circinnatus, or erythema cir- 
cinnatum; from both it is distinguished by the character of 
the eruption, papulae being never witnessed in any stage of 
either of these diseases. From urticaria, lichen urticatus is 
often writh much difficulty diagnosed; the chief distin- 
guishing characters are the wheal-like elevations with the 
paler centres, and the more decidedly evanescent nature, of 
the former. 
The only eruption with which lichen strophulus could be 
confounded is prurigo, but the age at which it occurs is suf- 
ficient to distinguish it from that disease ; moreover, in those 
forms of strophulus in which the papulae are red they are 
darker colored than in prurigo, and in the white varieties 
they are much paler. 
The more aggravated cases of lichen agrius, in their ad- 
vanced stages, bear much resemblance to chronic eczema 
rubrum, and are often with difficulty diagnosed from it; but 
careful examination will scarcely ever fail in detecting the 
papular character of the former; in it, too, the integuments 
are more swollen, thickened, and tubercular, the serous dis- 
charge and the epidermic desquamation considerably less, 
while the itching is more intense ; the peculiar red cracks 
and fissures from which the bloody ichor oozes are, more- 
over, not seen as in eczema. On the face, lichen agrius 
may be mistaken for acne rosacea, from which it is distin- 
guished by the pustular nature and deep crimson or viola- 
ceous hue of the latter ; they also affect different regions of 
the face, lichen being generally situated on the forehead LICHEN. 
155 
and the sides of the cheeks in front of the ears and lips, 
while acne rosacea occurs almost invariably on the nose and 
the most prominent portions of the cheeks. Impetigo oc- 
curring on the face in adults has been confounded with lichen 
agrius, but the pustular character, and greenish honey-like 
scabs of that eruption sufficiently characterize it. This 
form of lichen is not so liable to be mistaken for psoriasis 
as lichen simplex, the attendant serous discharge and the 
characteristic itching marking especially the difference be- 
tween them. 
Lichen is a very frequent form of syphilitic eruption; it 
is then characterized by the peculiar dull coppery hue it 
presents, by its being always of a chronic character, unat- 
tended with any inflammatory symptoms, either local or 
constitutional, by the absence generally of itching, and by 
the presence of the other secondary symptoms of the vene- 
real disease, together with the history of the individual case. 
In infants hereditary syphilis must be carefully distinguished 
from lichen strophulus; the former rarely presents a papu- 
lar form, and it occurs in patches or coppery stains, gene- 
rally attended with a serous or sero-purulent discharge, on 
various parts of the body, but especially about the pudendal 
region, and on those parts of the skin on which the hair 
grows. 
Prognosis.—In infants and young children, the occur- 
rence of lichen strophulus is quite unimportant, as it gene- 
rally runs its course in a few days, being unattended with 
the least danger or injury to health, requiring notice merely 
in consequence of the accompanying itching, rendering the 
little patients fretful. In adults and old persons an eruption 
of lichen, though never attended with danger, is extremely 
troublesome, in consequence of the local annoyance and suf- 
fering by which it is accompanied, and the tendency more 
especially of lichen agrius, to become chronic; like most 
other cutaneous eruptions, the longer its duration has been, 
the more rebellious is it to treatment. The disease is also 
more obstinate on the face or hands than when it is situated 
on those parts of the body that are ordinarily covered ; and 
the complication of other cutaneous eruptions with it inva- 
riably renders the treatment more difficult. In giving a 
prognosis in any of the severe forms of lichen, it should be 156 
PAPULA!. 
remembered that relapses are very liable to occur, the least 
exciting cause, such as even the heat of the sun in summer, 
being sufficient to reproduce the disease. 
Treatment.—In all papular eruptions a manifest indica- 
tion of treatment is derived from the hyperaesthesia of the 
cutaneous structure which accompanies them in their acute 
as well as in their chronic stages, and this should always 
influence our choice of remedies, whether tonics or antiphlo- 
gistics, according to individual circumstances, may be re- 
quired. In their early stages, local applications will in 
general be found sufficient to check the progress of the erup- 
tion, unless when symptoms of inflammatory action are pre- 
sent, but these are usually of a trifling nature and of short 
duration; when, however, they have become chronic, the 
most active constitutional alterative treatment is required, 
and even under its most judicious employment they not un- 
commonly baffle the physician’s art for a length of time. 
In lichen simplex occurring in young persons of a robust 
constitution, restricted diet should be enforced at its com- 
mencement, together with rest in bed if the eruption is at 
all extensive, and the administration of diaphoretics, the 
bowels having been previously opened by a mercurial purge, 
provided the papulae are well developed on the skin: the 
antimonial diaphoretics, combined with guaiacum and Dover’s 
powder, as in somewhat the following form, are usually pro- 
ductive of more benefit than saline diaphoretics : 
R. Antimonii Sulphureti prsecipitati, . gr. xx. 
Guaiaci Resinae, in pulvere, . . . gr. xxiv. 
Pulveris Ipecacuanhae compositi, . . gr. xij. 
Ope mucilaginis misce et in pilulas duodecim divide. 
“ One to be taken every sixth hour.” 
To allay the itching and local irritation, tepid baths of 
fresh water may be employed daily, and the skin, having 
been well dried, smeared afterwards with olive oil, to every 
ounce of which twTenty minims of chloroform have been 
added. When the general inflammatory symptoms are sub- 
dued by this treatment, if the disease exhibits any tendency 
to become chronic, the compound lead-cerate with glycerine 
may be applied to the surface, and the parts sponged twice 
daily with an alkaline spirituous wrash. LICHEN. 
157 
In any of the forms of lichen strophulus, medical interfer- 
ence is scarcely required, and especial care should he taken 
that no treatment, whether local or constitutional, be em- 
ployed by which the eruption might be repelled. If any 
derangements of the disgestive organs exist, they may require 
the use of mild alteratives or gentle mercurial purgatives, 
and when the eruption occurs at the period of dentition, the 
gums ought to be lanced freely. The annoying pruritus, 
which so constantly seems to accompany strophulus, is best 
allayed by the use of the tepid fresh-water bath with gela- 
tine, and the application of olive oil to the spots of eruption ; 
cold cream is also useful for this purpose, or the acetate of 
zinc cream, to every ounce of which two drops of oil of bitter 
almonds have been added, may be employed in more aggra- 
vated cases. 
In the early stages of lichen agrius, while the inflamma- 
tory symptoms are present, the treatment should be de- 
cidedly antiphlogistic, but unless in strong, healthy, young 
persons residing in the country, general bleeding is not 
admissible, the local abstraction of blood, by means of leeches 
applied in the neighborhood of the eruption, being in most 
cases sufficient. Even in the chronic stages of the disease, 
this form of local bleeding is in general attended with the 
best results, as it relieves the congested state of the capil- 
lary circulation which is present, but the leeches should 
never be applied on any part of the skin which is affected, 
as their bites might give rise there to troublesome ulcera- 
tion. At first the irritation caused by the eruption is best alle- 
viated by gelatine baths and soothing ointments or lotions; 
of the former the carbonate or acetate of lead cerate with 
chloroform, the compound lead cerate with glycerine, the 
oxide or carbonate of zinc ointment, wfith which oil of bitter 
almonds or prussic acid has been combined, or the hemlock 
ointment, will be used with benefit; of the latter, the weak 
lead wash, to which glycerine has been added in the propor- 
tion of a drachm to the ounce, equal parts of camphor mix- 
ture and distilled vinegar, a lotion containing a drachm of 
succus conii, half a drachm of glycerine, and a grain of car- 
bonate of soda to the ounce of elder-flower water, or alka- 
line washes with prussic acid, as in the following form, may 
be employed. 158 
PAPULA. 
R. Sodae Biboratis, 3ss. 
Aquae Rosae, fl 3viij. 
Acidi Hydrocyanici diluti, . . . . fl 3ij* Misce. 
If any connection can be traced between the appearance on 
the cutaneous surface of the eruption and disease of some 
internal organ, or deranged function, the remedial measures 
employed must be especially directed towards the alleviation 
of the former, and the correction of the latter. With this 
view saline and mercurial purgatives are generally required 
in most cases, and when debility exists, their employment 
may be conjoined advantageously with chalybeates or vege- 
table bitters, and the dilute mineral acid. Lichen is not 
unfrequently associated, in old persons, with the gouty or 
rheumatic diathesis, and in such cases, preparations of col- 
chicum, combined with the liquor potassae, or the carbonate 
of ammonia, should be prescribed. 
In the chronic stages of lichen agrius more active consti- 
tutional treatment is usually required, while at the same 
time attention is paid to any complication that may exist. 
Iodine and arsenic, either separately or in combination, in 
some of the forms described in former chapters, will be found 
necessary, and they may be given with tonics or diaphoretics 
according to individual circumstances. When there is gene- 
ral debility present, more especially an anemic condition of 
the system, iodine combined with iron in the form of the 
syrup, or pills of the iodide of iron is most useful. Tincture 
of aconite is also an excellent remedy, more especially if the 
hyperaesthesia of the cutaneous surface is well marked, but 
its administration must, as in all other diseases, be carefully 
watched; there is nothing to contraindicate its employment 
at the same time with the powerful alteratives above men- 
tioned. Sulphur and its preparations are highly recom- 
mended by many practitioners in chronic lichen, but I must 
confess that they have not proved so successful in my hands 
as they are stated to have done with others. It was at one 
time too much the custom to administer sulphur in nearly 
every form of cutaneous eruption, chiefly, I believe, in con- 
sequence of its being evolved so manifestly by means of the 
insensible perspiration; but for this very reason its use often PRURIGO. 
159 
proves highly injurious, owing to the direct stimulant action 
it thereby exercises in diseases which are of an inflammatory 
nature, or which are liable to be aggravated by determina- 
tion of blood to the cutaneous capillaries. 
Most of the local applications already spoken of will be 
found beneficial in chronic lichen agrius, but even in the same 
case they must be constantly varied, according to the se- 
verity of the local symptoms ; when all inflammatory tend- 
ency has subsided, an ointment containing twenty grains 
of the iodide of sulphur to an ounce of white wax ointment, 
to which six minims of chloroform are added, will be found 
productive of excellent effect, an alkaline spirituous wrash 
being at the same time used. 
Prurigo.—It is very doubtful whether this disease should 
be termed an eruption of the skin or not, so frequently does 
it occur without any visible phenomena to indicate its ex- 
istence, the only symptoms present being obstinate intense 
itching, without heat, pain, or sensible elevation of the sur- 
face. But as in many cases it is attended with the develop- 
ment of papulae, it must, in an artificial arrangement of 
skin diseases, be classed with lichen. The papulae, when 
they do occur, are of a somewhat larger size, rounder and 
less acuminate than those of lichen; and are of the color of 
the skin, or of a yellowish hue. The disease is essentially 
of a chronic nature, is not contagious, and is neither pre- 
ceded nor accompanied by constitutional symptoms; never- 
theless, when it has existed for some time, the health be- 
comes more or less deranged, in consequence of the extreme 
suffering caused by the itching and local irritation attendant 
on it. 
Three forms of prurigo have in general been described by 
dermatologists: Prurigo mitis, Prurigo formicans, and Pru- 
rigo senilis ; the first two are distinguished from each other 
merely by the degree of severity of the symptoms, and may 
therefore be considered together; the third, although de- 
nominated simply from its occurrence in old age only, yet 
requires to be noticed separately, in consequence of some of 
its phenomena being peculiar and characteristic. I shall 
PRURIGO. 160 
papulae. 
therefore describe the disease as consisting of two species, 
terming them,— 
Prurigo vulgaris. 
“ senilis. 
Prurigo vulgaris (Atlas, PI. IX. Fig. 5), then, may be 
either mild or severe, the latter being the more frequent. 
The mild variety is developed by the eruption on the cuta- 
neous surface of scattered papulae, about the size of a millet- 
seed, without the least redness, inflammation, or sense of 
heat; they are of the color of that part of the integument 
on which they may be seated, but little elevated, and scarcely 
to be distinguished unless with the aid of a lens, or by pass- 
ing the finger over the surface. The attendant pruritus is 
not very severe, although sufliciently sharp and stinging to 
cause the patient to scratch the affected parts with the nails; 
the papulae are thus torn, and a minute, blackish crust 
thereby formed on their apices, which gives a remarkably 
characteristic appearance to the affection. 
In the severe variety of prurigo vulgaris the disease may 
commence with or without the eruption of papulae, but in 
all cases they are usually developed in some of its stages ; 
when they do occur they are more numerous than in the 
mild form, of the same color, shape, and size, or sometimes 
even larger. It is, however, the remarkable cutaneous hyper- 
aesthesia and consequent intense pruritus which especially 
mark the aggravated character of the affection, and from 
whence it has derived its appellation—-formicans, the sensa- 
tions accompanying it being often compared to those pro- 
duced by the sting of an ant. This comparison, however, 
very faintly expresses the sufferings attendant on the dis- 
ease : not a single spot of the skin in its entire extent but 
is more or less the seat of an extreme degree of itching, 
which compels the individual affected to tear with his nails 
and rub the surface all but unceasingly ; at times compara- 
tive cessation of the pruritus occurs, occasionally lasting for 
two or three hours, more usually of shorter duration, but it 
is again exacerbated by the most trifling exciting cause, the 
friction of the clothes, changes of temperature—especially 
the heat of the fire or the warmth of the bed,—mental emo- PRURIGO. 
161 
tions, &c. In consequence of heat increasing much the 
local symptoms, the itching is always remarkably aggra- 
vated at night, rest is thus completely destroyed, sleep being 
rendered impossible, hour after hour is passed tearing the 
skin, and the sufferer is often compelled to seek relief by 
lying on the floor without any covering. In one case of ex- 
treme severity which I attended, the exacerbations and re- 
missions assumed a well-marked, intermittent, semi-quotidian 
type; the itching commenced every afternoon at about two 
o’clock, and continued until six o’clock, when it gradually 
abated, and there was comparative ease until the same hour 
on the following morning ; it then returned and lasted again 
for the same length of time, but the night sufferings were 
tenfold more severe than those of the day ; this intermittent 
character of the pruritus had lasted, at the time I saw the 
patient, a young man of twenty-three years of age, for more 
than two years, and his health, both mental and bodily, 
was sensibly affected from the constant suffering and loss of 
sleep. 
When the disease has lasted for any time, the cutaneous 
surface is torn and fissured from the constant scratching; 
if papulae existed, their site is marked by minute, blackish 
crusts or small excoriations, and the skin is thickened, un- 
even, and coarse, being found, on close examination, as re- 
marked by Wilson, “ raised into small, flat elevations, caused 
by the swelling of the little angular compartments between 
the linear markings.” The natural color of the skin is 
also much altered, its aspect being of a dirty brownish- 
yellow hue. 
The milder form of prurigo vulgaris seldom lasts for a 
longer period than two or three weeks, but the duration of 
the severe variety is in some cases almost indefinitely pro- 
longed, recovery rarely taking place in a shorter time than 
from four to six months. The papulae in both are developed 
in the first instance of the chest, the neck, the lumbar 
region, the shoulder, and the outside of the thighs, from 
whence, when the disease lasts for more than a month or 
two, they spread to the arms and legs, but do not appear 
on the face, the scalp, or the hands, although these parts in 
aggravated cases are rarely free from more or less pruritus. 
Such of the papulae as escape being torn by the nails termi- 162 
PAPULAE. 
nate in slight furfuraceous desquamation. The disease is 
not unfrequently complicated by the simultaneous occurrence 
of scabies and eczema, and in some cases of ecthyma. 
Prurigo senilis (Atlas, PI. IX. Fig. 6) occurs, as its spe- 
cific name indicates, only in advanced life; the pruritus, 
which is usually of remarkable intensity, is attended always 
with an eruption of papulae; these are of larger size than 
in either of the forms of prurigo vulgaris, but they are few 
in number, more dispersed over the surface of the body, and 
of a dull dingy-yellow color; soon torn with the nails, small 
blackish crusts appear on their apices, which also constantly 
bleed slightly when irritated. The chief peculiarity, how- 
ever, in prurigo senilis is, that it is almost invariably at- 
tended with the appearance of innumerable pediculi on the 
integuments of every part of the body—a complication 
never absent in the poor and in persons of filthy habits. 
Their presence aggravates much the other symptoms of the 
disease: the skin becomes of a livid color, thickened, rough, 
with a leathery aspect, and covered with superficial excoria- 
tions, and small pustules and indolent boils form in different 
regions of the body; the pediculi are renewed nearly as 
quickly as they can be removed from the surface, which has 
caused a controversy as to whether they are developed from 
the integuments or not. By some dermatologists the occur- 
rence of the pediculi is considered as only an accidental 
circumstance, and not constituting a symptom of the disease: 
by others it is regarded more correctly, I think, as an essen- 
tial feature of the eruption, and they have, therefore, fol- 
lowing Alibert, denominated the form thus characterized, 
prurigo pedicularis. 
Many of the French school describe, as a distinct disease 
of the skin, this development of pediculi on the cutaneous 
surface of the body, generally terming it Phthiriasis, and 
dividing it into three species, as it may be general or partial 
—Phthiriasis corporis, Phthiriasis capitis, and Phthiriasis 
pubis—considering the simultaneous appearance of the pa- 
pulae of prurigo as only a complication; but as I have almost 
invariably seen them occur together in old persons, I think 
it more correct to describe this singular affection as a variety 
of prurigo senilis. PRURIGO. 
163 
Prurigo vulgaris very frequently affects some special re- 
gion of the skin from which it does not spread, but becom- 
ing chronic there causes extreme suffering, and is very 
obstinate. It thus attacks the scrotum in males, and the 
pudendal region in females: the former, termed prurigo 
scroti, is a very troublesome affection, being attended with 
a constant itching, which, instead of being relieved, is much 
aggravated by scratching with the nails, yet the sufferer 
from it cannot resist the almost unceasing inclination which 
exists to attempt thus to alleviate the tormenting pruritus ; 
the habit thence acquired can scarcely be got rid of, and 
even long after the apparent symptoms of the disease have 
disappeared, the integuments are continually fretted and 
torn. In females, prurigo pudendi is situated chiefly on 
the mucous membrane of the labia, but often extends to the 
entire surface, both cutaneous and mucous, of this region ; 
it is a most distressing and obstinate disease, and not un- 
commonly produces symptoms analogous to those of nym- 
phomania. Another frequent form of local prurigo is pru- 
rigo podicis ; in it a constant itching of the verge of the 
anus exists, and papulae, which are often not present in the 
other local forms of the disease, are here almost invariably 
developed, and sometimes attain a considerable magnitude; 
occasional intermissions of the pruritus occur, but the least 
irritation, augmented heat of the surface, or derangement 
of the digestive organs, causes an exacerbated return of this 
tormenting sensation. Other regions of the skin are at 
times the seat of severe itching, and have been described, 
but without sufficient reason, as being then affected with 
prurigo; thus dermatologists have spoken of prurigo urethra- 
lis, prurigo prseputialis, prurigo pubis, and prurigo palma- 
ris: the latter has been specially mentioned by Alibert as 
affecting the soles of the feet, of which he states that he 
witnessed many examples. 
Causes.—Prurigo may occur at any age, but is most fre- 
quently seen in old persons, and more commonly in males 
than females: young persons are more liable to its attacks 
than adults, and it has been witnessed even in early infancy. 
That state of the constitution in which cutaneous irritability 
exists, as exhibited by the occurrence of troublesome ulcers 
from slight causes, and an inaptitude, so to say, of even 164 
PAPULA. 
the most trifling abrasion to heal, peculiarly predisposes to 
its development; there is usually in such a condition an 
impoverished blood circulating in the vessels, and a highly 
irritable nervous system. Bad or insufficient diet, want of 
care as to cleanliness, unhealthy habitations, sedentary oc- 
cupations, or confinement to the house caused by ill health, 
defective clothing, dissipated habits, &c., are both predis- 
posing and exciting causes of prurigo. I have often 
thought that in gaols and workhouses, amongst the aged 
inhabitants of which the disease is so common, and also 
amongst the poor, it may be caused by the sameness of 
food, which, too, is often defective in nutritive qualities. 
Other cutaneous eruptions which are attended with local ir- 
ritation, more especially scabies and lichen, not uncommonly 
are exciting causes of this affection ; and it is in old persons 
a frequent accompaniment of convalescence from debili- 
tating diseases, particularly fever, dysentery, and chronic 
diarrhoea. 
Diagnosis.—The most characteristic symptoms of prurigo 
are the intense pruritus, the blackish crusts which are pro- 
duced on the papulae, and the alteration that takes place in 
the appearance of the integuments. The diseases with 
which it is most likely to be confounded are lichen and 
scabies, and the mode of diagnosing it from them has been 
already noticed when describing these eruptions, but, as has 
been before remarked, they often co-exist. 
Prognosis.—Prurigo, when it becomes chronic, is one of 
the most obstinate diseases of the skin ; in old persons sel- 
dom yielding to any treatment. Although prurigo vulgaris 
cannot be said to be attended with danger to life, yet it ren- 
ders life miserable, sometimes for years, and from being a 
constant cause of irritation, may to a certain extent, affect 
the mind, as is witnessed in some cases. The senile form 
of prurigo, although it is not in itself a mortal affection, 
nevertheless seldom disappears unless with life, and when it 
occurs as a complication of some organic or chronic disease, 
unquestionably hastens the fatal termination. 
As regards the pathology of prurigo, it is evidently chiefly 
a hyperaesthesia of the cutaneous structure ; the changes in 
the state of skin which attend it being usually produced by 
the local irritation thereby occasioned. PRURIGO. 
165 
Treatment.—If this view of the pathology of the disease 
is correct, it is manifest constitutional remedies are most to 
be relied upon in its treatment, nevertheless, as in other 
nervous affections, topical medication should not be neglected, 
and is often attended with the best results. The state of 
the general health should in all cases first receive attention, 
for, until this is regulated as far as practicable, the employ- 
ment of remedies more immediately directed to the disease 
will be found useless. With this view, mild mercurial and 
saline purgatives may be prescribed to correct the secretions 
from the digestive organs, and when there is a deficiency of 
bile in the discharges, as is not unfrequently the case in 
adults and old persons, dried carbonate of soda and extract 
of taraxacum should be combined with mercurials. In 
females, the association of the disease with derangement of 
the menstrual function is often witnessed, and when such 
exists, there is generally an anemic state of the system re- 
quiring the use of the preparations of iron, but they should 
never be prescribed except in combination with sedatives, as 
otherwise the stimulant action is apt to augment the pruri- 
tus ; the same observation applies to the employment of 
chalybeates in the old and debilitated, for whom they are 
also generally indicated in prurigo. They may be advan- 
tageously combined, as in the following form:— 
R. Misturae Ferri compositae,. . . fl fviij. 
Infusi Humuli, fl liijss. 
Succi Conii, fl §ss. Misce. 
“A table-spoonful to be taken every sixth hour.” 
Or Dover’s powder may be given in rather large doses at 
night, preparations of iron being administered during the 
day. In very young persons antiphlogistics are sometimes 
needed as preludes to other remedies, but in no case should 
the strength be much weakened, as then the disease is more 
apt to become chronic. When prurigo has lasted for any 
time, or has resisted other plans of treatment, more active 
medicines of the class which especially influences the nerv- 
ous system should be prescribed ; nux vomica or its alkaloid, 
and tincture of aconite, thus often prove useful; the former 
has succeeded in my hands when all other remedies seemed 166 
PAPULAE. 
to fail; it may be given in the following form, a combina- 
tion which will be found to promote a healthy condition of 
the digestive organs, and to correct the loss of tone which 
they exhibit usually in this disease:— 
R. Extracti Nucis Yomicse, gr. iij. 
Fellis Bovini Inspissati, gr. vj. 
Extracti Taraxaci, . gr. xxiv. 
Pulveris Myrrhae, gr. xviij. 
Misce et divide in pilulas viginti quatuor. 
“ One to be taken three times daily.” 
The tincture of aconite should be given in the ordinary 
doses, from five to eight minims of the Dublin preparation, 
or half that quantity of Fleming’s tincture, and its effects 
carefully watched. I have also administered the succus 
conii, in doses of a drachm three times a day, in an ounce 
of the camphor mixture with magnesia, with excellent effect 
in some obstinate cases of senile prurigo. Preparations of 
sulphur are recommended by many in the treatment of this 
disease, and in the very chronic forms the sulphurous mine- 
ral waters, as those of Lucan, of Harrowgate, of the Pyre- 
nees, &c., prove of unquestionable benefit. Indeed, in all 
cases, change of air, if possible, to the original sources of 
mineral waters, the saline in the early stages, the chalybeate 
in the more advanced, and the sulphurous when the disease 
is very chronic and obstinate, so that they may be drank 
there is highly advisable. 
The local treatment is now to be spoken of: and at first 
nothing is requisite further than the daily use of the hot 
fresh-water bath, to which, if the itching is extreme, gela- 
tine should be added, or alkaline baths may be employed, 
if the eruption is well developed on the skin ; as the disease 
advances and becomes chronic, sulphuro-alkaline baths— 
three ounces of sulphuret of potassium, and an ounce of 
carbonate of potash to thirty gallons of hot water—will bo 
used with benefit; and in senile prurigo, especially that form 
in which pediculi cover the body, the surface should be 
smeared half an hour before going into the bath with mer- 
curial ointment diluted with three parts of prepared lard, PRURIGO. 
167 
and a drachm of glycerine added to each ounce. To allay 
the pruritus, various lotions and ointments have been recom- 
mended ; of the former, those containing the vegetable acids, 
such as lemon-juice, vinegar, and cherry-laurel water, are 
especially useful; black-wash has also proved very service- 
able when the disease is local; and lotions, containing cor- 
rosive sublimate, muriate of ammonia, watery extract of 
opium, prussic acid, preparations of lead or of sulphur, may 
be tried when other applications fail. From the use of 
chloroform in the form of ointment, as recommended in the 
Chapter on Urticaria, I have derived most excellent results; 
in fact, latterly I have seldom had occasion to employ any 
other application; but the substances mentioned above, as 
being used in lotions or washes, may also be applied as un- 
guents, and the addition of glycerine will generally be found 
of advantage. In very obstinate cases the chloroform may 
be combined with iodide of lead, as follows:— 
R. Iodide Plumbi, gr. xij. 
Unguenti Cerae Albae, .... fj. 
Chloroformi, m. viij. adm. xij. 
Glycerinae, fl 3j* Misce. 
When greasy applications are used, alkaline tepid baths 
should be employed daily to cleanse the skin, the patient 
remaining in the water for at least twenty minutes. 
Strict attention to diet and regimen is requisite in all 
cases; stimulant food or drink being especially avoided. 168 
SQUAMA. 
CHAPTER VI. 
SQUAMJ3. 
There is no class of diseases of the skin so well charac- 
terized by the apparent phenomena as that in which the 
formation of a scale constitutes the essential feature ; epi- 
dermic desquamation, as has been in the previous pages so 
frequently noticed, is present in many cutaneous eruptions, 
but that differs in many respects from the secretion and sub- 
sequent shedding of true scales, which consist, according to 
the admirable definition of Willan, of “ a lamina of morbid 
cuticle, hard, thickened, whitish, and opaque.” Although in 
some of the forms more or less change from the primitive 
characters of the eruption takes place in the progress of the 
disease, it is never such as to mask their scaly nature, and 
the diagnosis is consequently attended with less difficulty 
than that of most other cutaneous affections. Squamous 
eruptions may be defined to consist in the secretion of dry, 
laminated whitish scales on the cutaneous surface, usually 
occurring in patches, often of a circular form, but sometimes 
generally diffused, and covering an extended portion of the 
integuments. The scales, which are somewhat elevated 
above the level of the surrounding skin, readily fall off, to 
be again rapidly renewed, and the portions of the cutaneous 
surface on which they are formed are of a smooth, glistening 
aspect, reddish and dry. 
Scaly diseases are essentially of a chronic, non-inflamma- 
tory nature, are slowly developed, and are not propagated 
by contagion. They may appear on any part of the body, 
but they chiefly affect, at least in the first instance, the 
extremities, whence they usually spread to other regions, 
being rarely confined to a single locality, with the excep- 
tion of pityriasis, which occasionally occurs on some special 
portion of the skin. They are developed also at all seasons 
of the year, and are not apt, like other cutaneous diseases, PSORIASIS. 
169 
influenced by the atmospheric temperature, to disappear and 
again re-appear at certain times. 
The eruptions included in the order Squamae were divided 
by Willan into four groups—Lepra, Psoriasis, Pityriasis, 
and Ichthyosis—and his arrangement has been followed by 
many modern dermatologists; recently, however, it has 
been very generally admitted that Ichthyosis was incorrectly 
classed by him amongst scaly diseases, and doubt has been 
thrown on the propriety of describing psoriasis and lepra 
as different forms, they being, moreover, evidently regarded 
by the ancient medical writers as constituting merely varie- 
ties of the same eruption. Ichthyosis cannot with any re- 
gard to accuracy in classification, be grouped in this class, 
for it is not attended with a separation—throwing off scales, 
or desquamation, one of the most characteristic signs of this 
order of cutaneous eruptions; the epidermis is in it truly 
hypertrophied, and I shall therefore describe it as consti- 
tuting one of that group of skin diseases which I have termed 
Hypertrophige. To even a superficial observer it must be 
evident that psoriasis and lepra have no essential differences, 
and they require a precisely similar plan of treatment; 
regarding them, therefore, as distinct affections could only 
tend to complicate their study. The number of scaly dis- 
eases of the skin is thus reduced to two—Psoriasis, Pity- 
riasis. 
PSORIASIS. 
Psoriasis (Dry tetter; Dry scale)—under which terra 
it will be understood I include Lepra—is characterized by 
consisting in the formation on the cutaneous surface, and 
subsequent desquamation, of true scales, the scales being 
of tolerable consistence, dry and friable, of a silvery or 
grayish whiteness, and separating in laminae of about the 
size and consistence of particles of bran. The eruption 
appears in small, round, or irregularly-shaped spots, dis- 
tinct from each other, scattered over the cutaneous surface 
in large, circular patches, depressed in the centre, or in 
masses so closely aggregated and confluent as to envelop an 
extended portion of the skin in one vast coating of scales 
in consistent layers. The surface of the integument on 170 
SQUAMAE. 
which they are situated is raised, reddish, and apparently 
inflamed, but unattended with any discharge ; nevertheless, 
when the eruption has been of long duration, fissures and 
cracks through the deeper-seated tissues form, from which 
an ichorous, bloody secretion exudes. Psoriasis has been 
considered by many writers on diseases of the skin to be a 
special chronic inflammation of the cutaneous structures, 
the specialty consisting in the development of scales ; it 
cannot, however, I think be regarded as an inflammatory 
disease, for it is not attended with heat or other local sign 
or symptom of inflammation, except a slight degree of itch- 
ing, unless when the affected surface is irritated by some 
cause. 
The eruption appears in the form of minute, slightly-ele- 
vated papulae, with a small scale apparent at the apex of 
each on careful examination, and, no matter what pheno- 
mena it may afterwards present, this is its primary aspect; 
coming on slowly, it runs generally a most tedious course, 
often lasting for many years, and sometimes even for a long 
life. The several varieties of both psoriasis and lepra which 
have been described maybe conveniently reduced to three:— 
Psoriasis guttata. 
“ aggregata. 
“ leprseformis. 
Psoriasis guttata (Atlas, PI. X. Fig. 1).—This, which is 
the mildest form of the disease, is unattended in any of its 
stages with constitutional symptoms; a slight degree of 
itching of the skin occasionally precedes its appearance, but 
even this is not a constant sign. Numerous minute, papular 
elevations of the epidermis, at first not exceeding in size the 
point of a pin, are developed on the cutaneous surface, scat- 
tered irregularly but distinct from each other, except in the 
neighborhood of the joints, on the prominences of which 
they are usually more or less aggregated. On the apex of 
each little elevation a minute scale forms, which, at first 
slightly adherent, desquamates shortly after its appearance, 
to be succeeded by another somewhat larger and more con- 
sistent ; this scale is shining, of a silvery whiteness, and 
about the thickness of thin writing paper. The raised spots PSORIASIS. 
171 
on which the scales are situated enlarge slowly, not attain- 
ing the size of the head of a pin for several days, and very 
gradually acquiring a magnitude of from two to three lines 
in diameter, when they are of a somewhat circular shape, 
but irregularly circumscribed. In some parts two or more 
spots coalesce, and thus form small patches, rarely, however, 
in this form of the eruption, exceeding the size of a sixpence, 
except, as above remarked, near the joints, where they occa- 
sionally occupy a portion of the integument an inch or two 
in diameter. With the progress of the disease the scales 
continue to be continuously developed, and shed as rapidly 
as they are secreted; the affected spots are irregularly ele- 
vated, of a redish color in young persons, but of a dull 
brownish hue in the old, contrasting well with the shining, 
grayish-white scales, and present an irritated aspect. The 
only annoyance accompanying the presence of the eruption 
on the body, the disfigurement it occasions excepted, is a 
slight degree of tingling scarcely amounting to itching, 
caused by the separation and shedding of the scales. 
This form of psoriasis rarely becomes chronic ; in three 
or four weeks after its first appearance, the scaly desqua- 
mation begins to diminish in quantity, new spots, which 
continued to be developed on the sound skin amongst those 
which had previously existed, cease to form, the elevated 
patches gradually sink to the level of the surrounding in- 
tegument, and the disease usually terminates in from six 
weeks to two months, faint reddish stains, which after a 
short time fade away, marking the site of the eruption. It 
may occur upon any part of the body, but is most usually 
situated on the chest, the back, the arms, the face, and the 
scalp. 
In some rare cases, as originally noticed by Willan, the 
eruption is developed in the form of narrow patches or strips, 
consisting of the minute scaly elevations set closer to each 
other than usual. These stripes or bands, which generally 
appear on the trunk of the body, assume a singular shape: 
“ some of them are nearly longitudinal, some circular or 
semi-circular, with vermiform appendages: some are tortu- 
ous or serpentine, others are shaped like earth-worms or 
leeches; the furrows of the cuticle, being deeper than usual, 
make the resemblance more striking by giving to them an 172 
SQUAMJi. 
annulated appearance.”1 This, which is manifestly only an 
accidental variety of psoriasis guttata, has from its peculiar 
aspect been named psoriasis gyrata. 
Psoriasis aggregata (Atlas, PL X. Fig. 2). — I have 
ventured to change the specific appellation of this form of 
the eruption, which by Willan and his followers has been 
denominated diffusa, by Rayer conjiucns, and by many other 
dermatologists vulgaris. The latter term indicates correctly 
enough that it is the most common form of the disease, but 
does not afford any information as to its characteristics, 
while the first is not sufficiently specific, psoriasis guttata 
and psoriasis leprseformis being often as generally diffused 
with regard to locality over the cutaneous surface ; the name 
applied by Rayer is objectionable, solely because, in the 
English language, the word “ confluent” conveys the idea of 
the presence of fluid. Reluctant, then, as I am to alter the 
nomenclature of skin diseases, although anxious to reduce 
in number the terms used, I have thought it well in this in- 
stance to do so by employing a specific denomination, which 
while being frequently employed to designate other diseases 
of the cutaneous structure, and thus not being an innovation, 
would be both more correct and more expressive. 
This form of psoriasis, developed like that last described, 
without constitutional disturbance, appears as numerous 
minute, rounded elevations of the epidermis, closely aggre- 
gated together in irregularly circumscribed patches, varying 
in size from that of a silver fourpence to that of the palm 
of the hand, but very irregular, both as regards shape and 
extent; on these the scales are formed from the first, minute 
and tolerably adherent at the commencement of the disease, 
but gradually acquiring a greater magnitude, when they are 
shed and again secreted with astonishing rapidity. The 
scales are of the same color and consistence as in psoriasis 
guttata, but desquamate in rather larger pieces, their repro- 
duction, too, takes place much more quickly, so that they 
are consequently desquamated in greater quantity. With 
the progress of the eruption, new patches form on the inter- 
vening sound skin, which, sometimes coalescing with those 
that first appeared, increasing their size often considerably ; 
1 Willan on Cutaneous Diseases. London, 1808. 4to. p. 161. PSORIASIS. 
173 
the diseased surface is now distinctly raised above the level 
of the surrounding integument, rather more so at the outer 
border than at the centre, of a dull, reddish color, and co- 
vered with shining grayish-white scales. There is no dis- 
charge, either serous or purulent, but fissures or cracks are 
generally found through the affected parts, which present 
an irritated aspect, and through which blood occasionally 
exudes. 
This form of the disease often does not attain its full de- 
velopment for many months, although several of the patches 
acquire their utmost magnitude in three or four weeks, after 
which time they do not increase in size, but continue to 
secrete the characteristic scales incessantly. Its duration 
is essentially chronic, lasting usually for years if not sub- 
mitted to the employment of remedial measures. The 
disappearance of the eruption is in all cases slow and 
gradual, the first sign of amendment being the cessation of 
the development of new patches, a diminution of the scaly 
desquamation, and a sinking of the elevated surface to the 
level of the healthy integument; reddish stains remain for 
a considerable time on the surface, even after the disease 
is apparently cured, and from these a fine epidermic des- 
quamation, though small in quantity, continues for some 
weeks. 
Either of the forms of psoriasis now described, when they 
become very chronic, may assume an extremely aggravated 
character, and present local phenomena justly entitling them 
to the appellation which dermatologists then usually apply 
to designate their severity and obstinacy to treatment— 
psoriasis inveterata (Atlas, PI. X. Figs. 3 and 4). In it 
the various patches of the eruption coalesce, so as to cover 
completely the limb on which they may be situated, or even 
the trunk of the body; the entire of the cutaneous surface 
is one mass of dry, hardened, thick scales, or rather is 
enveloped in a case of them which covers the integuments 
like a coat of mail. Through this, deep fissures are formed, 
generally in straight lines, but sometimes following the 
course of the polygonal and lozenge-shaped linear furrows 
of the epidermis, so as to give the diseased surface a striking 
resemblance to a piece of tessellated pavement. From the 174 
SQUAMAE. 
fissures an ichorous and bloody pus exudes, the parts are 
constantly torn with the nails, itching, which is much aggra- 
vated by heat, being a constant accompaniment of this in- 
veterate form, and the entire of the affected region is a mass 
of leprous irritation, attended with a foul discharge, and a 
shower of desquamating scales flies off on the least motion, 
the bed of the patient presenting an appearance as if bran 
had been thickly strewn in it. 
The most usual site of psoriasis aggregata is the extre- 
mities, but it at times affects the entire body, being least 
frequent on the face, where it is always less general than 
on other parts of the cutaneous surface. In some cases it 
appears on special regions of the skin, and under such cir- 
cumstances has been particularly described, but the guttated 
form of the eruption is almost invariably present on the 
rest of the body at the same time. The local forms have 
been named, from the parts affected, psoriasis labialis, psoria- 
sis 'palpebrarum, psoriasis capitis (Atlas, PI. X. Fig. 6), 
psoriasis scrotalis, psoriasis prseputialis, psoriasis pudenda- 
lis, psoriasis palmaris, and psoriasis unguium ; of these the 
two last only require to be specially noticed. 
Psoriasis palmaris has, in common with certain forms of 
lichen and eczema, been regarded as one of the varieties of 
the so-called baker’s and grocer’s itch ; it may appear on 
the palmar aspect of the hands, extending also to the wrists 
and the under surface of the fingers. In its development 
it is attended with more local symptoms than any other 
variety of the disease, inflammatory redness, accompanied 
by heat and itching, marking its advent; the skin on the 
palm of the hand then becomes swollen, irregularly elevated, 
and of a reddish hue, and the itching generally increases 
much, being at times as intense as in scabies or prurigo. 
Large dry whitish scales, of tolerable thickness and consist- 
ency, are rapidly secreted on the affected surface ; these 
soon desquamate, and are reformed again and again, as in 
the other varieties of the eruption. When it becomes chronic, 
the itching and heat diminish, but the integuments of the 
palm of the hand and of the palmar surface of the fingers 
become hardened, thick like leather, of a whitish-yellow 
color, corrugated, scaly, and fissured ; the motions are then 
limited and painful, the fingers cannot be completely flexed PSORIASIS. 
175 
or extended, and any sudden movement tears the fissured 
parts, and causes them to bleed. In a rare form described 
by llayer, and termed by him psoriasis palmaris centrifuga, 
the eruption begins by the formation of a small, rounded, 
squamous elevation in the centre of the palm, around it a 
series of eccentric, raised, red circles are developed, from 
each of which epidermic desquamation takes place; the 
eruption spreads in this manner until it covers the entire 
palmar aspect of the hands, which is then deeply fissured 
and painful, and bleeds from the slightest cause. Psoriasis 
attacks the backs of the hands also in some instances, and 
occasionally the soles of the feet. 
The eruption extends to the nails in most cases of chronic 
psoriasis of the hands, but what has been described as pso- 
riasis unguium is a change from their healthy condition, 
with or without the existence of the disease on remote parts 
of the body ; one or more of the nails presents a brownish- 
yellow, scaly elevation near its roots, which gradually 
becomes brittle, breaking and scaling off constantly ; it ac- 
quires a dirty yellowish hue, and not uncommonly the entire 
nail is shed, to be succeeded by the growth of another 
equally diseased. 
Psoriasis leprseformis (Atlas, PI. X. Fig. 5), which as 
already remarked, is the form of scaly eruption described 
by most dermatologists as a distinct disease, and termed by 
them ‘ Lepra,’ is chiefly characterized by the development 
of the patches in usually a perfectly circular, but sometimes 
in an ovoid shape. It commences without either constitu- 
tional or local disturbance, in the form of numerous small, 
round, reddish stains, perfectly distinct from each other, 
and scarcely elevated above the surrounding skin, on which 
shining silvery-white scales soon appear. Gradually but 
slowly, the circles enlarge from their circumference, which 
is somewhat more raised than the centre, attaining a size 
varying from a few lines to one or two inches in diameter ; 
some of the patches coalescing, they occasionally cover an 
extended surface of the integument, and acquire an irregu- 
larly rounded shape,—this is almost invariably the case on 
the convex aspect of the joints and in their neighborhood, 
on which parts the eruption presents an appearance scarcely 
to be distinguished from psoriasis aggregata; but the cir- 176 
SQUAMAE. 
cumference of the patches, no matter how large they may 
he, is always more elevated than the centre, which, after 
some time, assumes a comparatively healthy condition, its 
color becoming more natural and but slight desquamation of 
fine epidermic scales taking place from it. From the borders, 
however, the constant secretion and shedding of true scales 
continues ; they become thicker and more solid, retaining 
their whitish aspect, and are sometimes imbricated on each 
other at the outer border of each patch ; the integument on 
which the eruption is situated also becomes somewhat hyper- 
trophied. 
Psoriasis lepraeformis always runs a very chronic course, 
not exhibiting any tendency of itself to disappear, the dis- 
ease being kept up more by the desquamation of scales from 
the patches of eruption originally formed, than by the de- 
velopment of new spots ; at length, when under treatment it 
begins to amend, the central healthy surface extends towards 
the circumference, upon which fewer and thinner scales are 
secreted; the eruption at the same time ceases altogether to 
spread, and finally, only slight stains with furfuraceous epi- 
dermic desquamation remain, as an indication of the parts 
which were affected : these in most cases gradually wear 
away, but they sometimes last for years, and scales form on 
them in spring and summer, or on the least exacerbation, 
either from local causes or from irregularities of diet, re- 
lapses thus frequently occurring. 
A variety of this form of the eruption has been described 
under the name of Lepra nigricans, in which the color of 
the diseased patches is dusky-brown or livid, and the scales 
are very thin, soft, and of a dull, grayish-white aspect; in 
all other respects it resembles psoriasis lepraeformis, and its 
peculiarities evidently depend on the eruption affecting old 
persons or those with a broken-down constitution, in whom 
only it is witnessed. The Lepra alphoides of Willan is a 
variety of psoriasis guttata, in which the spots are somewhat 
larger, and the scales more silvery-white than usual. 
The leproid form of psoriasis chiefly affects the extre- 
mities, yet it sometimes attacks the face and scalp, and 
the trunk of the body: I have seen it occur very exten- 
sively on the scalp, where the patches coalesce and envelop PSORIASIS. 
177 
the entire of the head in one vast crust of scales, being, 
however, present at the same time on other regions of the 
body; on the face it is almost invariably in rather small 
patches distinct from each other, but most numerous on the 
forehead and the upper parts of the cheeks, just beneath the 
eyes. The spots of this form of the eruption not unfre- 
quently assume a somewhat symmetrical arrangement on the 
two halves of the body, appearing on the corresponding 
portions of the cutaneous surface at each side of the mesial 
line simultaneously, and in patches of nearly similar shape 
and size; the same fact is also witnessed at times in the 
other varieties of psoriasis, but it is of more frequent occur- 
rence in this form of the disease. 
The psoriasis annulata of some dermatologists, the orbi- 
cularis of others, corresponds in all respects with psoriasis 
leprseformis. And the variety termed infantilis presents 
no peculiarity, except its occurrence at a very early age, 
when, in consequence of the fineness of the skin, the surface 
is more easily irritated, and the local symptoms are, there- 
fore, more prominent. In all the forms of the eruption 
these, as has been remarked, are in general very trifling, but 
when any do exist, they are much aggravated by warmth, 
such as that caused by the heat of the bed. 
The chief annoyance which psoriasis causes is the dis- 
figurement it occasions when situated over any of the ordi- 
narily exposed regions of the body ; but if the eruption has 
existed for any length of time, and becomes chronic, the 
health may be more or less affected from the obstruction to 
free cutaneous transpiration which it must produce; and thu3, 
should any acute febrile disease attack a person affected with 
the eruption, the danger arising from the former may be in- 
creased, and the treatment rendered more difficult. It is 
probably due to this cause, also, that diuresis and diarrhoea 
are such frequent accompaniments of scaly diseases of the 
skin ; the latter complication is often very incontrollable, 
and the appearance of the stools at times is such as to war- 
rant the belief, that it is caused by an epithelial desquama- 
tion from the mucous membrane of the intestinal canal, 
analogous to the shedding of altered epidermic scales from 
the cutaneous surface. 
Causes.—Psoriasis occurs at all ages and in both sexes, 178 
SQUAM.E. 
being probably equally frequent in males and females ; its 
special causation is, like that of all cutaneous eruptions, 
enveloped in much obscurity. That it is sometimes produced 
by the action of certain irritating matters on the skin can- 
not be doubted ; yet we see the same local forms of psoriasis 
arise in persons who, from their occupation or position in life, 
are not exposed to the causes which produce it in bakers, 
washerwomen, shoemakers, and individuals of other trades. 
That squamous diseases are sometimes hereditary is also 
true, but their hereditary nature is of a singular character; 
thus, so far as my own experience would lead me to infer, 
the disease does not descend directly from parent to child 
with the same regularity as other hereditary diseases, but 
the predisposition frequently appears to be derived from 
an uncle or aunt, whose own children may be free from the 
disease ; and it also seems not uncommonly to lie dormant 
in a family for a generation, and again re-appear. In a 
case which I not long since attended, one son of a family 
was affected from his childhood with psoriasis of an invete- 
rate form; none of his brothers or sisters had any cutaneous 
eruptions, nor had his parents or grand-parents, but a pa- 
ternal uncle was affected with a similar disease, and also a 
first cousin not the child of this uncle : it was, moreover, 
stated that a grand-uncle was a sufferer for years from cuta- 
neous eruption. A somewhat similar hereditary transmis- 
sion of the disease has fallen under my notice in several in- 
stances, namely, that while the immediate descendants have 
escaped, one or more members of collateral branches have 
been affected. The true hereditary nature of psoriasis may 
therefore be doubted, and the cases which occur, and are ad- 
duced as proofs of it, might be accounted for in the same 
manner as those in which no such origin can be traced, and 
which are usually stated to depend on some constitutional 
peculiarity, not better understood now than in the days of 
Willan, who described it as characterized by “ a slow pulse, 
or a languid circulation of the blood, and, what must be 
generally connected with it, a harsh, dry, impermeable state 
of the skin and cuticle.” The latter part of this observa- 
tion has been adopted by Mr. Erasmus Wilson, who says that 
“ the disease appears for the most part in those who are re- PSORIASIS. 
179 
markable for a dryness of the skin.” Yet I cannot help 
thinking that this is a confounding of the effect with the 
cause, and that it w'ould be rather hazardous to predicate 
the likelihood of psoriasis occurring to an individual because 
his skin was unusually dry or harsh. The other causes, or- 
dinarily enumerated by dermatologists as being likely to 
produce psoriasis, are similar to those supposed to excite 
other diseases of the skin, such as irregularities of diet, in- 
sufficiency of food, the use of salted or highly-seasoned pro- 
visions, derangements of the digestive organs, and, in the 
female, deficient or excessive menstruation ; but none of 
these can be supposed to act unless when original predispo- 
sition to the disease exists. 
Diagnosis.—The distinction between psoriasis and all 
other diseases of the skin, except pityriasis, is well marked 
by the presence of the characteristic scales ; several other 
eruptions are, as has been remarked when speaking of them, 
accompanied by a form of desquamation, but this is present 
in only certain of their stages, and the desquamation con- 
sists merely of the shedding of slightly altered epidermis, 
in minute, very thin, furfuraceous particles, not to be con- 
founded with a true scale; this takes place especially in 
chronic eczema, in herpes, and in lichen, but in the two 
former there is more or less serous or sero-purulent dis- 
charge attendant on some part of their course, and in the 
latter papulae are to be distinguished on careful examina- 
tion. When either of the two latter diseases assumes a cir- 
cular form, as in herpes circinnatus or lichen circumscrip- 
tus, it is more apt to be confounded with psoriasis leprse- 
formis, but the characteristics just noticed then serve also 
to aid the diagnosis, and the eruption in neither of them 
presents the distinctly rounded shape with the depressed 
centre and scaly circumference of this variety of the disease. 
Psoriasis very rarely occurs on the scalp, unless when the 
eruption is present at the same time on some other part of 
the body, and this serves to a certain extent to distinguish 
it from other scalp affections ; the scales, too, when they 
are secreted on this region, are thicker and more solid than 
when situated elsewhere on the cutaneous surface, and con- 
sequently much more so than those of any other eruption 
that may occur there, than which they are also more per- 180 
SQUAMA. 
sistent, often constituting a firm, imbricated, adherent, dry 
crust, the outer layer of which only desquamates. Secon- 
dary syphilitic eruptions not unfrequently assume a scaly 
character, and are with difficulty diagnosed from the ordi- 
nary forms of psoriasis ; the history of the case and the 
concomitant symptoms are the differential points to be 
chiefly depended on ; the color of the parts of the cutaneous 
surface which are affected is, moreover, of a dull coppery or 
livid hue. 
From pityriasis the eruption is distinguished by the ab- 
sence in that affection of elevation of the diseased parts, 
which are of a yellowish or reddish-yellow color, by the scales 
being fine and thin, and by their being generally diffused 
over the cutaneous surface, not in distinct patches or spots. 
The chief diagnostic marks between it and ichthyosis are the 
thick, hardened, and rugose condition of the skin in the 
latter, and the non-existence of any scaly desquamation. 
The aggregated form of psoriasis is distinguished from the 
guttated variety without any difficulty, but in some cases a 
distinction can scarcely be made between it and psoriasis 
leprgeformis, a matter of but little import, as the treatment 
for both is in all respects similar. 
Prognosis.—Squamous eruptions are essentially of a 
chronic nature, but even when of years’ duration, scarcely 
ever affect in any respect the general health. Developed 
under the influence of a peculiar constitutional state of the 
skin, essentially of an obstinate character, and most apt to 
re-appear even in months or years after they seem to have 
been completely cured, length of time is as important to 
their perfect removal as the most judiciously planned course 
of treatment. The physician should, therefore, in every 
case, be most careful not to promise a speedy cure, and 
always, before prescribing, explain to his patient the chronic 
character of the disease, and that it requires a steady per- 
severance in the use of remedial measures for at least two 
or three months before even an apparent amendment will be 
perceptible. The anxiety of mind which an individual labor- 
ing under a cutaneous eruption suffers is very great, and 
this, too, adds to the difficulty of treatment. The promise 
of an eventual cure, though after a lengthened period, tends 
to alleviate this anxiety, and prevents the repeated disap- PSORIASIS. 
181 
pointment, changes of medical advisers, and trials of new 
plans of treatment, which the hope deferred, when a speedy 
cure has been promised, causes. 
Pathology.—“It is an admitted fact,” writes Cazenave, 
“ that the therapeutics of these diseases rest upon purely 
empirical grounds, and that, unhappily, there exists no sure 
guide to direct to a rational mode of cure. This statement, 
sufficiently true of most eruptions of the skin, is equally so 
of many other diseases of the body, and it should teach us 
not to despise the light thrown on pathology by the expe- 
rience derived from therapeutics. When it is found that a 
certain class of remedies act beneficially on deranged condi- 
tions of the animal economy, concerning the true nature of 
which doubt exists, it cannot be termed a petitio principii to 
infer that such derangements have a similarity in greater 
or less degree to affections the nature of which is known, 
and which are benefited by the same class of remedies. In 
the treatment of scaly diseases of the skin, iodine, in some of 
its various combinations, and cod-liver oil are especially use- 
ful; and I would, even from this therapeutic fact alone, be 
inclined to look upon the peculiarity of constitution in which 
they occur as nearly allied to the scrofulous; in fact, that 
their appearance is but one of the protean forms in which 
scrofula may be developed. And, independently of the bene- 
ficial effects of iodine, if we look to the remedies ordinarily 
proposed as specifics for their cure—of course I speak only 
of those administered internally, or, so to say, constitution- 
ally—what are they but tonics, or alteratives, or diaphore- 
tics, generally employed in the treatment of scrofulous affec- 
tions ? Again, if we lay aside the analogy derived from 
therapeutics, in how many points do not scrofula and scaly 
eruptions of the skin agree ?—their hereditary nature, their 
slow development, the period of life at which they appear, 
their production by innutrition or mal-innervation of the 
system, their obstinacy, their liability to recur or be again 
reproduced, the diathesis of the individuals in whom they 
appear, &c. 
Treatment.—In consequence of its extreme obstinacy and 
usually chronic character, there is probably no eruption of 
the skin, for the treatment of which so many varied reme- 182 
SQUAHJS. 
dies have been and still are proposed, as for psoriasis. Some 
trust altogether to topical medication for its cure, while 
others rely exclusively on the employment of constitutional 
remedies; both are needed, and neither should be neglected: 
the former must be used when the eruption has lasted for 
any length of time, or where it affects an extended surface 
of the skin, to produce a new local action, and to remove 
the diseased condition of the integuments; while the latter 
is required to correct any deviation from a healthy state, 
whether functional or organic, of the internal organs which 
may be present, and to alter the constitutional derangement, 
to the existence of which the eruption is due. Before com- 
mencing any plan of treatment, therefore, it is necessary to 
take into account the age, constitution, and diathesis of the 
patient, the extent of surface affected, and the previous dura- 
tion of the disease. 
In strong, healthy, plethoric young persons of either sex, 
when the eruption is of the guttated form, or affects only a 
small portion of the skin, its progress will generally be 
stopped, and a cure effected by the use of tolerably active 
saline cathartics every second or third day, preceded by a 
general bloodletting, and the daily use of a /res/i-water bath 
at the temperature of 98°. In persons of a sanguine tem- 
perament, or of very plethoric habit of body, the bleeding 
may be repeated, but in all cases only a moderate quantity 
of blood should be drawn, for when much has been removed 
at a time, or the operation frequently repeated, the eruption 
is apt to take on an aggravated character, and to become 
chronic. The best cathartics that can be used are the saline 
purging mineral waters, such as those of Pullna, of Seidlitz, 
of Cheltenham, of Leamington, of Droitwich, of Kreuznach, 
&c.; or, in their absence, the compound saline powder may 
be given in the dose of tw'o drachms, dissolved in half a pint 
of lukewarm water, to which from twenty to thirty minims 
of the liquor potassa, or preferably, Brandish’s alkaline solu- 
tion, and the same quantity of some aromatic tincture, as of 
orange-peel, should be added ; in either case the purgative 
should.be taken in the morning early before breakfast. By 
these simple means, continued for five or six weeks, many 
of the milder cases of psoriasis may be cured, but more gene- PSORIASIS. 
183 
rally, and invariably when the eruption has existed for some 
time before it is submitted to treatment, it is only alleviated 
thereby. 
When the disease affects old persons or individuals of a 
weak constitution, all debilitating remedies must be carefully 
eschewed; in its early stages then stimulating diaphoretics, 
combined with tonics, should be employed, and the tepid 
bath, or tepid douche if the eruption be local, used once or 
twice a week when the patient’s strength admits, or the hot 
vapor bath may in some cases be substituted with benefit for 
the water bath. Guaiacum and mezereon often prove the 
best diaphoretics in these cases of psoriasis, and they may 
be given in combination, as in the following form:— 
R. Tincturse Guaiaci Ammoniatse, . . . fl 5j- 
Tincturae Serpentariae, fl 5ss. 
Mucilaginis Acaciae, m. xx. 
Decocti Mezerei, fl 3viss. 
Decocti Dulcamarae, fl 5j. 
Misce. Fiat haustus. 
“ One such to be taken three times a day.” 
In scrofulous children, the progress of the disease may in 
its early stage he stopped and a cure effected by the adminis- 
tration of cod-liver oil; and this medicine proves also very 
successful in many cases of the local forms of the eruption 
in adults; but with children or young persons the employ- 
ment of the tepid bath at the same time should not be neg- 
lected. 
In the more aggravated forms of psoriasis, however, or 
when the disease has become chronic, recourse must be had 
to the more active alteratives, some of which have acquired 
a sort of specific reputation for the treatment of scaly 
diseases; and of all that have been used none effects a cure 
so frequently as arsenic, whether it be given alone or its 
administration conjoined with the application of various 
local agents. In every case the beneficial action of this 
medicine is more decided and more speedily manifested 184 
SQUAMJ2. 
■when iodide or the iodide of potassium is employed at the 
same time, or alternated with it, and in those cases—not 
few in number—in which arsenic, no matter how prescribed, 
disagrees, the preparations of iodine suffice usually to cure 
the disease. Arsenic may be prescribed either in the fluid 
form or in that of pill, but, however given, the dose should 
be small, increased very slowly, and continued for a length- 
ened time, at least for several months. Of the liquid pre- 
parations, the liquor arsenicalis of the Pharmacopoeias, 
Powler’s solution—a convenient name for prescribing when 
it is requisite to conceal from patients or their friends that 
arsenical preparations are being administered—is probably 
the best, or the liquor arsenici chloridi, De Yalangin’s min- 
eral solution—introduced into the last edition of the London 
Pharmacopoeia—may be used; they should not be given at 
first in a larger dose than four minims three times a day in 
an ounce of decoction of dulcamara, to which, except in 
persons of a full habit of body, two drachms of syrup of 
mezereon may be added. The arseniates of ammonia or of 
soda may also be given in solution in water, with a little 
syrup, or in some vegetable infusion or decoction, in the dose 
of a twentieth of a grain, very gradually increased to the 
fifteenth of a grain, three times daily. The following form, 
for the administration of the arseniate of ammonia, was first 
proposed by Biett:— 
R. Ammonise Arseniatis, . . . . gr. iss. 
Aquae destillatae, fl liij. 
Spiritus Angelica, .... fl 3vj. Misce. 
“ One tea-spoonful, gradually increased to three, to be taken 
for a dose in some aromatic water.” 
Donovan’s solution of the hydriodate of arsenic and 
mercury, which has become officinal in the last edition of 
the Dublin Pharmacopoeia, is another liquid form that has 
been often employed successfully in the treatment of pso- 
riasis ; in consequence of its containing mercury it is espe- 
cially applicable for those cases in which the eruption is 
either a secondary symptom, or is connected with a syplii- PSORIASIS. 
185 
litic taint in the system; but, from my own experience, I 
do not think that mercurial preparations in any form are 
generally applicable for scaly diseases, except in the local 
forms appearing in children, and I have not unfrequently 
seen their use followed by an aggravation of the symptoms. 
I have consequently, for some years back, substituted for 
Donovan’s solution a compound in which mercury is replaced 
by the iodide of potassium ; this mixture may then be 
termed an loduretted solution of the Iodide of Potassium 
arid Arsenic ; it is prescribed in the following form :— 
R. Liquoris Arsenicalis, ... in. lxxx. 
Iodidi Potassii, gr. xvj. 
Iodinii puri, gr. iv. 
Syrupi Florum Aurantii, . . fl 3ij. Solve. 
This solution, which is of a rich wine-yellow color, and keeps 
unchanged for years, contains in each fluid drachm five 
minims of arsenical solution, a grain of iodide of potassium, 
and a fourth of a grain of iodine. Forty minims of it at 
first may be given three times a day in simple water, or in 
any tonic or diaphoretic vegetable infusion or decoction, as 
individual circumstances may indicate, and the dose gradu- 
ally increased to eighty minims: it is of course, scarcely 
necessary to observe that this compound, as are all which 
contain iodine, is incompatible with vegetable preparations 
in which starch is present, or with the stronger acids. In 
cases in which from any reason it may be advisable not to 
prescribe arsenic, the Fowler’s solution can be omitted from 
the above mixture, and, unless in the inveterate forms of 
the eruption, or when it has been of very long standing, the 
iodine preparations should in the first instance be tried 
alone. 
Where it is wished to prescribe arsenic in the solid form, 
the best preparation of it is the iodide, which may be given 
in pill, made with conserve of roses or with hard manna and 
mucilage, in doses of from the twelfth to the tenth of a grain, 
three times daily, very gradually increased until the fourth 
of a grain is taken at each time; the arseniates of ammonia 
or of soda may be given in the same form. In the more re- 186 
SQUAMAE. 
bellious cases of the disease, and especially when it occurs in 
persons of a debilitated constitution, an excellent and favor- 
ite formula for the administration of this powerful agent, is 
what has been termed the Asiatic pills, in consequence of 
their being first beneficially employed in the East Indies, 
whence we derived our knowledge of their efficacy; they 
are prepared by rubbing together a drachm of arsenic and 
nine drachms of powdered black pepper, with sufficient 
liquorice powder and mucilage to make 800 pills. Each of 
these contains about a 13th of a grain of arsenic, and one 
or two may be given daily. No matter what preparation of 
arsenic is employed, it should be administered after meals, 
as it is then less apt to derange the stomach, and the effect 
should be carefully watched: the continuance of headache, 
of sickness and pain in the stomach, of dryness of the fauces, 
or of tenderness with heat and redness of the eyes for a few 
days, requiring its omission for a short time, and the adminis- 
tration of an active cathartic, when it may be again resumed. 
It generally occurs that in the treatment of scaly diseases 
by arsenic or by iodine, the eruption at first presents an 
aggravated appearance, the affected parts exhibiting an irri- 
tated aspect, and the scaly desquamation being much aug- 
mented, but these symptoms soon pass away, and signs of 
amendment begin to show themselves. In all cases the use 
of the remedies which have proved successful should be per- 
sisted in for some weeks after the disease is apparently 
cured, so as to prevent a relapse. 
Chronic cases of psoriasis are very frequently complicated 
with derangement of the digestive organ, evidenced by vari- 
ous dyspeptic symptoms; the most prominent of these are 
nausea and vomiting, immediately after meals. This con- 
dition must be remedied by appropriate alterative and tonic 
treatment, previously to the employment of medicines, with 
the view of acting directly on the eruption, for if arsenic or 
iodine, in any form, be given while this condition is present, 
they will tend to increase the existing irritation, and their 
expected beneficial action be thereby prevented. The tepid 
fresh water, the douche, or the vapor bath, should be em- 
ployed at least once or twice a week, in addition to the use 
of the internal remedies now recommended. 
But cases of psoriasis occur which resist with obstinacy PSORIASIS. 
187 
the administration, even though much prolonged, of either 
or both of these powerful medicines, and then recourse must 
be had to some of the many other remedies, both constitu- 
tional and topical, which have at times proved useful, and 
have consequently found warm advocates. Sulphur and 
its preparations have been highly praised by many practi- 
tioners for their efficacy; and in the very inveterate forms 
of the eruption occurring in languid constitutions, or when 
there is no determination of blood to the affected parts, nor 
local irritation, the sulphurous mineral waters, both taken 
internally and employed in the form of tepid bath, cure the 
disease when other remedies have failed ; but to derive the 
full benefit from them, their use should be continued for 
several months, otherwise the eruption is sure to reappear. 
When the mineral waters cannot be procured, or the patient 
is unable to go to their sources, which is always most advis- 
able, sulphur may be given internally, and baths or lotions 
of the sulphuret of potassium used. In the local forms of 
the disease the iodide of sulphur ointment is a most valuable 
topical application, but it should be used only of moderate 
strength, from eight to twelve grains to the ounce of -white 
wax ointment, and its efficacy is much increased by the 
addition of a drachm of glycerine to each ounce. 
M. Cazenave has recently administered the carbonate of 
ammonia, in the treatment of psoriasis, with marked success; 
he prescribes it in the dose of about two and a half grains, 
from one to three times a day, in a table-spoonful of syrup 
of sarsaparilla. “ In general, the symptoms it causes are 
scarcely to be noticed; some slight disturbance of the di- 
gestive organs, and occasionally slight heat and tingling of 
the skin. Yet, after an interval of time, varying usually 
from three to eight days, when good results follow, the scales 
begin to be detached, those which succeed them are more 
and more fine and of a duller aspect, and the patches on 
which they are situated lose their red tint and gradually 
fade away; after a longer or shorter period a complete cure, 
and one which is often permanent, takes place.”1 When 
carbonate of ammonia was thus administered, M. Cazenave 
found it to occasion diarrhoea, preceded by colic, lassitude, 
1 Annales des Maladies de la Peau et de la Syphilis, tom. iii. p. 315. 188 
SQUAMAE. 
sometimes headache, slight acceleration with diminished full- 
ness of the pulse, alternations of heat and cold of the sur- 
face, &c.; these symptoms disappeared on omitting the use 
of the medicine for a few days, and this fact, together with 
their similarity to those caused by arsenic, led him to draw 
an analogy between the mode of operation of the two me- 
dicines. 
Amongst other constitutional plans of treatment proposed 
for psoriasis, bringing the system under the influence of 
mercury has proved successful in the hands of some prac- 
titioners ; it is chiefly applicable, as already remarked, to 
those cases in which a venereal tint exists; but it may also 
be used in the milder forms of the eruption, when they do 
not yield to the more simple treatment recommended above. 
The preparations of mercury which are preferred are those 
that act slowly, and rarely produce salivation, such as the 
red iodide or corrosive sublimate; the latter is very fre- 
quently prescribed in decoction of cinchona bark, a good 
combination, although not strictly chemical. 
Copland relies chiefly on the employment of emetics and 
purgatives at the same time, and their use is certainly at- 
tended with much benefit in most cases, previously to com- 
mencing the administration of the more active alteratives. 
The alkalies, especially the liquor potassse, have also been 
highly recommended, particularly in the local forms of the 
eruption, but in many cases in which I tried them the result 
was not satisfactory. From its original use by Biett, and 
the favorable notice taken of its action by Rayer, tincture 
of cantharides has been rather extensively administered, 
especially on the Continent, in the treatment of psoriasis; 
it certainly succeeds in some cases in which other remedies 
have failed, but its employment, even in small quantity, 
must be carefully watched, in consequence of the dangerous 
effects it is apt to produce on the urinary organs. It may 
be given in doses of five minims, gradually increased to fif- 
teen or twenty, three times a day, in at least an ounce of 
some emulsion or of decoction of linseed or barley. Nu- 
merous other medicines, especially diaphoretics, diuretics, 
tonics, and stimulants, have been employed in this disease, 
but none require mention here, with perhaps the exception of 
tar or pitch, which, when given internally, and at the same PSORIASIS. 
189 
time applied to the affected surface, is regarded by some 
physicians as quite a specific; I consider it, however, much 
inferior in its medicinal efficacy to most of the other thera- 
peutic agents which have been now noticed. 
Local applications, ointments, lotions, baths, &c., have 
been at all times favorite methods of treating psoriasis, and 
many have attempted to cure the disease by their use alone; 
with this view, also, it has been proposed to destroy the 
eruption by the free application of nitrate of silver to the 
affected parts, but such a proceeding tends only to aggra- 
vate the morbid state of the cutaneous surface, and is not 
altogether unattended with danger. The simple/resA-water 
tepid bath has proved, in my experience, the best topical 
remedy, I might almost say the only one needed, and it 
should be employed at least once a week in all forms of 
psoriasis; its use tends to restore the natural secretion of 
the skin, and to prevent the accumulation of scales. When 
the eruption is local, and attended with symptoms of irrita- 
tion or inflammation, soothing unguents, as those containing 
chloroform, preparations of lead, zinc, &c., or poultices pre- 
pared with the lead wash, often prove highly serviceable; 
and in the more chronic cases, when neither inflammation 
nor inflammatory irritation is present, stimulating applica- 
tions are occasionally required ; of these, probably the best 
is the iodine of sulphur ointment spoken of before, or the 
following, which was highly recommended by the late Dr. 
Anthony Todd Thompson :— 
R. Calomelanos, 3 j* 
Unguenti Picis liquidse, . . . . 3 iv. 
Adipis praeparati, 3 j. Misce. 
Of other local applications it will be sufficient to enume- 
rate blisters, creasote, turpentine, tincture of iodine, corro- 
sive sublimate in lotion, black and yellow wash, citrine oint- 
ment, &c.; the alkalies, when applied topically, generally, 
I think, prove injurious. 
Strict attention to diet and regimen is especially requisite 
in the treatment of psoriasis; a milk diet should be, if 
possible, enforced, except in cachectic or broken-down con- 190 
SQUAMAE. 
stitutions, and when from this or any other cause it cannot 
be altogether adopted, farinaceous articles and milk should 
be made as much as possible a portion of the general food, 
and in addition, fresh meat, plainly dressed, or poultry, 
should alone be allowed. From its being so much easier to 
carry out dietetic rules in hospital patients than writh those 
in private or in dispensary practice, more satisfactory results 
are usually obtained in treating the former, and consequently, 
perfectly accurate conclusions as to the effects of remedies 
in the treatment of any disease, whether of the skin or not, 
can only be drawn from hospital experience. 
PITYRIASIS. 
Pityriasis is a scaly cutaneous disease, characterized by 
an abundant secretion and desquamation of minute, furfura- 
ceous, white, and shining scales, from slightly elevated, 
irregular patches of the skin, of a yellowish, reddish-yel- 
low, or dark-brown color, varying in extent, or from the 
surface of the body generally. It is attended usually with 
smart itching of the parts affected, sometimes with painful 
inflammatory tingling, and both are much augmented by any 
cause that may produce increased capillary circulation of the 
integuments. It is non-contagious, unaccompanied by con- 
stitutional symptoms, and although attended in its early 
stages, and in some cases throughout its entire duration, 
with more or less local inflammatory action, almost invari- 
ably runs a very chronic course. Pityriasis is, for the pur- 
poses of description, naturally divided into varieties, as it 
may affect the cutaneous surface generally, or some special 
region of the skin. Willan, who has been followed amongst 
others by Cazenave and Schedel, described but one local 
form of it—that of the scalp, and divided the eruption, when 
it affected the body generally, into three varieties, according 
to the color which the diseased patches of integument pre- 
sented, namely, Pityriasis rubra, Pityriasis nigra, and Pity- 
riasis versicolor. Both Bayer and Erasmus Wilson consider 
the first of these only as being a scaly disease, and regard 
the other as simply alterations in the color of the skin, ac- PITYRIASIS. 
191 
companied by a foliaceous or mealy desquamation, and not 
by the separation of true scales. As, however, in both 
forms there is a squamous secretion, differing only in degree 
from the first, I prefer to regard them as sub-varieties of 
general pityriasis. Adopting, then, strictly the division of 
the disease into two forms,—general and local,—they may 
be termed:— 
Pityriasis diffusa. 
“ localis. 
The early stage of pityriasis diffusa (Atlas, PI. XI. Fig. 
2) is marked by a sensation of heat and tingling on various 
parts of the cutaneous surface, usually on the neck, the 
chest, the abdomen, the back, and sometimes on the face 
and hands; uncircumscribed patches of a yellowish or red- 
dish-yellow color, scarcely elevated above the surrounding 
integument, appear on the places which had been the seat 
of the itching, and on them minute, branny, micaceous 
scales soon form, at first in small quantity, but afterwards 
in very great abundance, desquamating freely when the 
spots are rubbed, or should the eruption be general, on the 
least movement of the body. The affected patches vary 
much in shape and size, being often of an irregularly rounded 
form separated at first by healthy skin, over which, in most 
cases, however, the scales gradually extend, and, becoming 
confluent, cover the body almost universally; the furfura- 
ceous desquamation is then extreme, and is attended with 
much itching, especially when the surface of the body is 
heated, and the disease assumes a very obstinate character. 
The skin from which the desquamation takes place—which 
in the commencement presents various shades of red and 
yellow intermixed, whence the specific appellation of pity- 
riasis versicolor has been applied to this form—gradually 
becomes of a lighter shade of yellow, and in many instances 
the secretion of scales then ceases, yellowish stains remain- 
ing on the surface for some time; but in others the desqua- 
mation, attended with more or less itching, lasts with extra- 
ordinary obstinacy for months, or even years, after the skin 
has resumed its natural color. 192 
SQUAM2E. 
In some cases the eruption is more partial, being confined 
almost exclusively to the integuments of the thorax, usually 
appearing on the chest; the spots or patches assume from 
the first a bright color, so marked that in the commencement 
they can scarcely be distinguished from erythema; they are 
also attended with much heat and itching, indicating the 
inflammatory nature of the disease; the characteristic scaly 
secretion and desquamation soon appear, however, and deter- 
mine its nature. This form, which is also very obstinate, 
has been termed pityriasis rubra; it is of much less frequent 
occurrence than pityriasis versicolor, but oftener witnessed 
than the next sub-variety. 
Pityriasis nigra is a very rare form of the eruption; it 
does not seem to differ in any respect from pityriasis rubra, 
except in the color of the diseased patches, which are dark- 
brown or nearly black, and usually appear on one or both 
of the lower extremities; according to Cazenave’s observa- 
tions, the black tint is in some cases so superficial that, on 
removing the epidermis, the derma is seen beneath, of a red, 
shining aspect; in others, however, the color affects the sub- 
epidermic layer of the derma. In both pityriasis versicolor 
and pityriasis nigra, the chromatogenous functions of the 
derma must be more or less disordered, to account for the 
peculiar coloration of the skin which accompanies them. 
As before remarked, Rayer considers the changed color as 
their essential characteristic, and he consequently terms the 
former Chloasma, and the latter Melasma; this view has 
been adopted by Wilson also. 
Several local forms of pityriasis have been described 
chiefly by Rayer; thus he notices it specially as it affects 
the eye-lids, pityriasis palpebrarum; the mouth and lips, 
pityriasis oris et labiorum; the prepuce and pudendum, 
pityriasis prceputialis et pudendalis; the feet and hands, 
pityriasis palmaris et plantaris; and the scalp, pityriasis 
capitis. None of these, except the last, differ essentially 
from the eruption as it affects the body generally, and do 
not, therefore, require to be specially described; many der- 
matologists, indeed, and I think with much correctness, 
admit the existence of but one local variety of pityriasis,— 
that of the scalp. PITYRIASIS. 
193 
The development of pityriasis capitis (Atlas, PL XI. 
Pig. 3) is not accompanied by any sign of constitutional 
or local disturbance, but soon after its eruption it gives rise 
to much itching, without heat or redness of the surface. 
The disease consists in the secretion of numerous minute, 
papyraceous, dry, and shining scales, in most cases scattered 
over the entire of the head, without any sensible elevation 
of the surface, and perfectly free from moisture. I cannot 
describe the precise manner in which the eruption originates, 
as I have never seen it until the squamous secretion was 
fully developed, there being no symptoms to direct the 
patient’s attention to it until then. The presence of the 
scales produces much itching, compelling the individual 
affected to scratch the head, by which they are very readily 
detached in large quantity, in the state of a fine powder or 
dandruff; their removal is rapidly succeeded by a further 
secretion. If the condition of the scalp in pityriasis capitis 
be examined, the surface is found to be closely covered with 
the imbricated scales, with small intervals here and there; 
the skin of the unaffected parts presenting a smoother or 
more polished appearance than natural. On removing one 
of the scales we find that the spot on which it is seated is 
raised, and that another finer scale may be removed from 
it; and it is not until after the removal of several scales, 
each finer than the preceding, that we arrive at the red- 
dened and inflamed surface of the scalp, which is somewhat 
depressed. The chief annoyance which it causes is itching; 
the patient, in scratching himself to allay this troublesome 
symptom, removes large quantities of dandruff; and in the 
child the irritation is often so great that the scalp is torn, 
becomes inflamed, eczematous vesicles appear, and the origi- 
nal affection is thus complicated. 
Although the hair in this eruption is not apparently 
diseased, it grows weak and thin, and falls out on the 
slightest cause, so that, when of long duration, baldness 
may result, which, except in very old persons, is, however, 
only temporary. 
Pityriasis diffusa may occur at any age, but it is most 
common in adults; it seems to affect both sexes with an 
equal degree of frequency. Pityriasis capitis is most usually SQUAMiE 
met with in infants at the breast, the frequency of its 
appearance decreasing with the advance of years towards 
puberty, at which age it is of very rare occurrence, but it 
again appears at the approach of old age. It thus seems 
to be most frequent when the head is least covered with 
hair, and it is also most generally seen in individuals whose 
hair is naturally thin. 
The causes of pityriasis are very obscure; in most cases 
it is manifestly a constitutional affection, but in some in- 
stances it is evidently produced by the action of local irri- 
tants. Thus its occurrence on the scalp may be often 
accounted for by the use of hard brushes or a fine tooth- 
comb, or from not drying the head sufficiently after it has 
been washed ; appearing, too, most frequently at those ages 
in which the scalp is least covered with hair, it may be then 
caused by the sudden changes of temperature to which 
the surface is consequently exposed. The eruption, when 
general, appears to be more or less connected with some 
deranged state of the nervous system, especially when this 
state is accompanied by increased cutaneous susceptibility, 
and is also not unfrequently attendant on a disordered con- 
dition of the digestive organs. I can confirm the observa- 
tion of Cazenave that in some cases especially in nervous 
females, pityriasis capitis succeeds repeated attacks of nerv- 
ous headache. The use of stimulating cosmetics, whether 
in the form of lotion or of pomade, is a not unusual exciting 
cause of the eruption. 
Diagnosis.—Pityriasis is distinguished from psoriasis by 
the fineness and thinness of the scales, which are not thicker 
than the healthy scarf-skin, even when the disease is very 
chronic; by their being desquamated in excessive quantity; 
by the parts affected being scarcely elevated above the 
surrounding integument; by the peculiar color of the sur- 
face of the skin on which the eruption is situated ; and by 
the attendant pruritus. It might be confounded with chronic 
lichen or eczema, in consequence of the furfuraceous desqua- 
mation which attends the advanced stages of both these 
diseases; pityriasis, however, is not preceded by any erup- 
tion, is never accompanied by any discharge, and in it the 
skin is never chapped nor fissured. From ichthyosis the diag- PITYRIASIS. 
195 
nosis is made without difficulty, the peculiar dry, hard, 
rugose, and, so to say, horny condition of the integuments 
being sufficiently characteristic of that affection. Pityriasis 
capitis is distinguished from the other eruptions which occur 
on this region of the body by its true scaly nature, the 
scales being minute, dry, papyraceous, and imbricated, 
though scarcely, if at all, elevated above the surface of the 
scalp, and readily separated in the form of a fine powder or 
dandruff; by there being no attendant inflammation unless 
it be produced by some irritating cause; by the absence of 
discharge; by the hair being unaltered, but falling out more 
easily than natural; and by its not being contagious; it 
occurs, too, most generally in advanced periods of life, being 
rare in childhood, adolescence, and manhood. 
Prognosis.—Trifling an eruption as pityriasis seems to 
be, it is one of extreme obstinacy, and not unfrequently, 
when it has continued long, causes more or less derange- 
ment of the general health, chiefly from the mental annoy- 
ance which its persistence occasions; this is especially 
witnessed when it affects the scalps of females at or about 
the age of puberty, to whom the falling out of the hair and 
the continued desquamation of dandruff are a source of con- 
stant distress: I have seen more than one instance in which 
extreme nervous and general debility wTas produced by 
this cause alone. The longer pityriasis has lasted the more 
difficult it is to cure, and relapses after apparently perfect 
recovery are very likely to occur. That the continued 
existence of the eruption generally over the surface of the 
body may not be altogether unattended with danger is 
proved by Rayer’s narrative of a case in which he saw it 
prove fatal. 
Treatment.—In the treatment of pityriasis, as of many 
other cutaneous diseases, it is too much the habit to resort 
to the indiscriminate use of active stimulants both internally 
and as topical applications; I do not mean to undervalue 
the benefit derived from their employment in many chronic 
eruptions, but I must protest against the custom which for 
some years back has become so general, of having recourse 
to them in all cases without regard to the fact that a majo- 
rity of the affections of the skin are inflammatory in their 196 
SQUAMJ3. 
origin, and that even in their advanced stages, when all 
tendency to inflammatory action has apparently disappeared, 
local irritation or capillary excitement often causes a fresh 
outbreak of the eruption, or an aggravation of the symptoms. 
These remarks, while they are true of many cutaneous 
diseases, are especially applicable to that now under con- 
sideration, which, though much less inflammatory than 
many others, is extremely liable to be reproduced by the 
action of stimulants,—whether constitutional or local,—a 
fact that every one, who has had any experience in the 
treatment of this class of affections, must, I feel certain, 
have observed. 
When pityriasis is of the diffuse form, if it occurs in 
strong, healthy, young persons, a small general bleeding 
proves often of service in its early stages, but the with- 
drawal of blood is not admissible otherwise; tepid gelatine 
baths should be used for at least half-an-hour daily, or 
every second day from the first, and purgatives be freely 
administered : of the latter class of medicines none prove 
so useful as the alkaline cathartic mineral waters, either 
thermal or cold, according to the age and constitution of the 
patient; for example, those of Carlsbad or Marienbad ; but 
a combination of mild mercurials with alkalies, as in some- 
what the following form, should be prescribed at the same 
time: 
R. Pilulse Hydrargyri, gr. ix. 
Sodse Carbonatis siccati, gr. vj. 
Extracti Taraxaci, gr. xij. 
Extracti Hyoscyami, gr. iij. 
Misce. Fiant pilulse sex. 
“ One to be taken every second day half-an-hour before 
dinner.” 
When the mineral waters cannot he procured, a drachm 
of the sulphate of soda—previously deprived of its water 
of crystallization by exposing it to a red heat—and twenty 
grains of the bicarbonate of soda, dissolved in half-a-pint 
of tepid water, may be given in the morning after the pill. 
Should the eruption resist this plan of treatment, and 
exhibit a tendency to become chronic, alkaline baths— PITYRIASIS. 
197 
four ounces of the carbonate of soda, or two ounces of 
purified carbonate of potash, in sufficient fresh water for 
an ordinary bath, at the temperature of from 80° to 92° 
Fahr., according to the season of the year—may be sub- 
stituted for those of gelatine ; and the surface of the body, 
previously well dried after leaving the bath, should be 
anointed with a pomade, composed of four ounces of pre- 
pared lard, well beaten up with an equal quantity of elder- 
flower water, then squeezed as dry as possible, and half-an 
ounce of glycerine added. The mercurials and alkaline 
saline cathartics must still be continued; but should the 
eruption become essentially chronic, the more active consti- 
tutional alteratives, iodine and arsenic separately or com- 
bined, as recommended for the treatment of psoriasis, must 
be prescribed. In cases in which the pruritus is extreme, 
chloroform, added to the pomade above recommended, in 
the proportion of from eight to twelve minims to the ounce, 
will be found the most effectual application for allaying it; 
lotions and ointments containing prussic acid or the pre- 
parations of lead, have been employed usefully for the same 
purpose. 
In some of the local forms of pityriasis, the vapor douche 
bath is of especial service, and the constitutional treatment 
applicable to the general disease is also indicated. When 
the scalp is the part affected, the hair should be cut close— 
not shaved off—and so kept during the progress of the treat- 
ment : this is not requisite in old persons when the hair is 
thin on the head. In the early stages, weak alkaline oint- 
ments and lotions, with the addition of glycerine to either, 
will be found the most beneficial applications; but when the 
eruption is of long standing, or occurs in persons of debili- 
tated constitution, the tannic acid or dilute citrine ointment 
should be substituted for the former, the lotion being still 
used each time before the ointment is applied. When the 
eruption appears on the scalp of scrofulous children, cod- 
liver oil will be beneficially administered ; but for those who 
are not scrofulous the alterative powders of the iodide of 
mercury and hydrargyrum cum creta, as I have recom- 
mended for other diseases of the scalp, are better adapted. 
In very obstinate cases of any of the local forms of this 
eruption, more stimulating applications may be tried, such 198 
SQUAMiJ. 
as ointments containing calomel or white precipitate, in the 
proportion of a drachm of either to the ounce of prepared 
lard or of white wax ointment, with the addition of glyce- 
rine, or lotions containing the cyanide of mercury or corro- 
sive sublimate; but their effects must be carefully watched, 
as they often cause a sudden aggravation of the symptoms. 
For the same reason the sulphurous mineral waters and sul- 
phurous baths should be used with caution, yet they unques- 
tionably prove at times of much benefit in chronic cases of 
the disease in persons of a languid circulation. 
Dietetic rules are most important in the treatment of 
pityriasis, and when the digestive organs are deranged, 
remedies calculated to restore their healthy tone should be 
employed. The food ought to be light but nourishing, as 
the strength must be supported, and therefore milk and 
farinaceous articles of diet are especially indicated : in the 
case of children, a strictly milk and vegetable diet should 
be enforced. Stimulating or heating drinks must be alto- 
gether prohibited, and the surface of the body kept as much 
as possible of a uniform temperature, extremes of heat and 
cold being avoided. In consequence of the liability to re- 
lapse, whatever treatment may be found to be successful 
should be continued for at least a month or six weeks after 
an apparent cure has been effected. HYPERTROPHIC. 
199 
CHAPTER VII. 
HYPERTROPHIC. 
In the Order Hypertrophic, I purpose to include all 
diseases of the skin which are specially characterized by 
an hypertrophied condition, attended with a morbid change 
from their normal state, of any or all of the anatomical 
elements which compose the tegumentary membrane. The 
affections to be described in this division are of a chronic 
nature both in their development and progress, rarely ex- 
hibiting in any of their stages signs of constitutional dis- 
turbance or inflammatory action, either local or general; 
yet some of them are unquestionably of constitutional ori- 
gin, while others are manifestly produced by the direct 
action of irritant causes. I have already mentioned the ob- 
jections which exist to the employment of the term “ Tuber- 
cula,” for the purpose of designating a group of diseases of 
the skin, or to its retention at all in cutaneous nosology ; 
applied formerly to include several affections, nearly all 
modern dermatologists who still retain it have restricted its 
application to some forms of secondary syphilitic eruptions, 
to Lupus, and to Elephantiasis ; now of these it is evident 
that the first will be both more correctly classed and more 
conveniently described with the other syphilitic diseases 
which affect the skin ; the second is specially characterized 
by its malignant nature ; and therefore the third only can 
with any degree of accuracy be designated as a tubercular 
affection, and yet although placed by Willan and Bateman 
in this class, it differs essentially from their own definition of 
a tubercle. 
The appellation I propose has the advantage of not being 
an innovation in cutaneous nosology ; it has a place in all 
modern natural systems of classification of affections of the 
skin, as constituting a special group, and I only seek to ex- 
tend its signification as in any artificial arrangement may 
be correctly done—there being no necessity here for regard- 
ing the so-called natural affinities, similarity of elementary 200 
HYPERTROPHIC. 
lesion or of external phenomena sufficing for the grouping 
of diseases. The order might certainly be made to consti- 
tute several groups were strict accuracy in arrangement the 
sole or even chief object in my inquiry; but regarding all 
systems of classification as altogether secondary, and useful 
more for the purpose of description than for affording any 
aid either in diagnosis or treatment, I think it better to 
make as few divisions as possible. The following are the 
diseases I shall describe in this Chapter : Ichthyosis, Mollus- 
cum, Stearrhoea, Elephantiasis, Verruca, Clavus, Callositates, 
Condylomata, Naevus. 
Ichthyosis (Fish-skin disease) (Atlas, PL XI. Fig. 4) is 
characterized by a morbid alteration and hypertrophied 
condition of the epidermis, by which it is converted into 
thick, dry, horny, adherent scales, the orifices of the hair 
follicles and of the sudiparous and sebiparous glands being 
thereby obstructed. This affection, classed by Willan and 
those who have adopted his views, amongst the Squamae, is, 
as I have stated in the last Chapter, distinctly separated 
from the eruptions contained in that group, by its not being 
attended with any desquamation of scales. Most modern 
writers on diseases of the skin differ as to what are the ana- 
tomical lesions by which it is constituted, and consequently, 
as to the precise position which it should occupy in nosolo- 
gical arrangement. Mr. Erasmus Wilson, in his earlier 
writings, regarded it as consisting in a hyperformation of 
the epidermis, but he has changed his opinion, and more re- 
cently announced his belief that the morbid condition of the 
integuments is composed of concretions of altered sebaceous 
substance ; repeated observation, aided by microscopic exa- 
mination, compels me, however, to differ with so eminent an 
authority, nor have I been able even to comprehend the 
grounds on which he has come to this conclusion. Dr. A. 
T. Thomson did not live to publish his opinions in the post- 
humous work which bears his name ; but that he had not 
been able to satisfy his mind as to the nature of the disease, 
is evident from the account of it given by his editor, Dr. 
Parkes. By Cazenave and the majority of the recent 
ICHTHYOSIS. ICHTHYOSIS. 
201 
French dermatologists, ichthyosis is looked upon as a lesion 
of epidermic secretion, and is, therefore, made to constitute 
a distinct group, of which it is the type. Gustav Simon, 
whose views I adopt, regarding ichthyosis as an hypertrophy 
or increased development of the epidermis,1 places it in his 
classification amongst the Ilypertrophise. 
Willan and Bateman described two forms of the disease, 
terming the one ichthyosis simplex, and the other ichthyosis 
cornea; they differ, however, merely as to the degree in 
which the epidermis is altered, and therefore cannot be cor- 
rectly separated from each other for the purposes of descrip- 
tion ; other varieties have also been constituted by different 
writers according to the appearance which the altered in- 
teguments may present in certain cases : thus Wilson divides 
the disease into Ichthyosis squamosa, and Ichthyosis spinosa ; 
a form has been termed Ichthyosis hysterix by Fuchs; and 
another, Ichthyosis scutellata by Schbnlein. 
Ichthyosis may be congenital, but more usually, commenc- 
ing a few months after birth, lasts for life, affecting gene- 
rally, after a short time, the entire of the cutaneous surface, 
except the palms of the hands, the soles of the feet, the 
eyelids, the lips, and the prepuce. It consists at first of an 
hypertrophied condition of the epidermis, which is dry, 
harsh, and corrugated, the natural linear markings dividing 
it into distinctly separated, polygonal, and lozenge-shaped 
compartments. This change, except in congenital cases, in 
which at birth it is very general over the body, is first wit- 
nessed in certain regions only, namely, the ankles, the 
knees, the backs of the hands, the borders of the axillae, 
and the neck; the morbid alteration becoming gradually 
more aggravated on these parts, extends superficially also, 
affecting next the scalp, the fronts of the legs, the backs of 
the arms, the folds of the groins, the breasts, and the lower 
part of the abdomen; by degrees, however, if the disease 
be unchecked by treatment, the epidermis of the entire 
body, with the few exceptions noticed above, becomes en- 
gaged. 
When ichthyosis is congenital, the skin of the infant at 
1 Die Hautkrankheiten (lurch anatoraischo Untersuchungen : Berlin. 
Second Edition, 1851, p. 49. 202 
HYPERTROPHIC. 
birth is dry, rough, uneven, and of a grayish-brown color, 
but the epidermis is little hypertrophied ; this condition of 
it may continue for years, or even for life, accompanied by 
a constant mealy exfoliation, without being farther aggra- 
vated, constituting the mildest cases of the affection. More 
generally, however, the epidermis soon becomes thickened, 
hypertrophied, and of a scaly aspect, bearing at times much 
resemblance to the scales of a fish—whence the name derived 
from the Greek word, a fish, was applied to the disease; 
the surface is deeply furrowed, shining, and of a sallow or 
greenish hue, free from hairs, and devoid of any secretion 
or natural moisture ; in parts the fissures occasionally extend 
quite through the hypertrophied epidermis, and the derma 
beneath is seen to be somewhat redder than in its healthy 
state, but it is not inflamed; the superficial thickened layers 
may be removed in scales by the nail, when the surface on 
which they rest presents also a similar appearance, but the 
epidermis is rapidly reproduced again in the same unhealthy 
condition. 
Although, as has been mentioned, the orifices of the sudi- 
parous, and sebiparous glands are quite obstructed, there 
are no constitutional symptoms caused thereby, the general 
health does not appear to suffer in any respect, nor is the 
altered state of the integuments accompanied by heat, itch- 
ing, or any other sign of local irritation. 
In some cases the epidermis is much more altered from 
its normal condition than has been described above, pre- 
senting the appearance of innumerable short spines aggre- 
gated together without any intervening space, over all those 
parts of the body which the disease affects; this form has 
been termed spinosa by Wilson, but Dr. Copland, regarding 
it as consisting in an hypertrophied and elongated condition 
of the papillae of the skin, proposes to name it 'papillary 
ichthyosis. The surface of the body of persons afflicted 
with it presents a singular and remarkable aspect, being of 
a greenish-brown color, and so hard as to feel like horn and 
to produce a grating noise when the hand is passed quickly 
over it, yet more or less elastic and yielding when pressed ; 
the diseased epidermis is firmly adherent to the derma, and 
if attempted to be torn off with the nail, the part on which 
it is situated bleeds and is painful. The spiny elevations ICHTHYOSIS. 
203 
may be separated from each other, when it will be seen that 
they are of a grayish or yellowish-white color—the dark 
tint existing only on the surface exposed to the air—and 
that they vary in elevation from an eighth to a quarter of 
an inch; some of them, however, attain a much greater 
prominence than this, forming excrescences, or, as they have 
been termed, horns, fully an inch or even more in length. 
On the parts of the body which are exposed to pressure, as 
on the buttocks and on the joints, callosities form, and in 
extreme cases the power of motion may be much limited. 
This form of ichthyosis is almost invariably congenital, not 
attaining its complete development, however, until at or 
about the age of puberty. 
Since this disease of the skin was first noticed, it has at 
all times attracted much attention, owing to the singular 
condition of the integuments by which it is characterized ; 
individuals affected with it in an aggravated form having 
been exhibited for money, in the case of males being termed 
porcupine men, and of females, mermaids, the latter from 
the supposed resemblance of the skin to the scales of fishes; 
but it has been more aptly compared to the hide of an 
elephant or of a rhinoceros. Not being of frequent occur- 
rence, moreover, in its full development some of these cases 
have been carefully described, the most celebrated probably 
being that of the family of the Lamberts, which occurred in 
the beginning of the last century, and to which I shall have 
occasion again to refer as illustrating the hereditary cha- 
racter of the disease. 
Whether ichthyosis is general or partial, the superficial 
layers of the hypertrophied epidermis are constantly being 
shed as a fine mealy desquamation, or, when softened by a 
warm bath, may be rubbed off with the hand, but are again 
rapidly renewed ; the disease is always more marked on the 
regions of the body noticed above, as the parts where it first 
appears, and especially in the neighborhood of the joints ; 
on the scalp the epidermis is not so much thickened as else- 
where, yet most of the hair is shed when it occurs there, and 
what remains is thin and weak. Although the general health 
seems to be unaffected in persons the subject of ichthyosis, 
attacks of diarrhoea are of constant occurrence, probably 
owing to the nearly complete obstruction of the cutaneous 204 
HYPEltTROrHIiE. 
transpiration ; and for the same reason those parts of the 
integuments which are not engaged, especially the palms of 
the hands and the soles of the feet, are constantly bedewed 
with moisture : the urinary and pulmonary secretions are 
also said to be increased in quantity, but in four cases of 
the disease which I have had under treatment this was not 
so. The affected parts are constantly below the natural 
temperature, and persons afflicted with the disease usually 
suffer much from coldness of the surface of the body. 
The nature of the anatomical changes which constitute 
ichthyosis have been carefully investigated, both microscopi- 
cally and otherwise. The following description of them is 
given by Franz Simon : “ The scales were of a gray or black 
color; when placed in water they softened, and on then 
placing a section under the microscope I found that the ab- 
normal structure was formed of compressed epithelial scales. 
On incineration the scales left an ash, containing carbonate 
and phosphate of lime and peroxide of iron ; the latter was 
in such abundance as to communicate a yellow color to the 
ash. The ash yielded by the incineration of the ordinary 
thickened skin on the hands and feet is perfectly white, and 
contains a mere trace of peroxide of iron.”1 This account, 
directly opposed to the views propounded by Erasmus Wilson, 
which have been before referred to, is confirmed by Gluge, 
who states that on microscopic examination he found the 
scales to be composed of epidermic cells. 
Causes.—Obscure as are the causes of skin diseases, gene- 
rally speaking, there is probably not one of which so little 
is known as to how or under what circumstances it is pro- 
duced, as ichthyosis. When congenital, it has been ascribed, 
like all the other deviations from a normal state which are 
observed occasionally in the foetus, to the effect of the 
mother’s imagination while pregnant, it being popularly be- 
lieved to be caused by a longing for some peculiar fish, or 
by fright arising from something connected with fish; but 
it need scarcely be remarked that these causes of the disease 
are altogether without foundation. It occurs in both sexes, 
but is much more frequent amongst males than females, in 
the proportion, according to Biett’s observations, of one of 
1 Animal Chemistry; Sydenham Society’s Edition, vol. ii. p. 483. ICHTHYOSIS. 
205 
the latter to twenty of the former ; this is well established 
by the report of those cases in which ichthyosis has been 
hereditary, as it not unfrequently is,—for example, in the 
family of the Lamberts above referred to, in which the dis- 
ease was transmitted for several generations from father to 
child, the female members of the family being in no instance 
affected. This hereditary transmission of ichthyosis has been 
noticed in the majority of instances, but many cases of the 
disease occur in children born of parents healthy in all re- 
spects, and in whose families, as far as could be ascertained, 
no trace of the disease ever existed. It is seen at all ages, 
but is usually congenital, or developed within the first year 
of life, very rarely appearing for the first time after the age 
of puberty, yet it has been witnessed as a primary affection 
in old persons, but always in a modified form. All the ex- 
amples of ichthyosis which I have seen have been in persons, 
whether children or adults, of a well-marked scrofulous 
diathesis. 
Diagnosis.—With no other disease of the skin can 
ichthyosis be confounded, so distinctly characterized is it by 
the abnormal condition of the epidermis : in the cicatrices 
of wounds and of burns a peculiar warty growth is occa- 
sionally developed, which, having been first well described 
by the celebrated French surgeon of the name, has been 
termed the warty ulcer of Marjolin ; this disease presents 
characters somewhat resembling those of ichthyosis, but it 
may be at once distinguished by its local nature, occurring 
only in those parts of the integuments which have been 
previously the seat of some severe injury. 
Prognosis.—Ichthyosis has been in all ages regarded as 
being incurable; it is at all events a most grave affection, 
and one which usually lasts for years, if not for life. When 
it presents the aggravated characters of the severe form, as 
above described, it should be regarded as beyond the reach 
of medical skill, but if it be submitted to treatment in its 
early stages, and while it is yet of a comparatively mild 
form, affecting the surface only partially, the progress of 
the disease may be arrested, and its further development 
prevented if it cannot be completely cured. 
Treatment.—From the extreme obstinacy and general 
incurability of ichthyosis, many plans, as may be supposed, 206 
HYPERTROPHIC 
have been recommended for its treatment, both constitu- 
tionally and topically. The latter have consisted chiefly 
in means to soften and promote the desquamation of the 
altered and hardened epidermis, and the former in the ad- 
ministration of the most powerful remedies which experi- 
ence has shown to act specially upon the skin. Warm water 
and vapor baths, w7ith the preceding or subsequent employ- 
ment of oleaginous and greasy applications, constitute the 
chief part of any method which has proved at all successful 
in the treatment of ichthyosis ; their action is evidently due 
to a direct effect in softening the hypertrophied integument, 
and thus promoting its separation ; but experience has shown 
that unless the state of the constitution on which the ab- 
normal secretion depends be at the same time changed, it 
is again rapidly reproduced in a similarly diseased condition. 
“ The easiest mode,” says Willan, “ of removing the scales, 
is to pick them off carefully with the nails from any part of 
the body while it is immersed in hot water. The layer of 
cuticle which remains after this operation is harsh and dry, 
and the skin did not in the cases I have noted recover its 
usual texture and softness; but the formation of the scales 
was prevented by a frequent use of the warm bath, with 
moderate friction.” More active local applications are 
recommended by some writers on the disease, such as sul- 
phurous baths, stimulating lotions, containing corrosive 
sublimate and other preparations of mercury, caustic, pot- 
ash, &c. 
In an account recently published by Professor Banks1 of 
two cases of the disease which he treated successfully, cod- 
liver oil was employed topically, and at the same time 
administered internally ; at bed-time the patients were 
placed in a vapor bath, and the surface of the body well 
rubbed afterwards with the oil, a flannel dress being always 
worn next the skin, with the view of keeping the surface 
constantly impregnated with it. The use of this remedy 
was, he says, suggested to him by the marked connexion 
which he has seen to exist between ichthyosis and the stru- 
mous diathesis. 
The internal administration of pitch was highly recom- 
1 Dublin Quarterly Journal of Medical Science, New Series, vol. xii. p. 80. ICHTHYOSIS. 
207 
mended in this disease by Willan and Bateman, and their 
experience of its benefits has been confirmed, especially by 
Dr. Elliotson: they ordered it to be made into pills with 
flour, and increased the dose gradually, until from half-an- 
ounce to an ounce was taken daily, and often continued for 
months. But both Rayer and Biett state that although 
they gave this remedy a fair trial, it failed completely in 
their hands. The cold water treatment has also been tried 
in the treatment of ichthyosis, but in one case which I saw 
it did not produce the least good effect; in this same case, 
enveloping the affected parts with wet lint, covered with 
oiled silk, also failed. 
The following plan of treatment I have employed in four 
cases of ichthyosis, in three of which the disease was local, 
being confined to the lower extremities in two, and engaging 
the upper also in the third, and in these the recovery was 
complete and permanent; in the other, the integuments of 
the body generally, except the face, the palms of the hands, 
the soles of the feet, and some patches of the trunk, were 
affected with the disease, which commenced five months 
after birth, and was of three years’ duration when I first 
saw the child. Here after a year and a half of treatment, 
the epidermis had regained a tolerably healthy condition, 
being only slightly hard and rough, but if the local appli- 
cations were omitted for four or five weeks, it again began 
to present a somewhat thickened appearance: this case is, 
consequently, still under treatment. The remedies I used 
were the iodide of potassium and iodine, from one to two 
grains of the former, and from a sixteenth to an eightji of 
a grain of the latter, according to the age of the child, given 
once daily, in from one to two ounces of the decoction of 
elm-bark, made with the recent inner bark, stripped from 
the growing tree; and an ointment, containing twenty 
grains, gradually increased to one drachm, of the iodide of 
potassium, a drachm of glycerine, and an ounce of prepared 
lard, with which the affected parts were well anointed 
morning and evening; an alkaline bath—one drachm of 
carbonate of soda to each gallon of fresh water, at the 
temperature of 90° Fahr.—having been used for fifteen 
minutes previously to each inunction, the body being well 
rubbed with a flesh-brush while in the bath. An inner 208 
HYPERTROPHIC. 
calico dress was worn constantly, and milk diet was strictly 
enforced. I have had no opportunity, however, of trying 
the effects of this method of treating ichthyosis in adults, 
the four cases in which it proved so successful being children 
below the age of eight years. 
MOLLUSCUM. 
Molluscum.—The origin of the employment of this term 
to designate a disease of the cutaneous structure, which 
is chiefly interesting in consequence of its extreme rarity, 
has been a matter of discussion. Used by Willan and 
Bateman at a time when they themselves, not having seen 
the affection, obtained their knowledge of it from the account 
of a case—published in 1793 by Ludwig—that occurred in 
the practice of Professor Tillesius of Leipsig, it is most 
natural to infer that its application was derived from the 
description therein contained, in which the small tumors 
that constitute the disease are said to consist in “ verrucis 
mollibus sive molluscisyet nearly all the French derma- 
tologists ascribe its employment to some imaginary resem- 
blance between them and the minute excrescences that form 
on the bark of the maple tree. It is characterized by the 
development on the skin of round, slightly umbilicated, soft 
tumors, varying in size usually from that of the head of a 
pin to that of a nut, but described as occasionally acquiring 
the magnitude of a pigeon’s egg; they are of a yellow or 
pinkish-white color, sessile, rarely pedunculated, scattered 
irregularly over the surface, yet occurring not unfrequently 
in small groups, of slow growth, and unattended with either 
local pain or constitutional irritation. When pressed be- 
tween the fingers, a small quantity of a thick, whitish fluid 
exudes from the minute aperture that forms the umbilicated 
apex of each tumor, the exudation being evidently altered 
sebaceous secretion. They appear on all parts of the cuta- 
neous surface, but are most frequently witnessed on the face, 
and most rarely on the extremities; their duration is 
uncertain, in some cases ulcerating and falling off sponta- 
neously, their site being marked by a slight cicatrix, in 
others lasting for life, without undergoing any increase in 
size, but the skin covering them becomes darker colored or MOLLUSCUM. 
209 
brownish, and the tumors themselves acquire a certain 
degree of hardness. The internal structure of the tumors 
of molluscum is cellular, a transverse section often exhibit- 
ing five or six divisions, each of which corresponds to a duct 
of the sebaceous follicle, and contains altered sebaceous 
matter. 
Bateman, after witnessing some cases of the disease, 
described it as consisting of two varieties, which he named 
molluscum contagiosum and molluscum non-contagiosum, 
but inasmuch as it is doubtful that the latter, as described 
by him, was truly molluscum, and at all events as the dis- 
tinction he drew cannot be regarded as sufficient to consti- 
tute a specific difference, his division must be abandoned. 
The eruption consisting admittedly in a hypertrophied 
state of the sebaceous follicles, and being therefore of the 
same nature, anatomically considered, as Acne, some recent 
French writers, especially MM. Caillault1 and Bazin,2 have 
regarded molluscum as a species of that disease; the former 
termed it Acne molluscoides, and the latter Acne varioli- 
formis : the absence of local inflammation, however, clearly 
distinguishes it from that affection. The best division of 
the disease, I consider, is that proposed by Dr. Craigie, in 
an able essay published in the seventy-fifth volume of the 
Edinburgh Medical and Surgical Journal, namely, into 
Molluscutn acutum. 
“ chronicum. 
Acute molluscum (Atlas, PI. XI. Fig. 5) agrees, in all 
respects, with the form which is generally regarded as being 
contagious; it occurs usually on the face and neck of chil- 
dren, and from them is conveyed to adults, almost invari- 
ably, however, of the same family. It is developed at first 
in the form of minute papulse, scarcely noticeable, and un- 
attended with any local symptoms; these gradually increase, 
until, in from six weeks to two months, they attain the size 
of a small currant, which they resemble much in shape, 
being somewhat pellucid, and sessile on the portion of in- 
tegument from which they grow. Their duration is seldom 
1 Archives Generates de Medecine, 1851, vol. xxii. pp. 40 and 316. 
2 Journal des Connoissances Medicales, 1851, p. 277. 210 
HYPERTROPHIC. 
prolonged for more than six months, but their progress is 
often more speedy, terminating either by ulceration, which 
first commences at the apex, an opening being there formed 
through which the altered sebaceous matter contained in 
them is discharged, when the small tumors collapse and 
shrink away, or by an attack of local inflammation, when 
they slough off, leaving a pit like that resulting from small- 
pox. In most cases the molluscous growths are developed 
in successive crops. 
In chronic molluscum,—the molluscum 'pendulum of 
Willan (Atlas, PI. XI. Fig. 6),—the tumors, which are 
more generally distributed over the surface of the body, 
attain a much larger size, and are more frequently pedun- 
culated ; they are sometimes very few in number, may even 
be solitary, but occasionally several of them are developed 
on different parts of the integument at the same time. 
This form is most frequently witnessed in adults, and runs 
an essentially chronic course, lasting often for life if unin- 
terfered with, yet with but little increase in size. Occa- 
sionally, as in the acute variety, inflammation attacks some 
of the tumors and they slough off. 
The chronic and acute forms of molluscum differ espe- 
cially, to use the words of Dr. Craigie, “ in the circumstance 
of the latter being propagated by a specific matter, while 
the former is, so far as is hitherto known, entirely incapable 
of such communication.” This contagious property, though 
its existence is denied by many modern writers on the 
disease, is, I think, too well established by the numerous 
cases which have been recorded by Bateman, Craigie, 
Thompson, Carswell, Henderson, Willis, &c., to admit of 
doubt. M. Caillault, in the essay on the disease recently 
published by him, to which I have referred above, states 
that he himself did not believe in its contagious nature 
until it was proved to him in April, 1851, in one of the 
wards at the Hospital St. Louis, at Paris, fourteen children 
out of thirty having taken the disease in the course of three 
months from a little girl who had been admitted with nume- 
rous molluscous tumors on the face. Mr. Erasmus Wilson, 
wrhile denying the communicability of molluscum by con- 
tagion, narrates a case in which one child of a family 
having been brought to him affected with the disease, it MOLLUSCUM. 
211 
appeared in a few weeks afterwards in the mother and two 
other children, an infant, and a girl six years old; he 
adds : “ I quieted her alarm relative to contagion, but was 
much struck by the fact of the almost simultaneous appear- 
ance of the disease upon four members of the same family.1 
I have myself witnessed two instances in which the acute 
form of this affection was communicated by children to 
adults, in each case members of the same family.” I have, 
therefore, no doubt in my mind as to its possessing the 
property of being propagated by direct contact, as from 
persons sleeping together, or in the case of children while 
at play. 
As regards the causes of molluscum, in either of its forms, 
but little is known ; the acute variety is most frequently met 
with in children of the female sex, rarely occurring in adults 
unless when it is communicated to them by children; the 
chronic form as already remarked, is generally witnessed 
after the age of puberty, and is not unfrequently connected 
with a deranged condition of the general health, while the 
former occurs in the most healthy individuals, the skin of 
those affected, however, is usually fine and soft. 
The diagnosis of this disease is unattended with difficulty; 
from warts, for which the little tumors might be mistaken, 
they are distinguished by their shape, their softness, their 
color, and the central depression at their apex; from fatty, 
or other pendulous tumors, in addition to these character- 
istics, their slow development and growth aid as diagnostic 
marks. 
Prognosis.—The chronic variety of molluscum may last 
for life without the least injury to health or impairment of 
the constitution, but occasionally troublesome symptoms 
may arise from attempts made to destroy or remove the 
tumors. In one instance communicated to me by Dr. Lees, 
the case of a female, aged 18, who was under his care in 
the Meath Hospital, the application of potassa fusa was 
followed by erysipelas, which terminated fatally. Acute 
molluscum generally disappears spontaneously in from four 
to six months. 
Treatment.—Internal remedies do not appear to have any 
effect over molluscum, and are therefore not required in its 
1 Ou Diseases of the Skin, Third Edition, p. 387. 212 
IIYrERTROPHIyE. 
treatment, except such as may be calculated to restore a 
healthy condition of the system generally, should it be 
deranged. Local applications are not advisable in the 
chronic variety of the disease, but the tumors may be 
snipped off with a sharp pair of scissors, and the surface 
then touched with lunar caustic, provided the patient be in 
a state of good health, but when such is not the case this 
should first be attended to. In the acute form, the employ- 
ment of a slightly stimulating lotion, as of sulphate of zinc 
or sulphate of iron, ten grains of either to an ounce of dis- 
tilled water and a drachm of rectified spirits, hastens the 
throwing off of the small tumors. 
STEARRIICEA. 
Stearriicea is a disease of the sebaceous follicles, char- 
acterized—as the name attap pf« indicates—by augmented 
secretion and discharge of their natural contents, the folli- 
cles themselves and their excretory ducts being at the same 
time somewhat hypertrophied. The increased secretion may 
consist merely in an excessive amount of the natural oily 
matter or smegma destined for the preservation of the skin 
from external irritants, or in its discharge on the cutaneous 
surface in a vitiated condition, where it concretes and forms 
a thick adherent layer, varying in color from a rich yellow 
hue to nearly black. The former is of very frequent occur- 
rence, and can scarcely be regarded as constituting a disease, 
while the latter, a rather rare affection, is of extreme obsti- 
nacy, usually resisting treatment for years. Three varieties 
of the disease, thus constituted, require to be noticed:— 
Stearrhoea simplex. 
“ flavescens. 
“ nigricans. 
Stearrlioea simplex (Sebaceous flux) is marked chiefly by 
an oily or greasy state of those parts of the integument in 
which the sebaceous follicles are numerous, as the nose, the 
cheeks, the ears, the scalp, and other regions where hair 
grows; it is an accompaniment usually of a coarse, sallow 
condition of the skin, and is generally -witnessed in a class 
of persons who are liable to be affected with acne, as noticed STEARRHfEA. 
213 
in the description of that disease. The orifices of most of 
the sebaceous follicles are usually much dilated, but others, 
becoming obstructed, present the appearance regarded as 
being characteristic of acne punctata. This state of the 
cutaneous surface is manifestly hereditary in most cases, 
and is a constant accompaniment, or rather may be regarded 
as a sign of the scrofulous diathesis ; it lasts generally during 
life, appearing in youth, but being less marked in old age ; 
and although indicative, cannot be considered as a cause, of 
an unhealthy constitution; when it exists, the natural per- 
spiration is deficient in quantity, and congestive or inflam- 
matory affections of some of the internal organs, assuming, 
however, a scrofulous character, are more apt to occur. 
Stearrhoea flavescens (Atlas, PI. XII. Fig. 1).—It is only 
of late years that this affection, which is of rather rare occur- 
rence, has attracted the attention of dermatologists ; Rayer 
was the first to describe it under the name of sebaceous flux, 
and after him it was specially noticed by Biett, who, regard- 
ing it correctly as dependent on a diseased condition of the 
sebaceous follicles, although admitting the difference which 
exists between it and the true pustular acne, made it a 
species of that eruption, under the name of acne sebacea. 
Erasmus Wilson gives an illustration of the disease in his 
beautiful Portraits of Diseases of the Skin, where he terms 
it Injlammatio Follieulorum, while in his octavo work he 
describes it under the name I have adopted. 
It is characterized by an exudation from the sebaceous 
follicles of their natural secretion, more or less altered, on 
the surface of the skin, where it forms a yellowish or green- 
ish-yellow crust or layer—in the former case resembling 
the cerument of the ear, of variable thickness and consist- 
ency, at times so soft as to be readily wiped off, but more 
generally hard and firmly adherent. By exposure to the 
action of the atmosphere the effused matter gradually ac- 
quires a darker tint, presenting at length a brownish hue, 
and numerous cracks or fissures divide it into small packets, 
which often correspond with the linear markings of the skin. 
The portion of the integument on which the diseased secre- 
tion had been seated, if examined after its removal, is found 
to be more or less injected, not unfrequently inflamed, and 
the sebaceous follicles hypertrophied, with their orifices en- 214 
HYPERTROPHIC. 
larged, and filled with the peculiar matter, the presence of 
which constitutes the disease. The crusts on the surface 
are rapidly renewed after their removal, and, if uninterfered 
with, soon form a layer three or four lines in thickness. 
The parts affected are the seat of sharp tingling, occasion- 
ally of stinging pains, accompanied by heat and itching. 
There is generally, also, a deranged state of the health, 
evidenced more especially by the condition of the digestive 
organs, in those persons on wThose skin the disease appears, 
and from its occurrence most usually on the face, causing, 
in consequence, much disfigurement, great mental distress 
is occasioned. 
Stearrhoea flavescens, as is evident from the description 
now given, is an affection of the sebaceous follicles, and is, 
therefore, witnessed only on those regions of the skin where 
these glands exist, being of most frequent occurrence in the 
parts in which they are most numerous ; it therefore appears 
usually on the nose, the cheeks, the eyelids, the ears, and 
the scalp, but it is also seen occasionally on other portions 
of the integument. It runs essentially a chronic course, 
spreading in general but slowly from where it is first de- 
veloped, and, if removed by artificial means, being again 
quickly reproduced. 
Stearrhoea nigricans (Atlas, PI. XII. Fig. 3), although 
differing from the form now described apparently only in 
the color of the effused diseased secretion, which is nearly 
jet black, deserves a special notice, in consequence of the 
singularity of the appearance which it presents, and its ex- 
treme rarity. In it the matter discharged from the follicles 
is of a thinner consistence than in stearrhoea flavescens, and 
is from the first of the same dark color, which, moreover, 
stains linen, or any other substance with which it may come 
in contact. From the few cases of the disease which have 
been recorded, it would appear also to be attended with 
more local irritation, at times amounting to severe pain and 
burning heat. Its occurrence is accompanied by general 
constitutional disturbance, and in one case recorded by Mr. 
Teevan,1 which had been first under the care of Dr. Read, 
1 Medico-Cliirurgical Transactions, vol. xxyiii. p. 611. STEARRHOEA. 
215 
of Belfast, if the secretion of the diseased matter on the 
surface was arrested by local treatment, black vomiting, and 
the discharge of a black substance from the bowels and 
kidneys, took place immediately. The black secretion in 
this patient, a young lady, was analyzed by Dr. G. 0. Bees, 
and found to consist of carbon, iron, lime, albuminous mat- 
ter, fatty matter, and alkaline chlorides and phosphates. 
The instances of this peculiar affection which have been pub- 
lished were seemingly even more obstinate than the second 
form of the disease which I have described: it was in all of 
them situated on the same region of the skin. 
The causes of any of the forms of stearrhoea are very 
obscure; the first is both congenital and hereditary, but 
the others have not been proved to be either ; they appear 
only in persons who have attained the age of puberty, and 
are very rarely witnessed in advanced life, yet I have seen 
one example in which stearrhoea flavescens was developed 
on the nose after the age of seventy; they occur, too, with 
much greater frequency in females than in males, and in 
the former their connection with suppressed menstruation or 
uterine derangement, has been in some instances noticed; 
but in the majority of cases their development is preceded 
and accompanied rather by derangements of the digestive 
organs. 
Diagnosis.—Stearrhoea simplex cannot be confounded 
with any other affection of the skin ; the other forms, how- 
ever, in consequence chiefly of their rarity, are often not 
recognized when they occur, and therefore occasion much 
doubt as to their nature. Thus, an account of five cases of 
what, from the description and accompanying illustrations 
I conceive to be stearrhoea flavescens, has been recently 
published by Drs. Addison and Gull,1 but denominated by 
them Vitiligoidea plana and Vitiligoidea tuberosa, from a 
supposed correspondence between the affection and the in- 
correct definition of vitiligo, which was given by Willan; 
and the case of Mr. Teevan, above referred to, was originally 
communicated to the Medico-Chirurgical Society of London, 
as being an example of Pityriasis nigra. 
1 Guy’s Hospital Reports, New Series, vol. vii p. 265. 216 
HYl’ERTROrHIiE. 
Prognosis.—Stearrhoca flavescens and Stearrhoca nigri- 
cans are both most obstinate affections, and appear to be 
equally rebellious to all plans of treatment, but are chiefly 
important in consequence of the disfigurement which they 
occasion, being not in the least degree attended with any 
danger to life. In the former, I have seen the sebaceous 
follicles take on an active inflammatory action when caustic 
applications were applied to the diseased surface, and indo- 
lent pustules form, which, on the continuance of the irrita- 
tion, terminated in obstinate ulcers, with hardened elevated 
edges. 
Treatment.—The first and most important point to be 
attended to is the restoration of a healthy condition of the 
system; this is best effected by the internal administration 
of alteratives, combined with alkalines, such as the hydrar- 
gyrum cum creta with dried carbonate of soda, or cod-liver 
oil with lime water, according to the circumstances of each 
case; the latter combination is readily taken in milk, from 
one to four drachms of the oil being given three times daily, 
in one ounce each of lime water and new milk, previously 
mixed. As soon as the state of the digestive organs is im- 
proved, or the menstrual function restored, preparations of 
iodine,—especially the syrup of the iodide of iron, or the 
iodide of potassium in some tonic vegetable decoction or 
infusion,—will be prescribed with benefit. Of course the 
employment of purgatives, when requisite, should not be 
omitted. The local applications that are found most useful 
are generally stimulating and astringent lotions and oint- 
ments. The affected surface should be sponged three or 
four times a day with the spirituous lotion recommended for 
acne simplex (see page 123), an ointment containing ten 
grains of the iodide of potassium to the ounce of cold cream 
being applied at night, or a solution of the iodide of iron,— 
two grains to the ounce of rose or elder-flower water, and 
dilute citrine ointment may be used. No matter what reme- 
dies, however, are employed, they must be continued for a 
very long time, and local means will be found unavailing 
until the general health is restored. The application of 
caustics I have invariably seen productive of injurious con- 
sequences. When the crust of effused sebaceous matter is ELEPHANTIASIS. 
217 
hard, dry, and adherent to the surface, it should be removed 
by the application of poultices or of water dressing, previ- 
ously to the use of topical remedies. 
ELEPHANTIASIS. 
The term Elephantiasis has been applied, both in ancient 
and modern days, to designate two perfectly distinct diseases 
of the integuments; the one, which has been specifically 
denominated elephantiasis G-rcecorum, is believed to be the 
true lepra or leprosy of antiquity, while the other, which, 
from having been first accurately described by the Arabian 
physicians, has been termed elephantiasis Arabum, does not 
bear the least analogy to it. Consistent with the scope of 
this work, neither of them requires or can obtain a detailed 
notice, inasmuch as the former is never witnessed in Euro- 
pean countries in the present time, and the latter is of ex- 
tremely rare occurrence. 
Elephantiasis Grcecorum (Atlas, PI. XII. Fig. 4) is 
characterized by the development on the integuments of 
numerous globular tumors, varying in size from that of a 
pea to that of an apple, soft and unyielding to the touch, at 
first of a dusky or livid hue, but afterwards becoming brown- 
ish-yellow or of a bronzed tint. They occur most usually 
and in greatest number on the face, but may appear also on 
every region of the body; the skin of the part affected is 
much hypertrophied, raised into irregular elevations, and of 
an unhealthy diseased appearance, causing the sufferers from 
the disease to present a hideous aspect, described by those 
who have witnessed it to be revolting in the extreme, whence 
they have in all ages been regarded with abhorrence, as indi- 
viduals specially afflicted. Both mind and body share at 
length in the local disease, the senses become obtuse, fatuity 
creeps on, and all the bodily functions are deranged. Even- 
tually the tumors ulcerate, exude in ichorous matter, and 
form unhealthy, open sores; the bones soften, and become 
affected with caries; mortification not unfrequently attacks 
the smaller joints, and death soon terminates sufferings 
which are extreme. 
This disease, which is still endemic in many countries in 
tropical climates, was, in the middle centuries, of common 218 
HYPERTROPHIES. 
occurrence in temperate latitudes also, hospitals being spe- 
cially built and endowed for the reception and isolation of 
those whom it attacked ; Professor Simpson, of Edinburgh, 
has published a most interesting and learned history of those 
that existed in England and Wales;1 there were several of 
them in Ireland also, and the name of ‘ Leper Hospital’ is 
still retained for the infirmary in the city of Waterford, now 
happily no longer required for the reception of individuals 
affected with a disease similar to that for which it was ori- 
ginally built. In some of the more northern regions of 
Europe, a form of elephantiasis Greecorum is even in the 
present day of not unfrequent occurrence ; it is known in 
Sweden and Norway by the name of ‘ Spedalskhed’ (Atlas, 
PI. XII. Fig. 5), and has been recently described and illus- 
trated in a magnificent work, undertaken by the desire and 
at the expense of the Norwegian Government, by two Dan- 
ish physicians, Danielssen and Boeck. 
Elephantiasis Graecorum was, in former times, regarded 
as highly contagious, but it is more probable, judging from 
the accounts of it which have come down to us, that it was 
rather endemic than infectious, and that it was directly 
caused by misery, deprivation, and filth. Treatment seems 
to have had but little effect over it, for although isolation 
and hygienic measures then and in the present day checked 
its progress, it almost invariably re-appeared in those whom 
it had selected as its victims. 
Elephantiasis Arabum (Barbadoes leg). (Atlas, PI. XII. 
Fig. 6.)—The popular name for this singular affection indi- 
cates its frequency of occurrence in the West India Islands, 
where it is endemic, but cases of it are also witnessed in 
Egypt, in America, in various countries of Europe, and, as 
was remarked originally by Dr. Graves,2 are not very un- 
common in Ireland; it is, however, less frequently seen now 
than at the time his account of it was published, twenty- 
six years ago. 
The disease consists in an extreme degree of hypertrophy, 
affecting one or both of the lower extremities, the scrotum, 
the hands or arms, and occasionally even the face, and the 
1 Edinburgh Medical and Surgical Journal, vols. lvi. and lvii. 
2 Dublin Hospital Reports, vol. iv. p. 54. ELEPHANTIASIS. 
219 
mamma and pudendum in females; the enlargement affects 
equally the skin and the subcutaneous and deep-seated areo- 
lar tissue, so as to produce an enormous swelling of the part 
attacked, one of the legs not unfrequently exceeding in mag- 
nitude the girth of the body. It commences usually with 
symptoms of local inflammation chiefly engaging the lym- 
phatic system, and general constitutional derangement; 
these attacks are of frequent occurrence, and after each, 
the parts engaged become more and more swollen, chiefly 
from effusion into the areolar texture; but in some cases, 
especially in temperate climates, the enlargement comes on 
slowly, and gradually augments without any apparent dis- 
turbance of function, local or general. When the affection 
is fully developed, the integuments, which are enormously 
thickened, are generally of a whitish color, rough and swol- 
len, and present deep furrows, occasionally the seat of ulcera- 
tion, a thin, ichorous discharge, which concretes into hard, 
scaly incrustations, then issuing from them. To the great 
hypertrophy of the integuments is due the name of this dis- 
ease, but in order to distinguish it from that last described 
the term Pachydermia, first proposed by Fuchs, has been 
adopted by many modern dermatologists. 
When the scrotum is the part affected, as it very fre- 
quently is in the colored population of tropical climates, it 
attains at times an enormous magnitude; Horner in his 
Medical Topography of Brazil, narrates two instances in 
which the tumor situated there measured four feet in cir- 
cumference. The upper extremities, when attacked by the 
disease, do not acquire as large a size as the lower, mani- 
festly in consequence of their containing less areolar tissue. 
The palms of the hands and soles of the feet are never 
affected. 
The causes of elephantiasis Arabum are altogether un- 
known, if we except its apparent connection with inflamma- 
tion of the lymphatics ; it is not contagious; it affects both 
sexes equally, and occurs at all ages, but is more frequent 
in adults than in children. Its much greater prevalence in 
hot countries, and its being more frequent there in those 
districts, which are characterized by the presence of mois- 
ture, indicate the effect of heat and damp conjoined as an 
exciting cause. 220 
HYPERTROPHI2E. 
There is no difficulty in diagnosing this disease in its 
advanced stages; in its commencement it might be mistaken 
for angeioleucitis; from which it appears to differ simply in 
its symptoms being less acute, and in its never terminating 
in the formation of purulent abscesses. Its duration is 
essentially chronic, but although its presence renders life a 
burden, it in very rare cases seems to prove fatal. 
An anatomical examination of the parts in this form of 
elephantiasis exhibits the derma and epidermis usually much 
hypertrophied, the former sometimes constituting a layer 
an inch in thickness, but the enlargement of the affected 
regions is due chiefly to the change in the areolar membrane, 
from the deposit sometimes of fat, but more usually of a 
substance almost as firm as fibrous tissue, and of a lardaceous 
appearance, which to the naked eye resembles the natural 
structure compressed. Lebert and Gustav Simon, who exa- 
mined the new deposit with the microscope, found it to con- 
sist in fibrous bundles of pure areolar tissue, fully deve- 
loped, or in the process of formation, with numerous fat 
cells in the interstices. 
Treatment.—In the early or inflammatory stages of ele- 
phantiasis Arabum, antiphlogistic treatment is clearly indi- 
cated, but this must be constitutional and not local; if a limb 
be the part affected it should be kept at rest, and placed in 
the horizontal position above the level of the body. Active 
purging seems to have been the plan of treatment that 
proved most successful in those cases which have been re- 
ported, and even in the chronic stages, when other remedies 
generally fail to prove beneficial, it has been useful. When 
the disease becomes chronic, iodine frictions and firm ban- 
daging have also been recommended, but they usually fail to 
produce any manifest effect: amputation of the parts, if pos- 
sible, has been then advised, and ablation of the hypertro- 
phied scrotum has, in many instances, been resorted to with 
success ; but as regards the limbs, the removal of one of them 
has been usually followed by the development of the disease 
in another, thus, in a case reported by Cazenave, in which a 
leg, the seat of elephantiasis, was removed, the arm became 
affected soon afterward. VERRUCA. 
221 
VERRUCA. 
Verruca [Warts), both in consequence of their appear- 
ance being familiar to all from their extreme frequency, and 
of their unimportance, scarcely require description; they 
consist in a hypertrophied condition of a small patch of the 
papulse of the skin, by which a round tumor, with a flat- 
tened top, varying in size from that of the head of a pin, to 
that of a large pea, is formed. They are of most frequent 
occurrence on the hands, next on the face, and are rarely 
witnessed on those parts of the body which are ordinarily 
covered. They are generally placed singly on the integu- 
ments, but occasionally two or three originate close to each 
other, and these sometimes coalesce. Warts appear in the 
early periods of life, being seldom developed for the first 
time in adults ; they often disappear spontaneously, and even 
suddenly, at the approach of puberty, but sometimes, becom- 
ing indolent, are permanent. 
Some persons are peculiarly liable to warts, and the ten- 
dency to them seems to be hereditary; their immediate 
cause has not been satisfactorily ascertained, but that it is 
more or less connected with local irritation, and the effects 
of the atmosphere on the skin, is evident from their being 
almost altogether confined to those parts which are ordinarily 
exposed to the action of the air. Small growths, soft to the 
touch and slightly pediculated, are of frequent occurrence 
on the face and neck, particularly of females, and are also 
regarded as a variety of wart; they appear to me to consist 
in the hypertrophy of a single papilla, but Mr. Erasmus 
Wilson believes them to be “ the emptied tegumentary sacs 
of small sebaceous tumors.” 
Warts are easily removed by the application of some 
strong caustic—strong nitric acid is, in my opinion, the best 
—to their apex ; the layer thereby cauterized should be 
pared off in twenty-four hours, and the caustic again applied, 
and this process repeated until the entire of the abnormal 
structure is destroyed ; when the wart is small, a single ap- 
plication sometimes suffices, provided a large drop of the acid 
is placed on the apex, and permitted to soak into its struc- 
ture. The soft pediculated warts are readily destroyed by 222 
HYPERTROPHIC. 
strangulation, by means of a hair or a thread of fine silk 
being tied tightly around their neck. 
CLAYUS. 
Clavi (Corns).—These excrescences, almost peculiar to 
the feet, being equally common, although causing a much 
greater degree of local uneasiness and suffering, do not re- 
quire more notice than warts. They consist in thickening 
and hardening of the epidermis of some prominent portion 
of the integument, usually over one or more of the joints 
of the toes, attended with hypertrophy of some of the 
papillae beneath ; the latter, which from the pressure acquire 
much hardness, are popularly believed to be the roots or 
core of the corn. They are regarded generally as being 
produced by pressure, but although they are kept up, and 
their growth increases by this mechanical cause, that they 
are originally occasioned thereby is, I think, disproved by 
their constant occurrence in the usual site on the feet of 
persons, who have never worn shoes or other covering 
whereby pressure could be caused on the parts ; of this I 
have seen numerous examples. Their development also 
between the toes, on a portion of the integuments especially 
protected from any undue compression, affords an additional 
argument against this view ; that the extreme degree of 
hardness, however, which they usually present, and to 
which the local suffering they give rise to is chiefly due, is 
dependent on pressure, is proved by their being compara- 
tively unindurated when situated here, whence they are 
termed soft corns. 
Corns occasionally become the seat of active inflammation 
when irritated by any cause, or when they have been cut 
too freely, and afterwards subjected too soon to compression 
and friction by the shoes in walking ; purulent matter then 
often forms beneath them, and, from its being firmly bound 
down by the hardened superincumbent tissues, extreme suf- 
fering results, followed sometimes by inflammation of the 
lymphatics and the formation of buboes in the groins ; they 
have thus ended even fatally, from the occurrence of erysi- 
pelas, and in some instances from tetanus coming on. 
Although, as above remarked, corns are almost invariably CALLOSITATES. 
223 
confined to the feet, they may also be developed on other 
parts of the body, but they then partake more of the nature 
of callosities; I have in a few cases seen them on the 
knuckles of the fingers of persons, too, in whom the hands 
were not exposed to any manual labor that could exert pres- 
sure on the parts affected. 
The treatment of these morbid growths consists in their 
ablation, by means of the knife patiently and gradually 
employed, until all traces of hardened tissue are removed, 
and afterwards protecting the parts for some time from 
pressure ; this is the only effectual remedy, and is the one 
always adopted by the self-styled chiropodists. The appli- 
cation of caustics never succeeds in destroying them com- 
pletely, but is of use in enabling the hardened surface to 
be pared off wdthout causing hemorrhage. Corns, whether 
hard or soft, may generally be kept in abeyance, as regards 
troublesome symptoms, by removing the superficial layers 
with the knife from time to time, according to the rapidity 
of their growth, or by rasping them with a file, the surface 
having been previously softened by maceration in warm 
water. Most of the corn-plasters which are ordinarily sold 
in the shops contain carbonate of potash, the alkali of which 
dissolves partially the horny substance which constitutes 
the outer layer of the growth, or, a round hole being cut in 
the centre of each piece, they act by removing the pressure 
from the most prominent point of the corn, which is directed 
to be pared previously to their application. 
CALLOSITATES. 
Callositates.—Callosities consist simply in thickening 
of the epidermis, which becomes of more or less horny con- 
sistence, produced by friction or continued pressure ; they 
are usually witnessed on the palms of the hands or on the 
soles of the feet, when their cause is in general sufficiently 
evident. Occasionally they are attended with some degree 
of inflammation of the derma over which they are developed, 
which may result in the formation of pus, or in the effusion 
of a serous fluid beneath the hardened integument. They 
are witnessed also over inflamed and enlarged bursae mucosae, 
especially on the metatarsal joint of the great toe, where 224 
HYPERTROPHIC. 
they are manifestly produced by pressure from the boot or 
shoe, and their presence tends to aggravate and increase 
the original disease. Their treatment in the chronic stage 
should be the same as that for corns, but when inflammation 
is present, cataplasms and soothing applications should be 
employed, and in all cases the exciting causes should of course 
be removed. 
CONDYLOMATA. 
Condylomata.—Generally the result of the syphilitic 
poison, but at times developed in persons in wrhom no such 
taint exists, these soft, fleshy tumors appear on those parts 
of the integument where the skin and mucous membrane 
meet, at the verge of the anus, or the prepuce, at the vulva, 
and occasionally, though very rarely, on the lips and nos- 
trils. They are of a soft consistence and a reddish-white 
color, varying in size from that of a pea to that of a marble, 
and have usually a broad base, with a flattened or rounded 
apex. They consist of numerous papillae in a highly vascu- 
lar condition, though apparently not much hypertrophied, 
and the epidermic covering is unchanged, except in being 
more vascular than in its healthy state. Various opinions 
have been propounded as to the nature of condylomata ; 
Simon and Rokitansky regard them as being a new forma- 
tion, consisting chiefly of areolar tissue, while Lebert be- 
lieves that they are epidermic or epithelial growths. They 
may be destroyed by the application of caustics, or strangu- 
lated with a ligature, which, by means of a needle, may be 
passed through the centre of the tumor, and then tied firmly 
at either side around the base. 
NCVUS. 
Nevus (.Mother mark). (Atlas, PI. XIV. Fig. 1).—Of 
the several varieties of this adventitious production which 
have been described, but one only can be regarded as a 
disease of the skin, namely, that which consists in a hyper- 
trophied condition of the capillaries of a portion of the 
cutaneous structure; the others, in which the vascular 
system of the areolar tissue, and sometimes even of the N2EVUS 
225 
deeper-seated parts, is engaged, are truly surgical diseases, 
requiring usually surgical interference for their removal, and 
are consequently treated of in all works on surgery. All 
the forms are usually congenital, and are popularly believed 
to be occasioned by the effect of the mother’s imagination 
upon the foetus in utero, an opinion shared in by the pro- 
fession even until modern times, and not yet altogether 
exploded. 
The variety of nsevus to be described here is character- 
ized by a permanent discoloration and slight elevation of 
the part affected, on which the minute veins of the cutis 
appear dilated and slightly tortuous, becoming gorged with 
blood from any exciting cause, and thus the color varies at 
different times, being dark red, or purplish, when the circu- 
lation is hurried or impeded. They vary in size, sometimes 
consisting of a small central point, from which several minute 
vesicles ramify—a form termed nsevus araneus,—in other 
cases covering a patch of the surface from the size of a 
shilling to that of the palm of the hand, when they are 
usually irregularly circumscribed, but often roundish. They 
seldom enlarge much after birth, but, occasionally affecting 
the deeper vascular structures, they become converted into 
one of the other forms of the disease, which consist of 
erectile tissues, when they acquire a greater magnitude, and 
are not unfrequently attended with troublesome or even 
dangerous symptoms. 
If the nsevus which engages the cutaneous capillaries be 
wounded, copious hemorrhage, often difficult to check, 
ensues, but otherwise they are of no importance, except 
from the disfigurement which their presence occasions, the 
more especially as they are usually situated on the face. 
On this account attempts have been at times made to 
remove them by caustics and other means, but a greater 
deformity is thereby often occasioned; unless, therefore, 
they exhibit a tendency to spread much, or to be converted 
into one of the other forms of the disease, they should not 
be interfered with. 226 
HEMORRHAGIC. 
CHAPTER VIII. 
HEMORRHAGIC. 
The single disease which constitutes the order Hemor- 
rhagic might perhaps be more correctly regarded as an 
affection of the system generally, but as its chief charac- 
teristic phenomena become apparent to the eye through 
the medium of the skin, custom has sanctioned its being 
described as a lesion of that structure. In cutaneous he- 
morrhages the blood does not escape from the surface of 
the body, but, being bound down by the epidermis, is 
effused beneath it in variously sized and differently shaped 
spots or patches. At times, in certain diseases, especially 
fevers characterized by low vital power, of which this 
constitutes one of the most important signs, the hemor- 
rhagic effusion is in the form of perfectly distinct, minute 
dots, termed Petechise. In other cases, occurring alone or 
complicating the former, it appears in irregularly circum- 
scribed patches, often of large extent, the blood escap- 
ing chiefly into the subcutaneous areolar tissue; these 
are denominated Vibices or Pcchymoses, the latter term 
being especially applied to them when they succeed a 
blow or injury. And in a third form, which constitutes 
Purpura, the only one here to engage attention, the he- 
morrhage is in perfectly circular spots: intermingled with 
them, however, are usually several patches—vibices or 
ecchymoses. 
PURPURA. 
Purpura (The Purples) is characterized by the appear- 
ance on the integuments, generally over the whole body, 
of small, perfectly circular spots of the color of the blood, 
attended with more or less derangement of the vital func- 
tions. The spots vary in size from that of the head of a 
pin to that of a small pea; on their first appearance the 
color is bright red, but augmenting slightly in extent, PURPURA. 
227 
still preserving their circular form, they gradually acquire a 
deep purple hue, ■which, as they fade away, passes through 
the various shades of greenish-yellow discoloration ordinarily 
presented by blood effused beneath the skin from a bruise. 
They are generally very numerous on the cutaneous surface, 
and often aggregated in masses on certain regions, yet per- 
fectly distinct from each other, except in some parts which 
may be exposed to pressure, where, becoming confluent, 
they constitute vibices or ecchymoses. Each individual 
spot of purpura runs its course from its first appearance 
until it fades away in from five or six to ten or twelve days, 
a slight stain remaining for some time to mark its site; but 
the disease may last for many weeks, or even months, its 
duration depending upon the development of successive 
crops of the eruption, an occurrence which takes place in 
the mildest cases. The spots or patches are not in the 
least degree elevated above the cutaneous surface, their 
presence being caused by an extravasation of blood into the 
derma or beneath the epidermis from the capillaries of the 
skin. 
The appearance of purpura is most usually preceded by 
slight febrile symptoms and general depression,—hot skin, 
quick yet compressible pulse, thirst, anorexia, malaise, and 
headache; but in some cases no premonitory symptoms are 
noticed. The circular spots are in the majority of instances 
present on the several mucous membranes of the body, and 
sometimes also on the serous, at the same time that they 
exist on the skin ; the blood being in them effused beneath 
their epithelial covering, through which structure, so much 
more delicate and fine than the epidermis, it commonly 
makes its way, and hemorrhage, often to a great extent, 
takes place, complicating the disease and rendering it much 
more dangerous. 
Several varieties of purpura have been described by der- 
matologists, all of which may, I think, be conveniently ar- 
ranged in two divisions :— 
Purpura simplex. 
“ hemorrhagica. 
Purpura simplex (Atlas, PL XIII. Fig. 1).—The spots 
in this form of the disease, which may be regarded as being 228 
HEMORRHAGIC. 
chiefly characterized by its mildness, appear for the most 
part on the extremities, and are developed very suddenly, 
often in the course of a single night, and usually without 
any preceding or accompanying constitutional disturbance. 
Yibices or ecchymoses are seldom intermingled with them, 
and they are generally much dispersed over the surface, not 
aggregated in masses ; successive crops, rarely, however, 
more than two or three, appear in most cases with an in- 
terval of from twenty-four to forty-eight hours between 
each, and some spots then occur also on various regions of 
the body, the shoulders, the chest, the face, &c., but they 
are always most numerous on the extremities. The disease 
runs its course in from seven or eight days to a fortnight or 
three weeks, at the end of which time the stains it occa- 
sions have totally disappeared. 
In some cases the extravasation of blood into the derma 
or beneath the epidermis, instead of occurring in distinct 
circular spots, without any elevation of the surface, takes 
place in raised wheals, resembling exactly in form the erup- 
tion of urticaria, and accompanied often by more or less of 
a stinging and tingling sensation, in consequence of which 
it has been termed purpura urticans (Atlas, PL XIII. Fig. 
2); the patches, owing to their extent, are of a deeper purple 
color than in the ordinary form of purpura simplex, and 
their duration is for the same reason prolonged to five or 
six weeks, although they are almost invariably developed in 
a single crop. Purpura urticans usually occurs on the lower 
extremities, and most frequently in persons laboring under 
some organic disease, and in those who have taken much 
mercury ; it also appears at times in females when the men- 
strual function is deranged. 
Purpura simplex occurring in old persons, especially of 
the female sex, when it appears very much intermingled with 
large vibices and some ecchymoses, was described by Bate- 
man as a distinct variety, under the name of purpura senilis; 
it is usually confined to the arms and legs, is developed in 
a single crop, unattended with any constitutional or local 
symptoms, and is an affection of but little disturbance, not 
impeding the usual avocations of life, and running its course 
in from a week to ten days or a fortnight. PURPURA. 
229 
When any of the varieties of simple purpura now de- 
scribed is accompanied by hemorrhage from the mucous 
membranes, it then constitutes a form of the second divi- 
sion of the disease. Occasionally purpura simplex is 
attended with some trifling febrile symptoms, rarely ex- 
ceeding slight heat of skin, thirst, and anorexia, yet by 
some writers it has been described under the name pur- 
pura febrilis simplex. The duration of the simple form 
of the disease, as has been above remarked, seldom exceeds 
a few weeks, but cases occur in which successive crops are 
developed for from eighteen months to two years or up- 
wards. 
Purpura hemorrhagica (Atlas, PL XIII. Fig. 3) is es- 
pecially characterized by the escape of blood from some of 
the passages of the body which are lined with mucous mem- 
brane; occasionally it takes place from the serous mem- 
branes also, when hemorrhage into the shut sacs occurs. 
The spots on the integuments are usually much more nume- 
rous, and generally acquire a larger size than in the former 
variety, and vibices and ecchymoses are more frequent; 
they appear on every region of the body, being most gene- 
rally witnessed first on the neck and shoulders, the face, 
and the upper extremities; they also occur on the conjunc- 
tiva, on the gums, the tongue, and the inside of the cheeks, 
and are found after death to be as thickly dispersed over 
the mucous membrane of the entire digestive tract as on the 
external integuments. 
The disease is ushered in usually by much constitutional 
perturbation, the chief symptoms being those of general 
oppression; in from twenty-four to forty-eight hours the 
spots begin to appear on the cutaneous surface, at first of 
a bright red color, but assuming a deep purple hue in 
about twelve hours; they are very numerous in most cases, 
and are rapidly developed; whatever region of the body is 
exposed to pressure, there large hemorrhagic patches are 
developed beneath the epidermis, and if the surface is 
scratched or torn, copious bleeding takes place from them ; 
in some cases the slightest pressure, even that caused by 
feeling the pulse, will produce an ecchymosed spot. 
Hemorrhage from the mucous membranes takes place 
often from the very commencement of the disease, some- 230 
HEMORRHAGIC. 
times it precedes the appearance of the spots of purpura 
on the integuments, but more frequently does not occur 
for several days after they are visible. Its most usual and 
mo'st manageable form is that of epistaxis, but the bleeding 
is also very common from the lungs, when it constitutes 
hemoptysis, and from the stomach and bowels, whence it is 
rejected by vomiting, or escapes by stool. In some cases 
of purpura hemorrhagica, the blood exudes from the gums 
in great quantity, apparently by a sort of oozing, which it 
is almost impossible to check, and not unfrequently proves 
fatal. The hemorrhage may take place also from the 
kidneys, the bladder, the urethra, the vagina, &c. These 
losses of blood are usually very great, and recurring con- 
stantly produce extreme depression and prostration, with a 
marked pallor or anemic condition of the entire surface of 
the body, that throws out into marked relief the purple 
spots and stains which are thickly scattered over it. 
The duration of this form of purpura is very variable; 
the local hemorrhages may be checked in seven or eight days, 
but they are very apt to recur, and thus the disease is often 
prolonged for several months, the cutaneous spots and 
patches continuing to be developed in constant, successive 
crops. When it has lasted for any time, the vital powers 
become extremely depressed, dropsical effusion takes place 
into the lower extremities, and uncontrollable bloody diar- 
rhoea not unfrequently sets in. 
When the constitutional symptoms attendant on purpura 
hemorrhagica assume a more febrile character than has 
been above described,—a general redness of the surface, 
with burning heat, preceding the appearance of the purple 
spots,—the disease has been specially noticed under the de- 
nomination of purpura febrilis hemorrhagica. This variety 
is chiefly remarkable from its not unfrequently appearing 
as an epidemic, especially where many persons are crowded 
together, as in gaols, poor-houses, &c. 
In many cases of purpura, the cutaneous phenomena are 
so trifling as to be scarcely noticeable, while the hemorrhages 
from the mucous surfaces are excessive; these constitute, in 
my experience, the most dangerous and uncontrollable cases, 
and death often occurs in them from extravasation of blood 
into some of the serous cavities. Dr. Graves described a PURPURA. 
231 
form of.the disease resembling this, in which, however, 
there was an exanthematous rash on the skin, resembling 
the red efflorescence so often seen in maculated typhus 
fever; in consequence of its presence he proposed to term 
the affection Exanthema hsemorrhagicum.1 
Erasmus Wilson describes as a form of purpura, under 
the designation of purpura cachectica, the occurrence of 
petechiae and ecchymoses of the skin, “ as the consequence 
of a reduced and debilitated state of the system, from what- 
ever cause the latter may arise.” We frequently see 
instances of this kind during the latter stage of various 
diseases, as of dropsies, or whenever the venous circulation 
is obstructed. The purpura contagiosa of Bateman corre- 
sponds with the petechial eruption of typhus fever. 
Purpura may occur at any age, but it is very rarely wit- 
nessed in infants or very young children; it affects both 
sexes also, but females are more prone to the disease than 
males. The hemorrhagic form is more frequent in the 
young, and in those in the prime of life, while the simple 
variety appears generally in old age. Persons of the 
sanguineo-lymphatic temperament constitute unquestionably 
the majority of those affected with purpura, yet it is seen 
in all constitutions, in the strong and robust as well as in 
the weak and debilitated. The causes of the disease are 
consequently very obscure; it was formerly believed to be 
always dependent on and to be a sign of general constitu- 
tional weakness—a view which influenced the exclusive plan 
of treatment recommended by Willan and his followers ; but 
it is now admitted to be often connected with plethora and 
sanguineous congestion. That low, ill-ventilated habitations, 
with deficient or unwholesome food, are occasionally predis- 
posing causes of purpura amongst the poor is undoubted, 
but inasmuch as it usually attacks only a single member of 
a family, some peculiar state of the constitution, the nature 
of which we are unaware of, is manifestly requisite to enable 
these causes to act. An exclusively meat diet, or an in- 
sufficiency of vegetables and milk, either of which produces 
the peculiar affection known as scurvy, does not seem to 
1 Clinical Lectures on the Practice of Medicine, Second Edition, vol. ii. 
p. 3G2. 232 
HEMORRHAGIiE. 
exert any influence in the causation of purpura; in the year 
1847, when scurvy was so general in this country, in conse- 
quence of the failure of the potato crop, purpura was not as 
prevalent as usual. In some cases of the disease which I 
have seen, a hereditary tendency to it could be traced, but 
this is not of so decided a character or so general as in the 
singular instances of the hemorrhagic diathesis, occasionally 
witnessed, in which the slightest injury causes often uncon- 
trollable bleeding, death sometimes, in consequence of it, 
resulting from the extraction of a tooth, or even from the 
wound produced by the scratch of a pin. The 'proximate 
cause of purpura is manifestly atony in the capillary system 
of blood-vessels, combined with an abnormal fluidity of the 
blood. 
Diagnosis.—This disease is so well marked by the visible 
phenomena that it can scarcely be confounded with any 
other; but it is necessary to distinguish the occurrence of 
purpura in the course of fever, or as a complication of any 
other affection, from its existence as an individual disease. 
The diagnosis between it and scurvy is unattended with diffi- 
culty, the characteristic condition of the gums, the extensive 
brown and purple discoloration of the integuments, and the 
absence of the round purpuric stains in the latter, are suffi- 
ciently distinctive marks. The spots of purpura are dis- 
tinguished from flea-bites with which a careless observer 
might confound them, by the presence of a central punctum 
in the latter, and their almost total disappearance on firm 
pressure being made with the finger, the marks of purpura 
being thereby unaffected. 
Prognosis.—Even cases of purpura that, in their com- 
mencement, do not present symptoms of severity, are not 
altogether free from danger, for the simple form of the 
disease not unfrequently becomes converted into the hemor- 
rhagic, and whenever bleeding from the mucous surfaces 
takes places in this affection, the prognosis must be cautious. 
When death occurs, it is either directly or indirectly conse- 
quent on the loss of blood: in the former case it may be 
sudden, as when apoplexy results from hemorrhage into the 
substance of the brain or from its membranes, and in the 
latter, it is generally less immediate, the patient dying with 
the symptoms usually caused by repeated losses of blood. PURPURA. 
The hemorrhage being profuse, or continuing unchecked by- 
treatment, is always an unfavorable sign, and until it 
ceases completely, and fresh spots no longer appear on the 
cutaneous or mucous surfaces, the patient cannot be re- 
garded as safe. Bleeding from the gums, particularly when 
at all excessive, is, in my experience, one of the gravest 
symptoms of the disease, even although there may be but 
little eruption on the integuments; I have rarely seen 
a case of purpura recover in which it was present to any 
extent. 
Occurring in the young, the strong, and the robust, and 
in the old, the weak, and the feeble, it is difficult to arrive 
at any correct view of the pathology of purpura. The 
precise condition of the circulatory apparatus, and of the 
blood itself, in which that fluid escapes from the vessels 
most remote from the centre, has not been sufficiently 
investigated as yet, to enable correct deductions to be 
drawn as to the real nature of the disease. It is true, that 
the blood in purpura has been chemically analyzed and 
microscopically examined, but the results afford no further- 
information than what had been previously gained by the 
unaided senses—that it is deficient in solid constituents, 
in consequence of which it is in most cases extremely fluid, 
and does not coagulate after its exudation through the 
mucous membranes, or should it he drawn from a vein ; 
yet, as shown by the analysis of Frick, of Garrod, and of 
Parkes, the fibrine may be in excess, and the property of 
coagulation not deficient in purpuric blood. The appear- 
ances in the internal organs found after death are, the 
presence of purpuric spots and vibices on the mucous, and 
occasionally on the serous membranes, and in some cases 
hemorrhage into one or more of the shut cavities. 
Treatment.—The treatment of purpura has been much 
influenced by the different opinions which have prevailed 
as to its true nature; many, adopting the views propounded 
by Willan as to the disease being nearly allied to scurvy, 
and consequently being essentially one of debility, agree 
also with him, “ that the treatment is simple, and may be 
comprised in a very few words: a generous diet, the use 
of wine, Peruvian bark, and acidsothers, regarding the 
doctrine of Parry, “that it is always of inflammatory ori- 234 
HEMORRHAGIC. 
gin,” as correct, recommend early and free venesection 
as holding out the only hope of successful treatment. In 
very few cases of the disease, however, is the decided 
antiphlogistic treatment here recommended either needed 
or beneficial, and in still fewer will the employment of 
tonics and acids be necessary or advantageous. Instances 
unquestionably occur in which the abstraction of blood to 
a small extent in the very commencement of the disease 
will at once stop its progress; these are cases of purpura 
simplex, affecting plethoric young persons of a sangui- 
neous temperament; but the bleeding should always be 
used with caution, and is rarely if ever admissible when 
hemorrhage occurs spontaneously to any extent from the 
mucous membranes. In that form of the disease which 
has been described as appearing on the lower extremities 
of old persons, whatever tends to strengthen the constitu- 
tion generally should not be omitted in the treatment; but 
if preparations of bark, or other tonics, be administered 
too freely, and without the simultaneous employment of 
remedies calculated to remove the hemorrhagic tendency, 
the symptoms are often suddenly aggravated, purpuric spots 
are developed over the body generally, and bleeding takes 
place from the mucous cavities, the simple form of the 
disease being converted into the hemorrhagic. 
Some years since I published an essay1 on the treatment 
of purpura by large doses of oil of turpentine, and illus- 
trated the efficacy of this remedy, when thus administered, 
by a report of several cases in which it proved singularly 
successful. Since then I have continued to employ it both 
in the simple and hemorrhagic forms of the disease, and my 
additional experience is fully confirmatory of the views then 
propounded. It must be given in doses sufficiently large to 
act as a purgative—from one to two ounces, according to 
the age and strength of the patient, for adults, and a pro- 
portionate dose for children ; to insure its purgative action, 
I was at first in the habit of giving it in combination with 
castor oil, but this, so far from being necessary, interferes, 
I think, more or less with the special effect of the turpentine, 
1 Dublin Journal of Medical Science, First Series, vol. xxviii. p. 189. PURrURA. 
235 
and therefore I now prescribe it combined simply with 
mucilage, as in the following form :— 
R. Olei Terebinthinae, fi sj. 
Mucilaginis, fl sj. 
Aquae Menthae Piperitae, . . . fl 5iss. 
Misce. Fiat haustus. 
This draught may be taken once or twice daily, according 
to the degree of its action on the bowels, and should there 
he much hemorrhage from the intestinal canal, or the 
stomach reject the draught, the same or a larger quantity 
of the oil of turpentine, suspended by means of the yolk of 
egg in decoction of barley, may be administered as an enema. 
The beneficial action of the turpentine in this disease is two- 
fold: first, it is a diffusible stimulant and styptic, which, 
when conveyed into the circulation through the digestive 
organs, is exhaled from the system by means chiefly of the 
mucous surface, as is manifested by the odor of the breath, 
and of the various secretions and excretions; it is thus con- 
sequently brought directly into contact with the capillary 
circulation, from which in this disease the hemorrhage takes 
place ; and, second, the free employment of purgatives in the 
treatment of purpura having long since been proved to be 
attended with most successful results, the administration of 
oil of turpentine to fulfil this indication is especially ser- 
viceable in consequence of its not being a debilitant. 
In cases in which from any cause—excessive debility or 
tendency to diarrhoea, &c.—purgatives are contra-indicated, 
the turpentine may be given in smaller doses, and repeated 
at shorter intervals; thus from twenty or thirty minims to 
a drachm may be prescribed every third or fourth hour, or 
three times a day, according to the amount of hemorrhage 
which accompanies the disease. Should there be extreme 
debility present, preparations of iron—those which are 
astringent being preferred—or other tonics, may be admi- 
nistered conjointly with the turpentine; but on the other 
hand, when there is much vascular excitement or general 
plethora, bleeding or other evacuants should be had recourse 
to at the same time that it is prescribed. 236 
HEMORRHAGIC. 
The employment of numerous other astringents and styp- 
tics has been recommended for the treatment of purpura; 
in cases attended with much hemorrhage from the stomach 
and intestines, or from the lungs, acetate of lead combined 
with opium often proves useful; the combination may be 
given in pill—two grains of the former with a fourth of a 
grain of the latter every fourth or sixth hour. But of all 
this class of medicines which have been used not one has 
proved so beneficial as gallic acid; it is especially of service 
in cases attended with profuse bleeding from the mucous 
surface, and may then be given in alternate doses with the 
oil of turpentine. Thus, a pill containing five grains of gal- 
lic acid made with sufficient mucilage or conserve of roses, 
should be administered every fourth hour, the turpentine 
draughts being given two hours before and after each pill. 
When excessive hemorrhage takes place from the mucous 
membrane of the gums and the inside of the mouth, it is, 
as before remarked, a most dangerous symptom, and the 
bleeding is extremely difficult to check—the most active 
styptics applied directly often failing to diminish it in the 
slightest degree. I have in such cases tried unavailingly 
nitrate of silver, saturated solutions of alum, of sulphate of 
iron, of gallic acid, <&c., Rusbini’s styptic, nitric acid, and 
even the actual cautery: pieces of lint dipped in oil of tur- 
pentine seem to have the most effect, but the general treat- 
ment above recommended can alone be then relied on. 
Sponging the surface of the body repeatedly during the 
day with cooling lotions—such as equal parts of vinegar and 
water, with the addition of a sixth part of rectified spirit, 
should there be much febrile heat—is an adjunct, too often 
neglected, of much value in the treatment of purpura. 
Acidulated drinks—lemonade, raspberry vinegar and water, 
should be always freely allowed, and the diet, though rather 
small as regards quantity, ought to be nutritious and tonic, 
but easy of digestion, consisting chiefly of milk, farinaceous 
food, and strong beef tea: all food and drink being taken 
rather cold than warm. MACULA. 
237 
CHAPTER IX. 
MACULJ5. 
The group of cutaneous affections classed in the order 
Maculae is characterized bj a morbid condition of the color 
of the skin dependent on some deranged state of the secre- 
tion of the pigment cells of the derma. The change may 
consist in either an augmentation or a diminution of the 
natural color, or it may be altered in hue or totally absent; 
in some instances it affects the entire surface of the body, 
but more usually occurs in spots or patches that vary much 
in shape and extent: in either case there is no sensible ele- 
vation or depression of the surface. The several affections 
belonging to the order may be congenital, or they may be 
developed at any period of life: in the former case they 
usually consist in the total absence of coloring matter, con- 
stituting what has been denominated, Albinoismus (Atlas, 
PI. XIII. Fig. 5),—individuals born so being termed Albi- 
noes,—or there may be only a deficiency of coloring matter 
in large patches, a condition which is rare, but most fre- 
quently witnessed in the children of negroes, who are thus 
piebald at birth. In certain diseases, as in jaundice, in 
chlorosis, in malignant and in most chronic affections, a 
peculiar alteration in color of the tegumentary membrane 
takes place, and which is regarded usually as one of the most 
important signs of the special diathesis or constitutional de- 
rangement which characterizes or accompanies the disease ; 
but it is readily recognizable, and cannot be confounded with 
the pigmentary alterations of the cutaneous structure here 
to be considered, which do not influence in any way the 
general health, and are therefore to be regarded solely in 
consequence of the disfigurement which they occasion, in 
many instances a cause of greater annoyance than a real 
disease. These changes in color may be conveniently de- 
scribed in two divisions, the one, that attended with defi- 238 
MACULJE. 
ciency of coloring matter—Vitiligo, including albinoismus ; 
and the other, marked by augmentation and alteration of 
the natural pigment—Ephelis. 
YITILIGO. 
Vitiligo (Atlas, PL XIII. Fig. 4) consists in a deficiency 
or total absence of the natural coloring matter of the skin, 
in consequence of which it presents a white and sometimes 
glistening aspect; the term, which was adopted hy Willan 
from Celsus, is conjectured to have been derived from the 
resemblance which the integuments thus affected bear to the 
flesh of calves—Vituli; and being sanctioned by usage and 
sufficiently expressive, I have been unwilling to change it 
for Leucopathia, an appellation more strictly correct, per- 
haps, which is employed by many modern dermatologists. 
The decoloration may be limited to certain regions of the 
body, occurring in patches, or may be general when the ab- 
sence of pigment is witnessed in the hair, the eyes, &c. In 
the former case, the peculiar condition of the skin is often 
congenital, but it may be developed at any period of life ; 
it constitutes the Achroma vitiligo of Alibert; the latter, 
the Achroma congenitale of the same author, is always con- 
genital; it is denominated, as before remarked, Albinoismus. 
Albinoismus cannot be regarded as a disease, and therefore, 
not coming within the scope of this work, need not be de- 
scribed here; it moreover is not within the sphere of medical 
art, being altogether an unalterable, and consequently an 
incurable affection. 
What then may be termed true vitiligo, when not congeni- 
tal, is developed in the form of rounded spots or patches, few 
or many, on some special region of the body, or on several 
parts at the same time; the spots are at first usually small, 
not more than a few lines in diameter, and nearly circular, 
but they gradually augment in size—often acquiring the 
magnitude of the palm of the hand, and become irregular 
in shape. It appears most frequently on the chest, the 
back, the scalp, and about the genital organs, but it may 
occur on any part of the integuments. The portions of skin 
affected present simply a white aspect, in some cases dull, VITILIGO. 
239 
in others bright and glistening, without any sensible eleva- 
tion or depression of the surface; if hairs grow naturally 
on the part they also become perfectly white, no matter of 
what color they may have been previously, and not unfre- 
quently fall out after a short time, leaving a bald, colorless 
patch. When the hairy scalp is thus affected, attention is 
at first usually attracted to it by a single lock of the hair, 
generally on the back part of the head or the temples, turn- 
ing white; this gradually becomes larger, and at length the 
hairs, which have lost their color, fall out, and one of the 
forms of alopecia, or what has been termed a variety of 
porrigo decalvans, is thus constituted. 
The causes of this singular affection of the skin are per- 
fectly unknown: it occurs at all ages, and is most frequent 
in the prime of life, especially when it appears on the head, 
but it is developed on the genital region usually in old per- 
sons ; it is witnessed, too, in individuals of all temperaments, 
yet I think it is more common on the scalp of those who 
have dark than of those who have light hair ; it is also, in 
my experience, more usual on the head in females, and on 
other parts of the body in males. Congenital vitiligo is 
rare in the white races, occurring with a much greater de- 
gree of frequency in negroes, infants at birth sometimes 
presenting a completely pied appearance. 
The diagnosis of vitiligo is unattended with difficulty; 
the longitudinal white furrows on the abdomen of females 
who have borne children, or of those who have had ascites, 
and on the breasts of nurses, might, by a superficial observer, 
be confounded with it, but their site and the history of the 
individual case are in all cases sufficient to prevent such a 
mistake. A form of lupus, to be hereafter described, is 
stated by Erasmus Wilson to be incorrectly regarded as 
vitiligo, and he consequently introduces this term amongst 
the synonymes of Lupus non-execlens, but, as will be shown 
in the next Chapter, the diseases are essentially different, 
and cannot be confounded. 
Prognosis.—An affection of the most trifling importance, 
as regards the general health, and accompanied by not the 
slightest local sign or symptom of irritation in its develop- 
ment or progress, vitiligo is, nevertheless, attended with the 
most serious mental suffering, especially to young persons, 240 
MACULiE. 
when it appears on the face or the hairy scalp, owing to the 
disfigurement which it there occasions. It is often most 
rebellious to treatment, and always extremely slow in exhi- 
biting any signs of amendment, yet, by continued attention, 
a cure is usually effected in time. 
Treatment.—Constitutional remedies should not be neg- 
lected in the treatment of vitiligo, but those required are 
simply such as will restore a healthy tone and vigor to the 
system : consequently, preparations of iron or of bark com- 
bined with iodine, cod-liver oil in scrofulous habits, cold salt- 
water bathing, general or local, in the form of the shower- 
bath or of the douche, and, above all, mental quietude, are 
the most essential. Topical applications, however, are chiefly 
to be relied on, and of these various stimulating remedies 
especially are employed with benefit; tannic acid ointment, 
in the following form, has proved of more service than any 
other in my hands :— 
R. Acidi Tannici, gr. xl. 
Adipis prseparati, 3j. 
Glycerinse fl 3ss. 
Olei Rosmarini, m. viij. Misce. 
A portion of this ointment should be rubbed forcibly into 
the parts affected three times a day, the surface having, pre- 
viously to each application, been washed well with a satu- 
rated solution of common salt in water. In very chronic 
or obstinate cases, blisters may be applied to the affected 
parts, in order to excite a new action in them, or tincture 
of cantharides made into an unguent, in the proportion of a 
drachm to the ounce of white wax ointment, rubbed in twice 
daily. Sulphuret of potassium, and other preparations of 
sulphur, in the form of lotion or ointment, employed locally, 
sometimes succeed when other remedies fail; but next to 
tannic acid I have found oil of turpentine prove most useful 
as a local application: a pomade may be prepared with it 
as follows :— 
R. Olei Terebinthinm, fl 5 ij« 
Sevi, ij. 
Balsami Tolutani, 5 ij« EPHELIS. 
241 
Simul liquefac lento igne, dein adde, 
Olei Rosmarini, m. xx. 
Olei Amygdalae Amarae, .... in. v. 
A small portion of this pomade should be rubbed into the 
affected spots twice or three times a day with a piece of 
flannel, the part having been previously well washed with 
an alkaline wash—a draclim of carbonate of potash to eight 
ounces of distilled wTater. 
EPHELIS. 
Ephelis.—This term, as its derivation (s*;, the sun) 
indicates, was originally employed to designate all discolora- 
tions of the skin caused by the direct action of the solar 
rays, but latterly it has acquired a more extended signifi- 
cation, and may, I think, now be understood to include all 
those affections in which the natural pigment hue of the skin 
is augmented or altered. Some of these changes being con- 
genital and unalterable need not be described here, while 
others are due and can often be traced to specific causes. 
Ephelis may be conveniently considered as consisting of three 
varieties:— 
Ephelis lenticularis. 
“ hepatica. 
“ violacea. 
Fphelis lenticularis (Freckles).—This discoloration of the 
skin is too well known to need description ; in many persons 
the buff-colored or reddish-yellow spots which constitute it 
are congenital, wdien they are beyond the reach of medical 
art; but in others they are developed on those regions of 
the body which are uncovered, by exposure to the weather, 
but especially to the direct action of the sun’s rays. They 
are seldom witnessed except in those who have a very fine 
and fair skin and are of the sanguine temperament. Ap- 
pearing usually for these reasons on the skin of young per- 
sons of the female sex, and on those parts of the surface 
which are most exposed to observation, freckles cause very 242 
MACULiE. 
serious annoyance, and a host of applications have been 
employed for their removal, which is often a matter of some 
difficulty; persons who are liable to them should, therefore, 
protect themselves as much as possible from the causes by 
which they are produced. The various empirical lotions 
which are sold for the removal of these spots, are composed 
chiefly of corrosive sublimate, or of the solution of the sub- 
acetate of lead in bitter almond emulsion, in the proportion 
of a fourth of a grain of the former, or six minims of the 
latter, to each ouncfe of either of them ; they are often very 
useful. Erasmus Wilson recommends the application of a 
liniment, “ composed of equal parts of lime-water and olive 
oil,” to which, if the heat of the surface is considerable, he 
adds “ liquor plumbi in the proportion of twenty minims to 
the ounce.” I have found the following lotion of much 
service:— 
R. Liquoris Sodse Chlorinatse, . . . fl 5'j- 
Aquae Florum Sambuci, . . . . fl svij. 
Aquae Lauro-Cerasi, fl 3vj. Misce. 
And the application at night of a pomade, consisting of 
equal parts of cold cream and cucumber cerate, to every 
ounce of which half a drachm of the solution of chlorinated 
soda is added. 
Arphelis hepatica is characterized by the appearance of 
one or more patches, of tolerable extent, on some portion of 
the cutaneous suface; they are of a dull yellow or huff color, 
occasionally of a bronze hue; at first distinct from each 
other; when more than one occurs, they gradually enlarge, 
and coalescing often acquire a considerable size, so that in 
some cases the neck, the face, the upper part of the trunk 
and the hands, being the parts usually affected, acquire a 
dark brown color. On the first appearance of the patches 
they are not unfrequently attended with some itching and 
tingling, and a fine mealy desquamation, increased by 
scratching or rubbing the surface, takes place ; but there is 
no sensible elevation or depression of the skin where affected. 
The coloration varies much in different cases, through all 
the shades of gray, yellow', and brown, being often evidently 
dependent on the natural color of the individual; at times, EPHELIS. 
243 
when it is very extensive, the contrast is so remarkable that 
the unaffected parts of the skin appear as if they were the 
seat of vitiligo. 
Ephelis hepatiea is a very chronic affection, in most cases 
lasting for many months or even for years, but it is occa- 
sionally of short duration, and even evanescent, disappear- 
ing suddenly a few hours after its development. In the 
latter case the discolored patch or patches generally appear 
in females just before the coming on of the menstrual dis- 
charge, and fade away when it commences. It is a more 
frequent affection in all its forms in the female than in the 
male sex, being a not uncommon attendant on pregnancy 
and on various uterine derangements; in both sexes it is 
rarely witnessed except in the prime of life, occurring, how- 
ever, with greater frequency in old than in young persons. 
A large patch of ephelis hepatiea is sometimes developed on 
the neck or the side of the face, by the action of the rays 
of the sun ; and a discoloration of the skin resembling it in 
hue—but differing from its occurring in large, irregularly- 
shaped rings, surrounding comparatively healthy skin—ap- 
pears on the lower extremities generally of old persons who 
expose their legs uncovered to the fire ; the latter has been 
specially described by Rayer, as being very common in Paris 
amongst the lower orders, especially females, who sit over a 
charcoal fire, and is termed by him Ephelides igneales ; in 
Ireland, also, it is common amongst the poor, chiefly in 
country districts where turf fires are used, and is vulgarly 
colled the Trouts. 
Diagnosis.—This affection is often confounded with a form 
of pityriasis, and, as already remarked when describing that 
disease, Rayer and Wilson consider pityriasis versicolor and 
pityriasis nigra as being nothing more than discolorations 
of the skin, and therefore to be classed with ephelis: my 
reasons for differing with them have been there given. The 
stains of ephelis hepatiea may be confounded with those 
which are symptomatic of a syphilitic taint in the system, 
from which they are chiefly to be diagnosed by the history 
of each case, and the concomitant symptoms. 
In the treatment of this affection it is requisite, in the 
first place, to direct attention to the general health, espe- 
cially the state of the digestive organs, with a deranged 244 
MACULJE. 
condition of which their presence is often associated, and to 
use remedies calculated to restore them, if requisite, to a 
healthy tone ; in females, moreover, should there exist any 
irregularity of the menstrual function, appropriate means to 
correct it must he employed ; but when the patches are de- 
veloped in the course of pregnancy, no treatment ought to 
he had recourse to, for they usually disappear after delivery. 
The local applications that prove most successful are those 
which have been recommended for the last described variety 
of ephelis ; when, however, the discoloration of the surface 
is very extensive, hot baths containing the sulphuret of po- 
tassium, or of the natural sulphureous waters will be found 
of service : these mineral waters also should be used inter- 
nally, and if drank at their sources so much the better. 
When a single large patch of ephelis hepatica becomes 
chronic, repeated blisters applied over it will sometimes re- 
move the discoloration of the part. 
Ephelis violacea.—When the internal administration of 
the nitrate of silver has been continued for a lengthened 
period without prolonged intermissions, the derma becomes 
chemically stained with it, and the entire surface of the 
body then presents a slate-colored, bluish-gray, or leaden 
hue, causing a frightful disfiguration, more especially as the 
face and those parts constantly exposed to the light are most 
deeply tinged. This discoloration is much less frequently 
witnessed now than it was some years since, when this medi- 
cine was so universally employed for the treatment of epi- 
lepsy and other nervous and convulsive diseases. The most 
certain way to prevent this result—one of so grave a cha- 
racter as almost to counterbalance any good effects which 
might be derived from the administration of nitrate of silver, 
as a medicine—is not to continue its use for a longer period 
than six weeks or two months, and should it be thought well 
to resume its employment again, to permit at least a month 
to elapse before doing so. 
This discoloration when once produced is permanent, and 
becomes even deeper with time, nor have any means hitherto 
tried for its removal had the slightest effect over it. The 
iodide of potassium, w'hen applied to the skin, even some 
days after it may have been stained by the direct appli- 
cation of the nitrate of silver, effectually removes the disco- EPDELIS. 
245 
loration ; its use in various ways has therefore been pro- 
posed for the general staining of the cutaneous surface 
above described. Professor Melsens, of Brussels, has given 
it in enormous doses, half a drachm, or even more, three 
times daily, exposing the patient at the same time to a hot 
vapor bath: the iodide is thus brought to the surface, when 
it may be readily detected in the perspiration by the ordi- 
nary tests. He continues this plan of treatment for months, 
but in one case.that I am cognizant of, which was treated 
by himself, the discoloration was not in the slightest degree 
removed. This, I think, was to be anticipated, for it is as 
iodine, and not as iodide of potassium that the preparation 
is given off by the skin after its use has been continued for 
some time; I would, therefore, suggest that the patient, 
while under the influence of the remedy, should be placed 
during for from half an hour to an hour in a warm bath con- 
taining carbonate of potash in solution, instead of employing 
the hot vapor bath, as thus the iodide of potassium might be 
brought into direct contact with the derma. 246 
CANCRODES. 
CHAPTER X. 
CANCRODES. 
The order Cancrodes includes two diseases of the skin, 
which possess a certain degree of malignancy, inferior to 
that of true cancerous affections, yet in many of their fea- 
tures bearing much resemblance to them, especially in being 
usually characterized by a slow and insidious ulcerative pro- 
cess, often attended with severe stinging pain, and by a 
marked tendency to return in the same or in some other part 
of the skin, after they have been apparently cured, or even 
after the diseased portion of the integument has been ex- 
cised. These diseases are by most dermatologists classed 
amongst the Tubercula of Willan, but for the reasons already 
stated in the introductory remarks to the seventh chapter I 
have omitted this order altogether, and even were it to be 
retained, the affections now to be described could not, with 
any pretensions to accuracy, be included in it. The term 
Cancrodes, which I have adopted from Copland’s classifica- 
tion of diseases of the skin,1 expresses well their peculiar 
features above referred to, and is at the same time sufii- 
ciently distinctive for all purposes of arrangement. The 
two diseases to be described in the order are: Lupus, Kelis. 
Lupus (.Eating tetter) appears on the skin usually of the 
face, but often on the scalp, in various forms : it is generally 
developed as an inflammatory affection, with more or less 
hypertrophy of the integuments attacked, soon terminating 
in ulceration, which may be either superficial or deep-seated, 
but is always painful, slow, and insidious, and especially 
characterized by a destructive tendency, whence the name 
—Lupus, “ a wolf—was originally applied to the disease. 
LUPUS. 
1 Dictionary of Practical Medicine, vol. iii. p. 799. LUPUS. 
The ulcerative process may be confined to the epidermis and 
the superficial layers of the derma, may extend quite through 
the cutaneous integument, or may even affect the deeper- 
seated parts, destroying the areolar tissue, muscles, carti- 
lages, and periosteum, laying bones bare, and thereby caus- 
ing caries in them. The disease is thus naturally divided 
into three forms, but in general two only are described by 
writers on cutaneous affections : the one, in which the ulcera- 
tive process attacks the deeper-seated tissues, being termed 
lupus exedens, and the other, which affects more superficial 
structures only, being for contrast denominated lupus non- 
exedens; in both, however, a similar form of ulceration, 
although differing in degree, occurs, and this division is, 
therefore, not strictly accurate. I shall describe the three 
forms, the leading features of which have been noticed above, 
under the following specific denominations :— 
Lupus superficialis. 
“ serpiginosus 
“ devorans. 
Lupus superficialis (Atlas, PI. XIY. Fig. 2) commences 
by the development of a slight thickening or elevation of 
the skin, not larger than a small pea, usually on the most 
prominent part of one cheek; it presents a somewhat in- 
flamed appearance, is soft to the touch, rather painful if 
pressed firmly, and is of a very indolent nature. A thin, 
hard, brownish scab appears on its surface after some time, 
often not for months, but is seemingly not preceded by any 
ulceration; when the scab is picked off with the nails, as it 
almost invariably is by the individual himself, the part on 
which it rested is seen to be superficially ulcerated, wTith 
thickened and slightly elevated edges; it is soon repro- 
duced, a little more consistent than before, but still of small 
extent, and increases very slowly in size, even when irri- 
tated by the use of stimulant applications or by other local 
causes. Generally, after several months, the dry crust or 
scab falls off that part of the integument on which it first 
appeared, while it is spreading slowly to the neighboring 
surface. The portion of the skin on which it had existed is 
wdiite and seamed, resembling much the condition which re- 
sults from destruction of the superficial layers of the cuta- CANCRODES. 
neous structure by a burn. With slow but steady progress 
the disease advances over the cheek, usually in one direction 
only, leaving its trace behind in the white seaming of the 
skin; at times it becomes the seat of active inflammation, 
generally from being rubbed or torn with the nails, when 
a small, painful ulcer results, but the local symptoms are 
never very severe, the chief annoyance it causes being due 
to the unsightly deformity which it occasions on the face. 
The progress of this form of lupus is so slow that the re- 
sulting superficial cicatrix above described, which is some- 
what circular, does not attain a larger size than that of a 
shilling in from two to three years after the first appearance 
of the disease,—at least such was the case in two persons 
affected with it whom I have had under my care. 
Lupus superficialis, as here described, is a rare affection, 
and has escaped the notice of many writers on diseases of 
the skin; Dr. Copland gives the best account of it that I 
have met with, under the appellation of Lupus superficialis 
non-tuberculosus.1 Its duration may be almost indefinitely 
prolonged; when it terminates in cure the scab falls off, 
and is not succeeded by another, but the mark on the 
cutaneous surface is indelible. 
Lupus serpiginosus (Atlas, PI. XIY. Fig. 3).—This 
variety of the disease—well named by Alibert, Lsthiomenos 
(from taOcco, “I eat,”) ambulans vel serpiginosus—is well 
marked by highly characteristic phenomena, which distin- 
guish it from either of the other forms of lupus, but it must 
be noticed that the specific name “ superficialis” has been 
applied to it by some dermatologists who do not appear to 
have met with the variety of the disease above described 
under that appellation. It commences by the development 
of one or more small, livid, or dusky-red tumors,—the 
tubercles of most authors,—about the size and shape of a 
pea, on some portion of the integuments, usually on the 
face or the scalp, but not unfrequently appearing on differ- 
ent parts of the body at the same time ; they feel thickened 
and somewhat hard to the touch, with an uncircumscribed, 
soft, and slightly swollen base, and are rather painful on 
pressure, a sense of heat and itching also attending them. 
1 Dictionary of Practical Medicine, vol. iii. p, 790. LUPUS 
249 
These tumors are very indolent, often remaining stationary 
for months, and scarcely increasing in size; interstitial ab- 
sorption of the deep layers of the derma is, however, slowly 
going on, and at length purulent matter makes its way to 
the surface, generally at the most prominent part of the 
elevations; ulceration then takes place, and, the pus es- 
caping, it is found that the surrounding integuments are 
more or less undermined by the process of destructive 
absorption which had been taking place. Additional tumors 
are now developed in the neighborhood of those which 
first appeared, and of a similar character in all respects to 
them: the intervening portion of integuments present an 
oedematous aspect, has a boggy feel, and, being first un- 
dermined by the ulcerative interstitial absorption, which 
continues its slow progress, at length gives way, and an 
unhealthy-looking, open ulcer, extending quite through the 
skin, and covered in parts by a hard, brown crust or scab, 
is formed. 
The ulcers constituted in the manner above described 
heal slowly, leaving an uneven excavated cicatrix or pit 
of a white glistening color, but the disease continues to 
spread from the circumference, creeping on—whence the 
specific name—almost invariably in the form of irregular 
rings. The interstitial ulceration in many cases re-attacks 
the parts which have cicatrized, and they again may thus 
become for a second or third time, or even oftener, the seat 
of the disease, which runs the same course as at first, but 
each time the surface heals, the resulting cicatrix is deeper 
and more uneven. It not uncommonly occurs that two or 
more patches of the lupoid ulceration coalesce in conse- 
quence of the disease spreading from the circumference of 
each, and an extended portion of the integuments may 
thereby be affected. 
Lupus serpiginosus occurs, as already remarked, with 
greatest frequency on the face and scalp, often extending, 
too, from one to the other, and being confined to them, but 
it is also witnessed on both the upper and lower extremities, 
and occasionally on the trunk of the body; it is usually 
attended with more or less local pain in all its stages, which 
is much aggravated at times by attacks of acute inflamma- 
tion, when it spreads more rapidly, but the constitution 250 
CANCRODES. 
very rarely participates, those affected with the disease being 
often apparently in excellent health, even although it may 
have lasted for years. It is always of a chronic nature, 
and its duration is extremely prolonged. When it termi- 
nates in cure, the intra-dermoid ulceration ceases to spread ; 
healthy granulations, at times rather exuberant, form on 
the surface, and cicatrization of the affected part takes 
place; the annular edges being elevated over the healthy 
skin, and of course much more over the cicatrized portion, 
and being of a bright-red color, which they retain for a 
long time, contrast remarkably with the shining white aspect 
of the latter : much disfigurement consequently results. 
Lupus devorans (noli me tangere) (Atlas, PI. XIV. Fig. 
4).—This variety of the disease commences in various ways, 
but no matter what appearance it may present at first, it is 
in its progress characterized by destructive ulceration of 
the various structures situated beneath the skin—areolar 
and adipose tissues, muscles, tendons, cartilages, and peri- 
osteum, being equally destroyed; the bones even do not 
escape, for where they are laid bare caries attacks them. 
It may be developed, like the last-described form, by the 
appearance of one or more rounded, dusky-red elevations 
of the integument—tubercles—on the alae nasi, on the 
cheeks, or on the roof of the mouth, which, however, run 
a somewhat more rapid course than in lupus serpiginosus, 
are the seat of more active inflammation, and are attended 
with a more destructive ulcerative process, which extends to 
the deeper-seated structures. In other cases, one of the 
alse of the nostrils becomes slightly swollen, painful to the 
touch, and of a violet-red color ; being attended with itching 
it is soon scratched with the nails, a brownish crust or hard 
scab results, which is surrounded by an inflammatory oede- 
matous base, and, purulent matter forming beneath it, ulcer- 
ation of the destructive character peculiar to the disease 
commences. In a third class of cases the tip of the nose 
swells, and presents a dead-white color, gradually but 
slowly enlarging a black crust forms at the very apex, the 
mucous membrane of the nostrils becomes thickened, chiefly 
from effusion into the areolar tissue beneath it, and at length 
ulceration takes place. And, lastly, the thickening and 
subsequent ulceration first appear in the soft palate or pos- LUPUS 
251 
terior nares, and, proceeding from within outwards eventually 
attack the septum naris, and the other cartilages of the nose. 
In whichever way the disease may commence, the re- 
sulting ulceration presents much the same characters; its 
tendency is to spread from the surface inwards, not unfre- 
quently undermining in its progress the healthy integuments 
before it attacks them, and being attended with a foul, 
unhealthy, purulent, often ichorous discharge. The parts 
first affected usually cicatrize in the course of the disease, 
when the cicatrices present a similar appearance to what is 
witnessed in lupus serpiginosus, but indicate a greater loss 
of substance beneath. This is especially remarkable on the 
nose, the most usual seat of this variety of lupus, this 
feature assuming then a peculiar pinched appearance, from 
a deficiency of some of its natural proportions. The amount 
of destruction caused by the ulcerative process varies much 
in different cases, in some removing only a small portion of 
the cartilages of the alse nasi, while in others the entire soft 
part of the nose, the aim and septum naris, and the soft 
palate, are destroyed, frightful deformity being thereby 
occasioned. As in the other forms of lupus, parts that 
have been cicatrized not unfrequently again become the 
seat of fresh ulceration, which runs a similar course to what 
it did at first, being then, however, more difficult to check. 
Lupus devorans most generally runs a very chronic course, 
its progress being slow, years often elapsing before it causes 
much destruction of the part it appears on; but cases occur 
—happily very rarely—in which it destroys with extreme 
rapidity those portions of the integuments and of the neigh- 
boring structure it attacks; thus, in from a month to six 
weeks the entire of the nose may be eaten away ; this variety 
of the disease has been appropriately enough termed lupus 
vorax. 
In some cases lupus devorans attacks the lower eyelid 
first, commencing by the development of a single rounded 
elevation of the skin, of a livid aspect; its progress is ex- 
tremely slow, but in the course of years it eats away all 
the structures around the eyeballs, laying the orbit almost 
completely bare, but sparing the eye itself, which appears 
just as if it had been dissected out by the ulceration. This 
variety of the disease was first accurately described by 252 
CANCIiODES. 
Professor Jacob, who, however, regarded it as a malignant 
ulcer and not as a form of lupus, and it has been ever since 
known to the profession in this country by the name of 
“ Jacob’s ulcer” (Atlas, PI. XIV. Fig. 5). llayer, who 
also gives an accurate account of it, believed it to be lupus, 
and with him my experience, derived from the prolonged 
observation of several cases, compels me to agree. The 
following graphic account of this lupoid ulceration is given 
by Professor Jacob:1 “The edges are elevated, smooth, 
and glossy, with a serpentine outline, and are occasionally 
formed into a range of small tubercles or elevations ; the 
skin in the vicinity is not thickened or discolored. The 
part within the edges is in some places a perfectly smooth, 
vascular, secreting surface, having veins of considerable 
size ramifying over it, which veins occasionally give way, 
causing slight hemorrhage; in other places the surface 
appears covered by florid, healthy-looking granulations, firm 
in texture, and remaining unchanged in size and form for a 
great length of time. The surface sometimes heals oyer in 
patches, which are hard, smooth, and marked with venous 
ramifications.” “The discharge from the surface is not of 
the description called by surgeons unhealthy or sanious, but 
yellow and of proper consistence ; neither is there more 
fetor than from the healthiest sore, if the parts be kept 
perfectly clean, and be dressed frequently.” It is surprising 
how little suffering, either local or constitutional, attends 
this frightful affection, the duration of which may extend 
from early life to an advanced old age. 
Lupus in all its forms is a disease of youth and of the 
prime of life, being rare before the age of 10, and very 
seldom developed for the first time in old age. As regards 
its causes, there is abundant evidence to show that it is 
intimately connected with the scrofulous diathesis especially, 
when it is hereditary, and many cases seem to prove that a 
constitutional syphilitic taint also is a frequent predisposing 
cause of it. In the majority of instances it appears at or 
soon after puberty, without any manifest exciting cause, but 
in some it follows an injury or some other local irritant. It 
1 Dublin Hospital Reports, vol. iv. p. 232. LUPUS. 
253 
is on the whole rather a rare disease, and is perhaps some- 
what more frequent in females than in males. 
Diagnosis. — The differential diagnosis of the various 
forms of lupus now described is unattended with difficulty, 
but some of them may be mistaken for other diseases of the 
skin. Lupus superficialis is of such rare occurrence that it 
is often not recognized when met with, yet its phenomena 
are highly characteristic, and it is of importance, with refer- 
ence both to prognosis and treatment, that it should be diag- 
nosed ; the peculiar cicatrization or seaming of the surface 
over which it has passed is its especial mark: a similar 
result is not met with in any other cutaneous affection. 
Lupus serpiginosus may be confounded with impetigo, from 
which it is distinguished by the destructive ulceration which 
attends it, by its spreading in rings, and undermining the 
integuments as it creeps onwards: pseudo-pustules are con- 
stantly developed on those parts of the skin which it attacks, 
but they differ from the pustules of impetigo in being flat- 
tened, more or less uncircumscribed, and presenting from 
the first a comparatively large quantity of purulent matter, 
with a very thin covering. This variety of lupus is in gene- 
ral described by dermatologists as being with difficulty diag- 
nosed from scrofulous ulceration of the integuments; but 
this is a matter of little import, for it rarely occurs except 
in persons of a well-marked scrofulous diathesis, and by 
many it is termed Dsthiomanic scrofula. A somewhat simi- 
lar form of ulceration constitutes at times one of the phe- 
nomena of secondary syphilis, but it is not of the same 
indolent and destructive character, is attended with other 
symptoms which mark the presence of this poison in the 
system, and is always more or less amenable to specific 
treatment. Lupus devorans may, in its early stages, be 
mistaken for acne indurata, but the distinctive signs have 
been already pointed out in the description of that disease 
(see page 122). From the syphilitic affections which occur 
on the face it is distinguished, by its malignancy, by its slow 
progress, and by its not directly implicating the bony struc- 
tures ; but in many cases the diagnosis is made with extreme 
difficulty, and then the results of treatment—more especi- 
ally when the history of the individual case cannot be 254 
CANCRODES. 
satisfactorily obtained—afford much aid in arriving at a 
conclusion. 
The form of lupus described above under the name of 
“ Jacob’s ulcer” is regarded by many as being nearly allied 
to, if not a variety of, cutaneous cancer; by most surgical 
writers the latter view is taken, and Copland regards it as 
a connecting link between the two diseases. But its chief 
characteristic phenomena, especially its tedious but onward 
ulcerative progress, not implicating the bony tissues, the 
freedom from pain which marks its course, the non-contami- 
nation of the constitution generally, and the absence of the 
hypertrophied condition so characteristic of cutaneous can- 
cer, sufficiently identify it, in my opinion, with the other 
lupoid affections. 
Prognosis.—In every form of lupus, the prognosis, though 
favorable as regards the general health, must be more or 
less unfavorable with respect to the local disease, the latter 
being by many regarded as altogether incurable; yet, al- 
though most tedious and obstinate, in the majority of cases 
resisting even judiciously applied and appropriate treatment 
for years, it not unfrequently eventually yields, the de- 
structive process of ulceration is arrested, and the affected 
parts heal. The superficial variety of lupus is the least 
important in all respects, but even it is most rebellious, and 
the diseased surface rarely takes on a healthy action until 
after several months of treatment, and after apparent cure 
it is very apt to re-appear in the old cicatrix. Lupus serpi- 
ginosus, when of small extent, is in some cases very amen- 
able to treatment; but when it affects an extended portion 
of the integuments is rarely cured in a shorter period than 
from a year to a year and a half or two years, and often 
after the disease is apparently perfectly removed, it breaks 
out afresh in one or two of the spots wrhich had healed, 
when it lingers obstinately for months. Lupus devorans is 
both the most severe and the most obstinate of the several 
varieties of the disease, its destructive progress, unless 
when submitted to treatment at a very early period after it 
commences, is scarcely to be arrested, nor does it seem ever 
to tend to spontaneous cure : the form denominated “ Jacob’s 
ulcer” is, in my experience, perfectly incurable in all its 
stages. Like most other cutaneous diseases, the longer the LUPUS. 
255 
duration of lupus, the more difficult is it to treat success- 
fully. 
As regards the pathology of lupus, it is manifestly nearly 
allied to cancer, especially by its malignancy, and the ap- 
pellation for the group of diseases of the skin in which it is 
here placed has, I think, been therefore happily chosen by 
Dr. Copland; yet they differ remarkably, in the latter 
being almost invariably marked by a general contamination 
of the system, which is never witnessed in the former; this 
is well evidenced by the glandular system in the neighbor- 
hood of the disease not becoming affected in the course of 
lupus, even when it has existed for years. 
Treatment.—The administration of constitutional reme- 
dies, in the treatment of lupus, is regarded by many as 
being useless, and the employment of local applications is 
solely relied on, but I agree with those who consider both 
to be requisite, and it is only from a prolonged perseverance 
in remedial measures, judiciously selected, that good results 
can be expected to follow in this obstinate and malignant 
affection. The intimate connexion that exists between the 
disease and scrofula being an admitted fact, the general 
treatment should consist in the use of those remedies which 
are calculated to correct that vitiated condition of the 
system, and the avoidance of all medicines which experience 
has proved disagree with scrofulous individuals, or aggra- 
vate any local derangement under which they may labor. 
The preparations of iodine and of iron, cod-liver oil, and 
the vegetable tonics, are therefore especially indicated in 
the treatment of the different forms of lupus, and general 
hygienic measures, calculated to invigorate the constitution 
and to remove its vitiated condition, should never be neg- 
lected. 
Iodine in some form, given in combination with tonics or 
alteratives, according to individual circumstances, is the 
remedy which, in my experience, is most to be relied on; 
for the majority of cases the iodide of potassium is the 
preparation best adapted, but, as I have already remarked 
in a previous part of this work, its beneficial effects are 
more certainly obtained by being administered in rather 
small doses, continued for a long time, than if it be pre- 
scribed in large quantity at first—a practice which has 256 
CANCRODES. 
been recently much followed in the treatment especially of 
secondary syphilitic diseases. In persons in whom the 
constitution is unimpaired, and the muscular and adipose 
tissues well developed, it may be prescribed in somewhat 
the following form :— 
R. Iodidi Potassii, gr. xij. 
Infusi Cascarillge, fl 
Liquoris Taraxaci, fl 5u* Misce. 
“ Two table-spoonfuls to be taken three times a day.” 
The quantity of the iodide of potassium should be in- 
creased by the addition of a grain to the mixture each time 
it is renewed, until it contains twenty-four grains, when it 
should be omitted for a few weeks, and again recommenced 
in the small dose. For weakly persons, or those of a broken- 
down habit of body, the iodide of iron should be substituted 
for the iodide of potassium, and it may be given in decoction 
of fresh elm-bark; when the scrofulous diathesis is very 
well marked, and the lupoid ulceration extensive, threaten- 
ing to engage the deeper seated structures, iodine itself 
will be advantageously combined with the iodide of potas- 
sium or iodide of iron: if with the former, it may be pre- 
scribed according to the formula at page 185, the arsenical 
solution being omitted. 
Cod-liver oil also proves an excellent remedy in the 
treatment of lupus, especially when the disease occurs at 
an early age; from my own experience of its effects I do 
not think it is attended with so much advantage when given 
in the enormous doses recommended by some, as when 
administered in smaller quantity, and its use persevered in 
for a very long time: a teaspoonful three times a day, and 
increased so gradually that at the end of six months two 
table-spoonfuls, as frequently given, will be the amount 
arrived at, a dose which need not be exceeded, is the manner 
of administering the medicine that I have seen proved 
eminently successful in lupus. By some of the French 
dermatologists, however, many of whom speak in rather 
extravagant terms of its efficacy in this disease, the dose 
is increased as rapidly as the stomach will admit, until LUPUd 
257 
from a pint and a half to two pints are taken in the 
twenty-four hours. 
Arsenic alone, or combined with iodine, has been highly 
recommended by many practitioners for the treatment of 
lupus; the late Dr. Anthony Todd Thompson was in the 
habit of relying chiefly on it in the form of the iodide of 
arsenic; I have found this preparation very useful in the 
form described above as constituting lupus superficialis, but 
in the other varieties of the disease it has not proved so 
beneficial in my hands as iodine and the iodide of potassium. 
The liquor arsenici et hydrargyri hydriodatis proves of espe- 
cial service in those cases in which there may exist in the 
system an hereditary or acquired syphilitic taint. 
So many other medicines have been at different times, 
and still are, proposed for the treatment of lupus, that it 
would be almost impossible even to enumerate them; a few, 
however, require to be shortly noticed. The animal oil of 
Dippel—obtained in the distillation of hartshorn shavings 
in close vessels—has acquired some character on the Conti- 
nent; it is given in doses of five or six drops, at first, 
gradually increased to twenty or twenty-five. The chloride 
of barium and chloride of calcium have both been much used; 
that they possess some efficacy, due certainly to their anti- 
scrofulous powers, has been proved by the publication of 
several cases in which a cure resulted from their administra- 
tion. Various preparations of mercury have also been tried 
for the treatment of lupus, and the red iodide is especially 
recommended by M. Raver for those cases in which there is 
much hypertrophy of the integuments ; but in consequence 
of the injurious effects so often occasioned by the adminis- 
tration of mercurials to persons of the scrofulous diathesis, 
I cannot agree with those who advocate their use in this 
disease. 
The general hygienic measures to be adopted require 
merely to be alluded to ; they consist, of course, in attention 
to every circumstance which can fortify the constitution, and 
remove the depraved condition on which the presence of the 
local disease depends : the chief of these are, breathing a dry, 
pure air, the use of nourishing, unstimulating diet, residence 
on the sea-shore, and when the strength admits, cold salt- 
water bathing. 258 
CANCRODES. 
The local treatment of lupus has at all times attracted 
more attention than the constitutional, and, as before re- 
marked, many consider that the disease can by it alone be 
cured. It may be considered under two heads: first, the 
ablation of the affected portion of the integuments by the 
knife, or its destruction by caustics; and, second, the em- 
ployment of astringents or other medicinal agents, calcu- 
lated to promote cicatrization, or excite a new action in the 
parts. In the superficial variety of lupus, the chief object 
being to prevent disfigurement by arresting the progress of 
the disease, the use of the knife is not admissible, for, were 
its employment even certain to effect a cure, the resulting 
eschar would occasion as much, if not greater, deformity; 
for the serpiginous form it is not applicable, nor has it been 
recommended, except by a few surgeons, to remove the 
hypertrophied edges: and, therefore, it is only in lupus 
devorans that excision holds out any prospect of being use- 
ful. An almost insurmountable difficulty, as regards its 
application, however, is experienced in all cases in which the 
disease has existed for any time, owing to the manner in 
which the ulceration spreads, and the consequent impossi- 
bility of removing the entire of the parts affected; when it 
is but of short duration, and the deeper-seated structures 
are not involved, the operation has occasionally proved use- 
ful, especially in “Jacob’s ulcer;” but the employment of 
the constitutional treatment above recommended should not 
be neglected at the same time, as thereby alone can it be 
expected that the return of the disease will be prevented. 
The stronger caustics, from being more easy of applica- 
tion, and more certain than the knife in their effects on the 
uneven, penetrating ulceration which characterizes this form 
of lupus, have been more generally employed. Those chiefly 
used are the nitric and hydrochloric acids, the acid nitrate 
of mercury, caustic ammonia, chloride of zinc, chloride of 
gold, caustic potash, solution of the terchloride of antimony, 
and arsenical pastes or powders. The chloride of zinc has 
many advocates, and where the edges of the ulcer are ragged 
and unhealthy, and the surface discharging a sanious pus, it 
in many cases proves useful by exciting a new action; as 
much of the surface as it is wished to destroy should be 
touched lightly with the solid salt, and the application re- LUPUS 
259 
newed every alternate day until the desired effect is pro- 
duced: the stronger acids may also he applied, in the same 
manner. I have generally known the employment of caustic 
applications prove injurious in lupus serpiginosus, yet they 
are highly praised by several writers, nitrate of silver being 
usually preferred to any other; in many cases that I have 
seen them used, the parts to which they were immediately 
applied healed up temporarily, but the serpiginous ulceration 
from the circumference continued to spread unchecked, un- 
dermining the surrounding integuments, generally with in- 
creased rapidity. In lupus superficialis, caustics, if effectu- 
ally applied, cause a worse disfigurement than the original 
diseases, which, moreover, they do not check. 
Under the second division of local applications may be 
noticed, first, those which, though not actually caustic, are 
highly stimulant and resolvent, such as the dilute acids, 
Donovan’s solution, the animal oil of Dippel, lotions or oint- 
ments containing the chloride of zinc, nitrate of silver, 
caustic potash, &c. The oil of Dippel is employed very 
extensively on the Continent, and, it is said, with excellent 
effect, especially when the nose is the part affected, as a 
modifier of the diseased action ; it is applied by means of 
a camel’s-hair pencil, the surface being lightly touched with 
it, and the application repeated several times. The solu- 
tion of the hydriodate of arsenic and mercury also proves 
most useful as a lotion in many cases of the disease ; it is 
especially of service in the superficial form of the affection, 
the crusts having been removed by poulticing previously. 
M. Cazenave has recently published his experience of the 
effects of the red iodide of mercury as a local application, 
from which it would appear to produce most beneficial results, 
especially in those cases attended with much hypertrophy. 
“ Under the influence,” says he, “ of the application of the 
biniodide of mercury frequently repeated, I have seen after 
the disappearance of the sharp but fleeting local inflamma- 
tion produced by it, and as a consequence probably of its 
general action, the hypertrophied points become resolved, 
the tubercles to disappear, and soft, superficial, smooth cica- 
trices, on a level with the rest of the skin, form ; in short, 
I have seen the most frightful cases of lupus cured without 
leaving any other traces than an apparently thinned skin, 260 
CANCEODES. 
with white or red spots here and there, according to the 
length of time which had elapsed from the formation of the 
cicatrices.”1 M. Cazenave applies a thin layer of the pow- 
der, undiluted, to a portion only of the diseased surface at 
a time; it causes severe pain and much inflammation, the 
former lasting for six or eight hours, and the latter for three 
or four days; a thick crust is left, which falls off at the end 
of six, eight, or ten days, when, should there be occasion, 
the application may be renewed. 
The topical remedy which I have found most useful in 
the treatment of lupus serpiginosus is the acetate of zinc ; 
the ulcerated surfaces should be touched with the solid salt 
—care being taken to use a crystal which has not effloresced 
—twice a day, daily or every second or third day, accord- 
ing to the degree of activity of the local inflammation, and 
a lotion containing from three to five grains to the ounce of 
distilled water should be used, lint wet with it being applied 
and the parts covered with oiled silk when practicable. In 
this form, as well as in lupus devorans, the local inflamma- 
tion, of which from time to time rather smart attacks occur, 
should be checked by the application of leeches as near the 
affected parts as possible, but sufficiently distant to prevent 
the bites from becoming involved in the disease, and emol- 
lient poultices should be used occasionally with the same 
intention, and to remove the hard crusts which form. 
No matter what local treatment be employed in the treat- 
ment of lupus, attention must be especially paid, when the 
nose or mouth is the seat of the disease, to prevent the 
natural outlets from becoming obstructed during the progress 
of cicatrization. 
In conclusion, I may again repeat that, as the result of 
considerable experience in the treatment of this obstinate 
and serious disease, I regard the employment of topical 
agents as altogether secondary ; they are unquestionably 
useful in modifying the diseased process that is going on, 
and in exciting a new action in the parts, but they must 
be regarded as only auxiliary to the constitutional treatment, 
which should engage the chief attention of the practitioner, 
the fact being always kept prominently in viewT, that it is 
1 Annales cles Maladies de la Peau et de la Syphilis, tom. iii. p. 59. 1851. KELOlS. 
261 
alone by the prolonged use of remedies, and diligent atten- 
tion to general hygienic measures, that a favorable result 
can be expected. 
KELOlS. 
Kelois {Cheloid tumor) is an extremely rare disease of 
the skin, which was first noticed in the latter end of the last 
century by Itetz, and was soon afterwards fully described by 
Alibert, who applied this name to it from a fancied resem- 
blance which he thought it bore to the claw of a crab (zyiy, 
“ forfex cancrorum”): for a similar reason he first denomi- 
nated it Cancroide, and also because this latter term ex- 
pressed the analogy which he believed to exist between the 
disease and cancer; it is for the latter reason that I have 
included it with lupus, in the order Cancrodes. It consists 
in the development on the cutaneous surface of an irregular- 
shaped, or somewhat oval, hard, and prominent excrescence, 
slightly depressed and uneven in the centre, the edges being 
raised and thickened; the surface has a polished, shining 
aspect, of a rose or reddish-white color, marked with bright- 
red and white lines, and corrugated so as to present nearly 
the appearance of an old, much hypertrophied cicatrix. 
When pressed with the finger it is somewhat resilient, and 
the part pressed upon becomes momentarily colorless. The 
morbid growth, which varies in size from a few lines to an 
inch or more in diameter, is extremely adherent to the in- 
teguments, roots projecting from it into the deep layers of 
the skin. It first appears in the form of one or more small, 
hard, wartlike tumors, accompanied by itching and some 
pain; as it increases in size the pain becomes much aug- 
mented, being of a severe stinging character, and in some 
cases has been described as being almost unbearable. 
The cheloid tumor is most generally solitary, being, in 
the majority of cases which have been reported, developed 
on the anterior surface of the thorax, either below the 
clavicle on either side, or on the sternum, but in a few in- 
stances several of them have been witnessed to exist at the 
same time on different regions of the body: its growth is 
comparatively slow, it does not ulcerate, nor is it painful to 
the touch, and may continue indolent for years, but in a few 262 
CANCKODES. 
cases, it has been reported to have become gradually smaller 
by interstitial absorption, until it finally disappeared alto- 
gether, its site being marked by a white cicatrix. 
The causes of this disease are very obscure; in one or 
two instances it has been stated to have followed local 
injury, and some cases have been published in which the 
tumor was developed on the old cicatrix of a burn or 
wound, but many have with sufficient reason questioned the 
fact of these being examples of true kelois. No proof exists 
of its being hereditary, or of its occurring in persons whose 
parents had been affected with cancer or scrofula, nor does 
it appear to be connected with any special temperament or 
diathesis. It would seem to affect both sexes nearly alike, 
but it has not been observed in early life, those who labor 
under it being individuals usually of mature age. The 
extreme rarity of the disease is very remarkable, and conse- 
quently its nature, history, and characteristics are not w’ell 
understood, from want of sufficient opportunity for their 
being studied : Wilson states that the total number of cases 
recorded amounts only to 24, of which he himself has seen 
7 ; but it has been witnessed also in Ireland, casts and 
drawings of it existing in the Museum of the Richmond Hos- 
pital in this city, although the cases have not, as far as I am 
aware, been published. 
Diagnosis.—The only affection with which kelois is 
likely to be confounded is cancer; it is distinguished from 
it by its indolent nature, its indisposition to ulcerate, the 
absence of contamination of the glandular system, and its 
peculiar site. 
Prognosis.—Were it not for the extremely painful sen- 
sations which usually attend this affection, it would be of 
little moment, there being no risk of life, nor local dan- 
gerous symptoms likely to be occasioned by its presence. 
The duration of the disease is almost invariably prolonged ; 
years elapsing in those cases in wrhich it has disappeared 
spontaneously, before absorption had commenced. 
Treatment.—Excision of the chelo'id tumor has been pro- 
posed and practised, but such course seems to have been 
invariably unattended with successful results; the wound 
made was difficult to heal, and the disease returned after 
some time in the cicatrix or in the integuments of some KELOlS. 
263 
other region of the body. The spontaneous cure of the 
affection by absorption having occurred in, comparatively 
speaking, many cases, should inculcate the propriety of ab- 
staining from meddlesome interference, and teach that 
reliance ought to be placed chiefly on constitutional treat- 
ment by means of alteratives and corrigents where neces- 
sary, and the local use of mild stimulants or sedatives to 
allay pain. With the latter view I would suggest the 
employment of an ointment containing the iodide of potas- 
sium and chloroform. Cazenave recommends the sulphur 
douche; Wilson, the application of collodion and the tinc- 
ture of iodine; and Rayer, that firm and constant com- 
pression should be made on the tumor when its situation 
permits. DERMATOPHYTE. 
CHAPTER XI. 
DERMATOPHYTE. 
The general application within the last few years of the 
nse of the microscope in investigating diseased conditions 
of animal structures, has afforded most important and 
valuable assistance to the morbid anatomist and pathologist, 
by throwing new light upon much that was before obscure ; 
our knowledge of cutaneous affections has, along with other 
subjects in practical medicine, been advanced thereby, and 
chiefly by the discovery that in certain of them a vegetable 
production—a cryptogamic plant—is present on the surface 
of the skin. It is in consequence of this discovery that a 
necessity has arisen for constituting the present group or 
order of diseases of the skin, and which is termed Derma- 
tophytse—from Ssppa, “ the skin,” and tyviov, “ a plant— 
it includes, then, those cutaneous affections which are depen- 
dent on, or are characterized by the presence of parasitic 
plants on the diseased surface of the integuments. By 
some the existence of these vegetable growths is altogether 
denied, while others, who admit their existence, regard 
them as being accidental productions, a consequence and 
not a cause of the disease which they accompany ; the 
investigations, however, of Dr. Hughes Bennett, of Edin- 
burgh, and of Robin, Gruby, Lebert, and others, on the 
Continent, in my opinion, place beyond doubt not only that 
these parasites are developed in certain diseases of the skin, 
but that they constitute their essential nature. In addition 
to the two affections, Porrigo and Sycosis, which I shall 
include in this order, the presence of a cryptogamic plant 
has also been recently ascertained in Pityriasis versicolor 
(Chloasma), but I agree with Dr. Bennett, in the opinion 
that “ although this disease frequently presents epiphytes 
among the scales, it owes none of its essential characters 
to this circumstance.” PORRIGO. 
265 
PORRIGO. 
Porrigo (.Favus; Tinea; Scali-head). (Atlas, PI. XV. 
Figs. 2 and 3.)—This peculiar affection, which, from its 
appearing most frequently on the scalp, is generally de- 
scribed as being peculiar to that region of the body, is cha- 
racterized by phenomena so distinct from those of all the 
other eruptive diseases which are apt to occur there, that it 
cannot possibly be mistaken for any of them. It is deve- 
loped in the form of small, elevated, dry spots, about the 
size of a pin’s head, of a bright yellow color, seated on the 
surface of the skin, which is depressed slightly by them ; 
each spot is distinct, hemispherical, slightly concave or cup- 
shaped on its free surface, and convex beneath, where it is 
adherent to the skin. On removing the small, diseased 
mass, that portion of the scalp on which it was seated is 
found to be somewhat depressed, smooth and shining. A 
single crust of the disease, or favus,—as it has been termed, 
from its resemblance both in color and central depression to 
the superficial surface of a honeycomb,—is often traversed 
by one, and sometimes by two hairs, which appear to grow, 
as it were, from the very centre or most depressed portion; 
this has given rise to the notion that the disease is one of 
the bulbs of the hair, but the fact of its appearance on other 
parts of the body which are quite free from hair affords a 
sufficient refutation of this opinion. The eruption spreads 
by additions to the outer edge or circumference of each crust, 
which thus retains its hemispherical character, until it ac- 
quires a diameter of two or three lines, or sometimes more; 
some of the favi on the trunk at times attain fully half an 
inch in diameter; on the head, however, they rarely exceed 
the size above mentioned. The adjacent favi, as they in- 
crease, unite with each other, and form large, irregularly- 
shaped masses, in which the original circular form of the 
individual crust is in a great degree lost; the centre also of 
each is~cha«ged in appearance, and, instead of the cup- 
shaped depression, the entire surface is covered with alter- 
nate elevations and depressions, or, so to speak, ridges and 
furrows, concentrically arranged. The eruption thus in- 266 
DERMATOPHYTE. 
creasing, the whole of the scalp, often, too, the forehead, 
the neck, and parts of the trunk, become encased in one 
large, yellow crust, at the edges of which some favi, of the 
peculiar characteristic appearance, are invariably to be 
seen. 
The crusts of porrigo are of a pale sulphur-yellow color ; 
they are hard and dry, and break with a short fracture, ex- 
hibiting within a mealy powder of a paler yellow than the 
external surface. They may generally be removed with 
facility from the scalp, but they bring away with them a 
thin layer of epidermis, which is firmly adherent to their 
under surface, through which small projections may be seen 
with a moderate lens, sometimes with the naked eye. These 
projections, or processes, pass into the dermis beneath, and 
when the crusts are torn forcibly away, blood issues from 
the small orifices into which they were inserted. From the 
very commencement of the eruption the hair becomes altered; 
much of it falls out, and the straggling hairs that remain 
are thin, broken, weak, whitish, and readily removable with 
the crusts of the disease, in which they are firmly imbedded. 
When this affection has continued for any length of time, 
bald patches are left after cure, on which the hair does not 
again grow; and even where it has been cured at an earlier 
stage, the hair seldom regains its proper character, being 
often weak, thin, and of a diseased appearance, and of a 
whitish-yellow color. Porrigo, in its first stage, does not 
give rise to either heat of the scalp or itching, and, conse- 
quently, is very rarely noticed until it is fully developed. 
It usually commences on the forehead, at the edge of the 
hairy scalp, but it spreads rapidly over the head, soon in- 
volving nearly the entire surface, the healthy patches which 
are left between the diseased spots being but very few, and 
small in extent. The eruption is also met with on various 
parts of the body, the trunk or extremities; but I have 
very rarely seen it there except when it existed at the same 
time on the scalp. As the disease advances, much irritation 
of the surface is produced; small pustules form here and 
there in spots as yet unaffected with the eruption : the tingling 
and heat are so unbearable as to compel the patient to tear 
the surface with his nails, even to such a degree as to cause PORRIGO. 
267 
ulceration ; innumerable pediculi are engendered ; the favus 
crusts emit an abominable odor, resembling that of mice ; 
and a copious offensive discharge is secreted by the pustules 
and ulcerated spots: in short, an individual affected with 
this disease in its aggravated form becomes a loathsome and 
disgusting object. 
I have already referred to the vegetable nature of this 
eruption : it is in the spongy, friable contents of the favi 
that its characters are best seen. “ Reduced to powder, and 
placed under the microscope, it presents,” says Robin, “ a 
mixture—1. of tortuous, branching tubes, without partitions, 
empty, or containing a few molecular granules (mycelium); 
2. straight or crooked, but not tortuous tubes, sometimes, 
but rarely, branched, containing granules or small, rounded 
cellules, or elongated cellules, placed end to end, so as to 
represent partitioned tubes, with or without jointed articula- 
tions (receptacles or sporangia, in various states of develop- 
ment ?); 3. finally, sporules, free, or united into bead-like 
strings. The mycelium is very abundant near the inner sur- 
face of the external layer, to which it adheres. The spongy, 
friable mass of the centre of each favus is principally formed 
of sporules and the different tubes containing mycelium 
already described (sporangia, or receptacles ?). We often 
find mixed with them mycelium tubes, but in small quantity. 
All these elements pass insensibly into each other : empty 
tubes (mycelium); tubes containing small, round corpuscles; 
tubes with corpuscles as large as the smaller sporules; spo- 
rules placed end to end, so as to resemble a hollow parti- 
tioned cylinder, with a tendency to separate at the joints ; 
and free sporules. Bennett has given a good drawing of 
this arrangement.”1 M. Robin gives a minute description of 
the various parts of which the fungus is composed, as well 
as faithful and well executed illustrations of this vegetable 
parasite, the correctness of which I have had various oppor- 
tunities of verifying within the last few years, and recently 
with the assistance of Dr. Lyons, who has devoted so much 
time and talent to promote microscopical medical investiga- 
1 Des Vegetaux, qm croissent sur l’Homme et sur les Animaux Vivians, 
par Ch. Robin. Paris, 1848. 268 
DERMATOPHYTAE. 
tions in Ireland. The botanical characters of the plant are 
appended in a note.1 (Atlas, PI. XVI. Figs. 5 and 6.) 
This is a rather rare affection, appearing, however, from 
the observations of those who have written specially upon 
it, to be more common on the Continent and in Ireland than 
in England. When I first wrote on this disease in 1848,2 
my experience was drawn from a limited number of cases ; 
since then, however, I have had under my care a compara- 
tively large number of examples—twenty-three. 
It may appear at any time of life, but is very seldom 
met with except in childhood, from the age of 3 to 12 ; it 
may be developed on almost every part of the body, but, 
as already remarked, occurs with by much the greatest 
frequency on the scalp, and next to it on the back of the 
trunk. When it appears on those portions of the integu- 
ment which are not covered with hair, the favus crusts 
acquire a larger size, and increase more rapidly than when 
it is seated on the scalp, but it presents precisely similar 
characters. 
Great confusion long existed amongst dermatologists as 
to what special disease was understood by the term, “ Por- 
rigothe many eruptions ■which have their seat on the 
scalp were at one time described as being merely varieties 
of a single genus, which was indiscriminately denominated 
Favus, Tinea, or Porrigo; this confusion has, however, been 
lately much removed, and the latter appellation—the others 
being synonymous with it—is now strictly confined to the 
cutaneous affection above described, and which corresponds 
with the Porrigo lupinosa of Willan. Cazenave divides it 
into two species characterized by the form in which the 
crusts are developed, the one he terms Favus dissemine, and 
the other Favus en cercles ; this is, I think, an unnecessary 
refinement, tending to complication, and presenting no ad- 
vantage in practice. Wilson, who denies the vegetable 
1 “Aciiorion Schonletnii. Eemak. Orbiculare, flavum, coriaceum, 
cuti humanse presertim capitis insidens ; rhizopodion molle, pellucidum, 
floccosum, floccis tenuissimis, vix articulatis, ramossissimis, anastomoti- 
cis(?). Mycelium floccis crassioribus subramosis, distinctd articulatis, ar- 
ticulis inaaqualibus, irregularibus, in sporidia abeuntibus ; sporida rotunda, 
ovalia vel irregularia, in uno vel pluribus lateribus germinantia.” 
2 Eruptive Diseases of the Scalp. Dublin, 1848, 12mo. PORRIGO. 
269 
nature of the morbid production on the scalp, describes 
favus, which is the name he adopts, as being a disease of the 
hair-follicles. 
The causes of porrigo have given rise to much difference 
of opinion, especially with reference to its contagious na- 
ture ; the correctness of my adhesion to the views of those 
who hold that it is so, which I avowed some years ago in 
the little wTork already referred to, has been confirmed by 
almost every day’s experience since, for I have seen nume- 
rous instances of the propagation of the disease from indi- 
vidual to individual, by direct contact, in the majority of 
cases from children to children, but sometimes even from 
children to adults. The mode in which I believe the con- 
tagion to be conveyed is by the propagation of the vegetable 
parasite, by means of the mycelia. But its contagious cha- 
racter has been denied by many on the grounds of the rarity 
of the disease, and the failure to produce it by inoculation, 
as tried by Gruby and others; the former of whom produced 
the disease only once out of seventy-six trials on vegetables, 
and not at all on animals. But Remak succeeded in inocu- 
lating his own arm in August, 1842 and Bennett, who 
had previously failed in his own person after repeated trials, 
succeeded completely in 1845, in producing the disease in 
one of his class by inoculation and close contact of the favus 
crusts, obtained from the head of a boy at that time in the 
Royal Infirmary. An account of his experiment, and also 
of Remak’s, will be found in the Northern Journal of Me- 
dicine for September, 1845, p, 202. Now in all these trials 
to generate the plant, one important fact connected with the 
natural history of parasitical fungi has been overlooked by 
all, namely, that they require for their growth a peculiar 
soil; thus we find one genus is found only on snow, another 
on cheese, another in yeast, different varieties on different 
decaying vegetable matters, and individual genera and spe- 
cies on various living animals and plants; nay, even differ- 
ent sorts on different parts of the same animal. This holds 
true with the Achorion Schonleinii; it requires for its re- 
production to be planted in a peculiar soil, that is, on an in- 
dividual whose system is in a peculiar cachectic condition; and 
1 Medicinische Zeitung, for 1842. 270 
DERMATOPHYTE. 
until it is ascertained what this condition is, a single instance 
of its propagation by contact—and such instances are not 
uncommon—must be held as sufficient proof of its contagious 
character. 
Some have held that this eruption occurs in scrofulous 
persons only; others that it is an hereditary disease; but 
neither statement is consistent with the observation of the 
cases which I have seen. It appears to have some connection 
with, though I cannot say that it is caused by, poverty, filth, 
wretchedness, and a weak development of the mental facul- 
ties. Unquestionably where the disease has long existed, 
the mind is weak, and the countenance presents a somewhat 
idiotic expression. 
Diagnosis.—With no other disease of the skin can por- 
rigo be confounded, it is so distinctly characterized by the 
dry, yellow, favus crusts, and the total absence of discharge 
or scaly desquamation in any of its stages; occasionally, 
pustules form, it is true, on the surrounding integuments, 
but they are evidently due to the irritative inflammation, 
caused by the morbid growth on the cutaneous surface, or 
the application of acrid or stimulating unguents, lotions, &c. 
In its very early stage, when seated on the scalp, porrigo 
might be mistaken for the commencement of an attack of 
impetigo, but the rapid development of the pustules in the 
latter soon renders the diagnosis simple; and it does not 
present any features in common with the other eruptive dis- 
eases of the scalp. Should a doubtful case, however, occur, 
any difficulty that may exist will be at once cleared up by a 
microscopic examination. 
Prognosis.—A disease of gravity, and always regarded 
with extreme abhorrence in consequence of the disagreeable 
symptoms with which it is attended, its unsightly aspect, 
and its contagious nature, porrigo nevertheless in no respect 
tends to shorten life, or even to injure the general health, 
unless in so far that it almost necessitates strict confinement 
to the house and isolation. The fatuity which is so com- 
monly witnessed to accompany its advanced stages is cer- 
tainly to a great extent a consequence of its existence, for 
it is not seen in any remarkable degree in individuals in 
whom the affection has been of-short duration. The effect 
caused on the growth of the hair must also be taken into PORRIGO. 
271 
account in forming a prognosis, as its loss is often regarded 
as one of the most grievous consequences of the disease ; 
when the crusts cover the head completely, and their dura- 
tion has been at all prolonged, the pressure produced by 
them causes absorption of the superficial layers of the 
derma, and consequent destruction of the hair-follicles, per- 
manent baldness then necessarily results ; but when the 
morbid growth is removed at an early stage, although the 
hair is most usually deteriorated and its subsequent growth 
injured, no ill consequences to it follow in some cases. As 
regards the eruptive disease of the scalp, porrigo is the 
most obstinate and most rebellious to treatment of them all; 
by many dermatologists it has been regarded as being 
almost incurable, and, consequently, the most violent reme- 
dies have been proposed for its treatment, but I have never 
failed in curing it permanently by the simple method to be 
now described. 
Treatment.—There is probably no disease of the skin 
which has been subjected to a greater variety of plans of 
treatment, some of them of the most painful character, 
than this, chiefly in consequence of its extreme obstinacy, 
and the opposing views which have been and are even still 
held as to its nature: before proceeding to speak of the 
remedies used by others, I shall first describe the method 
which has invariably succeeded in my hands, and the efficacy 
of which has been now for so many years proved by the 
testimony of others. It consists in the simultaneous em- 
ployment of constitutional remedies and local applications; 
the former, used with the intention of correcting or altering 
that vitiated condition of the system generally, to the exist- 
ence of which is due the development of the morbid growth 
on a congenial soil; and the latter, to remove the diseased 
mass constituted by the peculiar vegetable parasite, and to 
prevent its reproduction. 
A combination of the twTo alternatives which experience 
has proved to be the most powerful in the removal of cuta- 
neous diseases—arsenic and iodine—has, in my experience, 
effectually fulfilled the requirements of the constitutional 
treatment. They maybe given in the fluid form, as already 
recommended for the squamous eruptions, combined, if 
requisite, with vegetable tonics, or in the solid state, as in 272 
DERMATOPHYTE. 
the following prescription, the dose ordered being that 
adapted for a child ten years old:— 
R. Arsenici Iodidi gr. j. 
Mannse durse gr. vj. 
Mucilaginis quantum sufficit ut fiant pilulse duodecim. 
“ One to be taken three times a day.” 
This is the preparation which I usually prescribe in the 
treatment of porrigo; in some cases, after it has been taken 
daily for five or six weeks, headache and dryness of the 
mouth and fauces are complained of, which quickly disap- 
pear, however, on intermitting its use for a few days. As 
in the other cutaneous affections, for which these medicines 
prove so valuable a remedy, their administration must be 
persevered in for a long period, and the dose increased very 
gradually and slowly; they must also be given for some 
time after all traces of the local affection have disappeared. 
In decidedly scrofulous children, the administration of cod- 
liver oil simultaneously with that of the iodide of arsenic 
is attended with the best effects, and in cases in which from 
any cause arsenic may disagree, iodine may be given dis- 
solved in the cod-liver oil, in the proportion of the twelfth of 
a grain in each fluid drachm. The following is an outline 
of the local treatment: when the disease is situated on the 
scalp the hair is to be cut, not shaved, as closely as possible, 
and a large linseed-meal poultice applied and kept on for 
twelve hours, so as to soften the crusts, and repeated for a 
second or third time if necessary. As soon as the poultice 
is removed, the head is well washed with a strong carbonate 
of potash lotion—a drachm to a pint of distilled water—and 
slightly brushed with a soft hair-brush or roll of lint; the 
scalp is then covered with the carbonate of potash ointment 
—a drachm to one ounce of prepared lard and a fluid drachm 
of glycerine—spread on lint, and over it a closely-fitting 
oil-silk cap is placed; the ointment is renewed twice daily. 
By the use of these applications the crusts of the eruption 
are generally completely removed in from two to three days. 
The carbonate of potash ointment is at the expiration of PORRIGO. 
273 
this time replaced by one containing the iodide of lead, in 
the portion of half a drachm of the iodide to an ounce of 
prepared lard, which is to be renewed morning and evening, 
the head being well washed with the carbonate of potash 
wash every time before the ointment is re-applied. In some 
cases it will be found that the, iodide of lead ointment 
excites a certain degree of inflammation of the surface of 
the scalp after it has been used for some days ; when such 
occurs it should not be applied for a day or two, and the 
lotion employed alone three or four times daily. After this 
first attack of inflammation disappears it rarely recurs again, 
although the use of the ointment be persisted in for months. 
The strength of the ointment should be increased after a 
fortnight, and if the disease again appear, even to double 
that above indicated. The oil-silk cap should be kept on 
the-head until a cure is effected; the advantage derived 
from it is twofold; in the first stage of treatment, by keep- 
ing the hard and firmly-plated crusts of the disease in a 
constant atmosphere of warm moisture, it softens, and thus 
renders them more easily removable; and in the after-treat- 
ment the mucedinous vegetable being retained by it in the 
closest contact with the iodide of lead and the emanations 
arising therefrom, is more certainly destroyed, and its re- 
production prevented. 
After continuing this treatment for at least three weeks 
or a month, all external applications should be stopped, and 
the hair allowed to grow, so as to ascertain if the fungus 
will be reproduced; for it often lies dormant, and suddenly 
shoots forth, increasing rapidly when no longer subject to 
the action of the iodide of lead. Should it again return, 
the local applications must be had recourse to as before, im- 
mediately on its appearance. The administration of the 
iodide of arsenic should be continued until we are quite 
satisfied that the cure is complete. 
During the entire progress of treatment, the patient must 
be kept on a strictly milk and farinaceous diet, and the 
bowels regulated by the administration of mild mercurial 
alteratives and saline cathartics—especially the saline mine- 
ral waters—when necessary. 
A most cruel, almost barbarous, method of treating por- 
rigo, when it occurs on the scalp, originally proposed in the 274 
DERMATOPHYTES. 
ancient days of medicine, is still followed to a great extent 
on the Continent. It consists in the application to the hairy 
surface—the crusts of morbid growth having been previously 
removed as much as possible by poulticing, &c.—of some 
adhesive plaster, such as Burgundy or common pitch, or 
ammoniacum spread on strips of stout calico, which, being 
caused to adhere firmly, and left on for several days, are 
torn off in a direction opposite to that ia which the hair 
grows, so as to remove as much of the latter as possible; and 
they are applied again and again until the entire of the 
scalp is completely deprived of hair. The sufferings occa- 
sioned by this proceeding are, as may readily be imagined, 
something horrible, and the Brothers Mahon, who strongly 
advocated its employment in a somewhat modified form, 
mention that even death has resulted from it. As a reme- 
dial measure, it originated in the false idea that the disease 
was an affection of the hairs solely, and that by their total 
ablation it would of necessity be cured, and in modern days 
it has been continued chiefly from a theory which found 
many supporters, that the production of perfect baldness 
would suspend the morbid action sufficiently long to allow 
the diseased surface to return to a normal state. 
A host of powerful topical applications has been used in 
the treatment of porrigo: the strongest caustics ; blisters ; 
ointments containing quick-lime, the sulphuret of lime, tar- 
tar emetic, arsenic, pepper, &c.; lotions of corrosive sub- 
limate, and of other irritants and stimulants ; but inasmuch 
as the method of treatment which I have recommended 
above, has proved invariably successful in my experience, 
this simple enumeration of them will suffice here. 
No matter on what part of the cutaneous surface porrigo 
may be developed, the constitutional and topical remedies 
to be employed are the same. 
SYCOSIS. 
Sycosis (Atlas, PI. XV. Fig. 1).—It is conjectured that 
this term, which is of very ancient origin in medicine, was 
applied to designate the cutaneous affection which is now 
understood by it, or one nearly allied thereto, from a fan- SYCOSIS. 
275 
cied resemblance -which the eruption bears to the rough 
exterior of a fig {avxov): from the special seat of the erup- 
tion it has by many modern writers been denominated men- 
tagra, which must therefore be regarded as synonymous. 
By Bateman the disease was classed in Willan’s order of the 
Tubercula, from which it has been removed, together with 
Acne, to the order Pustulm by those dermatologists of the 
French school who have adopted an artifical arrangement of 
diseases of the skin. Erasmus Wilson also regards it as 
being nearly allied to Acne, and consequently describes it 
with that affection in his group of “ Diseases of the Sebi- 
parous Glands.” As regards the appearance of the eruption, 
in one of its stages it certainly bears much resemblance to 
acne in being more or less pustular, but the pustules which 
are present are, in my opinion, the result of irritative in- 
flammation, caused by the existence of a parasitic vegetable 
production, first described by Gruby, and, since the pub- 
lication of his observations in 1842, by other observers also. 
As the result of repeated microscopic examination, I fully 
coincide with M. Gruby and Dr. Hughes Bennett as to the 
existence of this parasitic cryptogamic plant in sycosis; I 
have therefore placed it with Porrigo in the group of cuta- 
neous diseases to which the term Dermatophytse has been 
applied. 
This affection, the site of which is limited to that portion 
of the face on which the beard grows—the chin, the cheeks, 
and the upper lip, rarely extending to the integuments im- 
mediately adjacent—is developed at first by the appearance, 
around the roots of the hairs, of slightly inflamed-looking 
elevations, on which a dry, grayish scurf soon appears; this 
increases pretty quickly, and its presence exciting inflam- 
mation, which is much augmented by the use of the razor 
in shaving, conical pustules soon form, and mask much the 
original character of the disease. The eruption escaping 
notice in most cases in its early stage, has caused it to be 
described as being pustular from the first; but careful ob- 
servation has convinced me that the pustules are secondary, 
and that they originate from the irritation caused by the 
vegetable parasite, which must therefore be regarded as the 
essential characteristic of this affection. The crust or scurf 276 
DERMATOPHYTE. 
increases very slowly in extent, but, the attendant inflam- 
mation attacking the subcutaneous structures, is accompanied 
by much heat, pain, swelling, and tension, which are further 
augmented by the formation of the pustules; these pustules 
maturate slowly, and when they at length burst, a dry, hard, 
brown scab forms, which is very persistent, and if its re- 
moval be attempted, the surface to which it adheres bleeds 
freely and is very painful. 
In the commencement of the disease a small portion only 
of the skin is affected, and the attack is often of short dura- 
tion, the crusts and scabs falling off, and the surface pre- 
senting a tolerably healthy appearance, reddish stains mark- 
ing the previous site of the morbid growth; but most usually 
the eruption returns after a short time, -when it spreads 
more rapidly, and engages a much larger extent of surface, 
the local symptoms also being more severe. After repeated 
outbreaks thus characterized, the integuments of the chin 
become generally much hypertrophied, of a dusky-red color, 
hard, and covered, in patches of a greater or less extent, 
with a thick, grayish crust pierced by the hair of the beard, 
with hard, dry, brown scabs, from beneath which pus exudes 
here and there, and with conical, elevated pustules, many of 
which, in consequence of their being developed over the 
site of a hair-follicle, are perforated by hairs. The inflam- 
matory action, when sycosis presents these aggravated 
symptoms, is usually very severe, small abscesses some- 
times form in the subcutaneous areolar tissue, and, engag- 
ing the hair-follicles, the beard falls out in patches, and 
permanent bald spots on the face result. Although the 
disease is in the majority of instances confined to that por- 
tion of the chin on which the beard grows, in very severe 
cases the upper lip and the surface covered by the whiskers 
are also engaged, and occasionally it is confined to these 
parts alone. 
In 1842, M. Gruby first announced to the French Aca- 
demy of Sciences, his discovery of the existence of a cryp- 
togamic plant (Atlas, PI. XVI. Fig. 4), surrounding the 
roots of the hair of the beard in sycosis, and he believed 
that its presence constituted a previously undescribed variety 
of the disease, which he proposed to term Mentagra conta- SYCOSIS. 
277 
giosum. This parasitic vegetable does not appear above the 
surface of the integuments, and thus differs altogether from 
that of Porrigo. “ On examining the crusts or scabs under 
the microscope,” writes M. Gruby, “ they are seen to be 
composed of epidermic cells; but a microscopic examination 
of the hair demonstrates that the entire of that part of it 
which is inserted in the skin, is surrounded by cryptogamic 
plants, which form a layer between the sheath of the hair 
and the hair itself, so that the hair is placed, as it were, in 
a cryptogamic sheath, just as a finger in a glove. But it is 
a remarkable fact that the parasitic growths never extend 
above the surface of the cutaneous epidermis; they have 
their origin in the matrix of the hair, and in the cellules 
of which its sheath is composed, and they increase so as to 
envelop the portion of the hair inserted in the skin. The 
sporules are almost innumerable in every part of the sheath, 
and are firmly adherent both to it and to the hair itself, 
so that it is difficult to separate them without tearing the 
sheath.”1 The stems of the plant are granulated in the 
interior, and are bifurcated at angles of from 40° to 80°. 
M. Gruby has given a table of the distinctive characters 
between the parasitic cryptogamic of porrigo and of sycosis; 
but Vogel, who corroborates his views as to the existence of 
the vegetable growths—the correctness of which has been 
denied by many—regards them as being only varieties of 
the same species. 
Sycosis is a rather rare affection, and its causes are con- 
sequently obscure, the only manifest one being contagion, 
the disease being propagated, as in porrigo, by the mycelia 
of the parasitic vegetable; of this an example is recorded 
by M. Foville, who witnessed the transmission of sycosis 
to several individuals by means of a razor which had been 
used in shaving a person affected with it. To enable the 
disease to be communicated by contagion, we must, how- 
ever, believe in the pre-existence of a peculiar constitutional 
state of the system, as in porrigo. It, of course, affects 
adults and persons of the male sex only ; one or two in- 
stances have been recorded of its having been witnessed in 
females, but it is probable some other cutaneous eruption 
1 Comptes rendus des Stances de l’Acaddmie des Sciences. 1842, p. 512. 278 
DERMATOPHYTE. 
was confounded with it. The irritation produced by shav- 
ing, and the use of acrid shaving soaps in persons of a 
delicate skin, are usually enumerated amongst the causes 
of sycosis, but although they must be regarded as a means 
of keeping up and of aggravating the disease when once it 
is developed, I do not consider that it can be thus origi- 
nated ; they unquestionably often cause other affections of 
this region of the skin, which are very often mistaken for 
this disease. 
Diagnosis.—Acne, impetigo, ecthyma, furunculi, and sy- 
philitic eruptions on the face, when they appear on the chin 
or the lips, are not unfrequently confounded with sycosis, 
especially when they become chronic, and indeed, by some 
dermatologists, all pustular eruptions, when seated on that 
part of the face on which the beard grows, are denominated 
sycosis ; this term, however, should, I think, be restricted 
to designate the disease above described, as being cha- 
racterized by gray and yellow crusts or scales and a thick- 
ened and indurated condition of the integuments, and at- 
tended with the development of conoidal pustules, terminat- 
ing in dry, brown, adherent scabs; in doubtful cases, a 
microscopic examination of the roots of the hairs will aid 
the diagnosis. 
Prognosis.—Although seemingly not injurious to the 
general health, sycosis is a cutaneous disease of much gra- 
vity in consequence of its extreme obstinacy, the great suf- 
fering it occasions, and the repulsive appearance which it 
gives to the face of those who suffer from it. If submitted 
to treatment in its early stages, it is in most cases readily 
cured, but it is extremely apt to return, and almost invaria- 
bly in a more severe form than at first; when once it has 
become chronic it usually resists every plan of treatment 
for years, and sometimes lasts for life, or, if removed, leaves 
its disfiguring traces behind, in the form of hypertrophied 
livid-red patches on the parts which had been affected, 
and often in the existence of irregularly-shaped, uneven, 
bald spots, on which the beard is not re-produced. Such 
being the character of sycosis, as regards its duration and 
ultimate results, it is of the utmost importance that the 
disease should be carefully diagnosed before a prognosis be 
formed. SYCOSIS. 
279 
Treatment.—The first point to be attended to in the 
treatment of sycosis is the state of the general health, 
which will be found more or less deranged in most persons 
affected with the disease ; and the condition of the diges- 
tive organs especially demands attention. To regulate it, 
mild mercurials, purgatives, alteratives, or tonics should 
be prescribed, according to the indications in each case; 
and when the eruption has been of long standing, and en- 
gages an extended portion of the integument, preparations 
of iodine with the vegetable tonics and diaphoretics should 
be administered. As regards the local treatment, the first 
indication is to counteract, as far as possible, the irritation 
caused by the growth of the beard; with this view the use 
of the razor should from the first be altogether omitted, 
and the hair kept cut as close as practicable with a sharp 
pair of scissors during the entire progress of the treatment. 
The application of three or four leeches beneath the jaw 
or behind the ears, once or twice a week, during the in- 
flammatory stages of the disease, or whenever the affected 
parts present a swollen or irritated appearance, is produc- 
tive of especial benefit; in the more chronic stages, or 
when it has been of long duration, they should be used with 
caution, and their application repeated not oftener than 
twice a month. Numerous topical remedies have been re- 
commended for the treatment of sycosis ; that which I have 
found most useful is a cerate containing calomel and chlo- 
roform, as in the following formula, applied three times 
daily :— 
R. Calomelanos, 3SS* 
Cerati Galeni, 3j- 
Chloroformi, m.xij. Misce. 
But in very obstinate cases, or those which resist the use of 
this combination, the iodide of lead ointment, as recom- 
mended for the treatment of porrigo, with the addition of 
the quantity of chloroform above prescribed, will be found 
of much service. Whichever be employed, the diseased 
surface should be well sponged previously to each applica- 
tion with equal parts of new milk and the weak alkaline or 
lead-wash. The ointment of the iodide of sulphur, also, 280 
DERMATOPIIYTJ3. 
has been highly recommended by many for the treatment 
of this disease, and in some very obstinate cases I have 
found it of service. Attention to diet and regimen is par- 
ticularly demanded in all cases, the use of spirituous liquors, 
and of all rich or heating articles of food, being carefully 
eschewed. THE SYPIIILIDES. 
281 
CHAPTER XII. 
THE SYPIIILIDES. 
As a consequence of the absorption of the syphilitic poison 
into the system during the existence of the primary or im- 
mediate symptoms of the venereal disease, several secondary 
affections are in most cases developed in a space of time, 
the exact limits of -which experience has not yet enabled us 
to define, but which usually varies from six weeks or two 
months to from six to twelve months; amongst these, cuta- 
neous eruptions hold a prominent position, chiefly in conse- 
quence of their extreme frequency, and their disfiguring 
effects. The diseases of the skin which owe their origin to 
this cause present the same elementary characters as those 
which are not so produced, and may assume in different cases 
the form of nearly every variety of eruption which has been 
described in the preceding pages; but they have certain 
specific features by which they are readily distinguished, 
and the treatment by which their removal is to be effected 
consists in the employment of remedies calculated to eradi- 
cate from the system, or counteract the effects of the con- 
stitutional taint to which their existence is due. It is for 
these reasons that most modern dermatologists have thought 
it necessary to describe the syphilitic eruptions as constitut- 
ing a distinct group of cutaneous diseases. 
Secondary syphilitic symptoms, more especially those 
which affect the skin, may also be developed in individuals 
who have never had the primary disease, the venereal virus 
being transmissible from parent to child; thus, a cutaneous 
eruption is not uncommonly witnessed soon after birth, the 
origin of which may be traced to the previous occurrence of 
syphilis, whether primary or secondary, in either parent, it 
may have been even many months previously. Secondary 
symptoms are also by many practitioners, chiefly those of 
the English school, believed to be directly communicable by 
contagion, as in the case of the breast of a nurse berng 282 
THE SYPHILIDES. 
affected by suckling an infant who has a venereal eruption 
on the mouth, by the act of kissing, &c., but the truth of 
this view, one so difficult to be proven, has been ably im- 
pugned by M. Ricord,—an analysis of whose observations 
has been given in the twelfth and thirteenth volumes of the 
Dublin Quarterly Journal of Medical Science,—and his ar- 
guments, fully corroborated by my own experience, incline 
me to agree with the opinion that secondary symptoms are 
not contagious. 
Syphilitic cutaneous eruptions have certain features in 
common, by which they are specially characterized, and dis- 
tinguished from other diseases of the skin ; these it will be 
well to consider shortly before speaking of the individual 
varieties. 
Since they were first recognized as being dependent on a 
special cause, it has been noticed that although the syphilides 
may differ in the elementary form which they assume, they 
invariably present a peculiar dull tint of a brownish or cop- 
pery hue, which is more or less evident in all their stages, 
and also that they are rarely accompanied by the active, 
local inflammatory symptoms which so often attend other 
cutaneous eruptions. The shade of color by which they are 
marked varies in different cases from pale brown to a dull 
copper, the difference depending both on the natural color 
of the complexion and on the degree to which it is affected 
by the syphilitic cachexia ; thus, when the secondary erup- 
tions appear in a short space of time after the occurrence of 
the primary symptoms, the hue of the diseased surface is of 
a less dull tint than when they are not developed for several 
months, the venereal virus affecting the system more, and 
consequently producing a more decided constitutional effect, 
the longer it has lain dormant in the system. For the same 
reason the more acute forms of syphilitic eruptions, or those 
which are occasionally attended with some degree of local 
inflammatory action, occur either when the primary symp- 
toms are still present, or shortly after they have disap- 
peared. 
Another remarkable feature which the syphilides possess 
in common is a tendency for the eruption, no matter where 
situated or of what form, to assume a circular or annular THE SYfHILIDES. 
283 
shape as regards its distribution, and to spread over the sur- 
face of the body in rings or crescentic-shaped patches; this 
is especially remarkable when they are of the papular, the 
squamous, and the hypertrophic types, and least manifest in 
the syphilitic maculm and pustulm. 
They are also characterized by their more general occur- 
rence on the exposed regions of the skin, especially on the 
scalp, the forehead, the cheeks, and the alse nasi, than on 
those parts which are ordinarily covered; the eruption, too, 
is more thickly disseminated there. They appear, however, 
more frequently on the trunk of the body than on the ex- 
tremities, being especially developed on the back and the 
shoulders. 
Lastly, syphilitic eruptions engage the more deeply-seated 
cutaneous structures to a greater extent than the non-specific 
diseases of the skin, as is evident by the greater hypertro- 
phy of the integuments that attends them, the firm, indu- 
rated feel by which they are characterized, and the greater 
elevation over the surface of those which are papular or pus- 
tular. They are moreover, essentially chronic in their 
nature; the stains which remain on the skin after they have 
been cured are usually very permanent; and they are even 
more apt to return than the other cutaneous eruptions, which 
are complicated by no special constitutional taint. 
The development of the secondary symptoms of syphilis, 
in the form of a disease of the skin, is almost invariably 
preceded and accompanied by well-marked signs of derange- 
ment of the system generally. The individual about to be 
affected may have recovered in all respects from the imme- 
diate consequences of the primary attack, and even a con- 
siderable period of time may have elapsed, during which he 
seems to be and feels in the enjoyment of his ordinary health, 
when, without any manifest exciting cause, a degree of 
cachexy is established :—the complexion becomes sallow and 
earthy-looking, unwillingness to take part in any active exer- 
tion, whether of mind or body, is experienced, the appetite 
fails, thirst becomes constant, often extreme, pains in the mus- 
cles and bone, much exacerbated at night, are complained of, 
and venereal periostitis and sore throat in some cases pre- 
cede and in others accompany the cutaneous eruption which 284 
THE SYPHILIDES. 
now appears—the outbreak being in general immediately 
preceded by a pretty smart feverish attack. To a certain 
degree the syphilides resemble the eruptive fevers, and by 
many writers the analogy between them has been made a 
subject of special observation : the similarity consists in both 
having a stage of incubation following the contagion, a period 
of febrile oppression preceding the eruption, and a charac- 
teristic fever attending its development, which ceases to a 
greater or less extent when the eruption appears fully on 
the surface. 
As the scope of this work does not admit of any account 
being given of the other secondary symptoms of the vene- 
real disease which usually accompany the syphilitic cuta- 
neous affections, and which in many cases aid much in 
arriving at a correct diagnosis between them and the non- 
specific affections of the skin, I shall now proceed to speak 
of the special characteristics of the individual eruptions— 
describing them in the order of classification which I have 
adopted, as they present the symptoms of the groups therein 
contained. 
SYPHILITIC EXANTHEMATA. 
The Syphilitic Exanthemata may present the apparent 
phenomena of Erythema, of Urticaria, or of Roseola. 
Syphilitic Erythema is characterized by the occurrence 
in an individual whose system has been tainted with the 
venereal poison of irregularly-shaped, dingy-red, copper- 
colored patches, more or less circular, but uncircumscribed, 
intermingled with which generally are numerous small, 
rounded elevations of a darker shade; the eruption in the 
majority of cases thus resembles erythema papulatum, from 
which it is chiefly distinguished by its peculiar color, and 
the other concomitant secondary symptoms which are almost 
invariably present. The patches of eruption are permanent, 
not fugacious, and although they fade somewhat, do not 
disappear, even on firm pressure ; they are most usually wit- 
nessed on the forehead or some other part of the face, and 
on the chest and shoulders; in some cases they are confined 
altogether to the palms of the hands, when they are ex- 
tremely obstinate, recurring again and again, even after SYPHILITIC EXANTHEMATA. 
285 
they have apparently yielded to treatment. This eruption 
is at times ushered in by rather smart febrile symptoms, but 
in general it is not attended with any well-marked distur- 
bance of the system, nor is it accompanied by local pain, 
heat, or itching. It is rather a frequent form of syphilitic 
cutaneous disease, and not uncommonly complicates many 
of the other varieties. 
Syphilitic Urticaria is especially marked by being at- 
tended with the characteristic burning and tingling sensa- 
tions of the ordinary disease; it resembles in shape and 
mode of development urticaria tuberosa, and like it is seated 
chiefly on the extremities, but it differs in being of a dull 
red or violaceous tint, the centre of each elevation being of 
a coppery hue; it appears, too, generally during the night, 
when the local annoyance it produces is also most trouble- 
some, but it does not fade away, although it is less promi- 
nent, during the day. It is an uncommon form of syphilitic 
eruption, but when it does occur is extremely obstinate. By 
some dermatologists it is stated that syphilitic urticaria is 
not unfrequently developed on the skin as a symptom of the 
primary disease, in consequence of its appearing while a 
blennorrhagic discharge is present; but when an eruption 
of urticaria is witnessed in such cases, it most probably 
always depends on the administration of copaiba, which has 
been before noticed as being a cause of the disease. 
Syphilitic Roseola.—This is the most common of the 
secondary eruptions belonging to the group; it generally 
appears in from four to six weeks after the apparent cure of 
the primary symptoms, but sometimes months even elapse 
before its outbreak. Cazenave and Wilson both describe it 
as occurring on the skin while chancres still exist on the 
genital organs, and also as a frequent concomitant of. blen- 
norrhagia; but Ricord, with whose views my experience 
coincides, regards its causation in such cases to be rather 
referrible to a previous venereal attack; at all events, all 
must admit the almost total impossibility of arriving at a 
true history of the precedent occurrences in individuals labor- 
ing under any of the symptoms of syphilis. The eruption 
is developed usually on the forehead, and the upper part of 
the face, but sometimes on the trunk and extremities also, 286 
THE SYPIIILI DES. 
in the form of small circular patches, scarcely elevated 
above the surface of the skin; they are of a dull rose-red or 
bronze hue, and fade but slightly on pressure. The indi- 
vidual rings do not at first exceed the size of a shilling, but, 
gradually increasing, two or more coalesce, so as to form 
large uncircumscribed patches, the borders of which, how- 
ever, still retain an annular character. The outbreak of the 
eruption is in general preceded by some slight febrile symp- 
toms ; it comes out rather rapidly on the skin, being often 
fully developed in twenty-four hours; and it runs a more 
acute course than most of the other syphilitic cutaneous 
affections. Occasionally slight itching attends it, but this 
soon disappears with some superficial epidermic desquama- 
tion : in all cases copper-colored stains for some time mark 
the site of the eruption after it has disappeared. As in 
ordinary roseola, a similar eruption on the throat very fre- 
quently is present in the specific form, independently of the 
usual secondary venereal affection of that part. Syphilitic 
roseola occurs not unfrequently in infants as one of the 
symptoms of congenital syphilis. 
SYPHILITIC VESICULJE. 
The Syphilitic Vesiculj? may appear in the form either 
of Eczema, of Pemphigus, or of Rupia; by some writers it 
is stated that a secondary venereal eruption, agreeing in its 
local phenomena with Herpes, also occurs, but this I have 
never witnessed, and the descriptions of it which have been 
given are, I think, more applicable to eczema. 
Syphilitic Eczema is a rare variety of secondary symp- 
toms, but wTell-marked cases of it from time to time occur, 
and of these I have a most characteristic example at present 
under my care. The eruption appears chiefly on the face, 
the scalp, the ears, the trunk of the body, and the region of 
the genital organs, rarely extending to the extremities; the 
vesicles are developed tolerably numerous on small, nearly 
round, patches of skin, of a reddish copper color; these 
patches gradually enlarge, and additional vesicles are deve- 
loped on them, but no matter what size they may attain by 
coalescing, the outer border still retains more or less of a SYPHILITIC VESICULJ3. 
287 
circular character, and the disease spreads in an annular 
form, distinct rings sometimes appearing at the edges. The 
vesicles maturate slowly, and are accompanied by compara- 
tively slight serous discharge ; the stains, attended with some 
epidermic exfoliation, remain on the surface of the skin for 
a considerable period, and fresh crops of vesicles are from 
time to time developed on them ; the integuments, however, 
do not become thickened and fissured, as in non-specific 
eczema. In some cases, when the eruption has existed for 
a long time, or is attended with more active inflammation 
than usual, it presents many of the characters of eczema 
impetiginodes, but the crusts or scabs which form are dark 
brown or blackish, hard, dry, and very persistent. Syphili- 
tic eczema is generally late in being developed after the dis- 
appearance of the primary symptoms, several years not 
uncommonly elapsing, so that if we were to reckon, as some 
do, from time, and not according to order of occurrence, it 
might be classed in most cases as a tertiary and not a 
secondary affection. 
Syphilitic Pemphigus is a very rare form of venereal 
eruption, which occurs more frequently, however, in new- 
born children than in adults. It is not preceded by any 
apparent constitutional disturbance; several moderately 
sized bullae are simultaneously developed generally on the 
palms of the hands and the soles of the feet, but I have 
seen them on the buttocks also ; each bulla is surrounded 
by an areola of a dull violet tint; the contained fluid is 
turbid from the first, does not completely distend the epi- 
dermis under which it is contained, and is rather slowly 
absorbed, the dark stain remaining. After the absorption 
of the effused serum, the spot on which the bulla was 
situated most generally becomes the seat of an unhealthy 
ulcer, and then the disease almost invariably proves fatal. 
Syphilitic Rupia presents nearly the same characters as 
the prominent variety of the non-specific eruption. The 
vesicles which are rather large and flattened, are developed 
in successive crops, especially affecting the face, but appear- 
ing also on nearly every region of the body, being most 
rare on the hands and feet. Each bulla is surrounded at 
first by a tolerably broad margin of a dull-red or copper 288 
THE SYPHILIDES. 
color, over which, as in ordinary rupia, the characteristic 
crust gradually extends. The crust is large, remarkably 
prominent, extremely hard, and very adherent to the integu- 
ments ; and when removed from the surface it leaves a deep, 
unevenly ulcerated pit, slow to heal, and on which a similar 
crust, but usually of a larger size, is rapidly developed. 
This form of secondary eruption is rarely witnessed for a 
long time, often not for several years, after the cure of the 
primary symptoms, and is of most frequent occurrence in 
persons advanced in life, or in those with a broken-down 
habit of body; it is therefore attended with much constitu- 
tional derangement, the result of the saturation of the 
system with the syphilitic poison. In extreme cases the 
symptoms are of a grave character: the greater portion of 
the cutaneous surface is thickly set with the black, promi- 
nent, horny-looking crusts, giving a frightful appearance to 
the countenance; the throat is deeply ulcerated, and perios- 
titic nodes exist over the bones of the legs and on the 
cranium: severe nocturnal pains are present, and the indi- 
vidual not uncommonly dies, a victim to syphilitic cachexia ; 
or, should recovery take place, the cure is most protracted. 
Cazenave speaks of syphilitic rupia as being very rare, but 
in my experience it is a rather frequent form of secondary 
venereal eruption. 
SYPHILITIC PUSTULiE. 
The Syphilitic Pustule may occur in any of the three 
forms which characterize this group, viz., as Acne, as Im- 
petigo, or as Ecthyma, and are amongst the most frequent 
of the venereal secondary eruptions. 
Syphilitic Acne, which is the most common of the three, 
occurs usually on the ordinary sites which the disease, when 
not specific, occupies, being especially witnessed on the 
forehead. The pustules appear distinct from each other, 
and are very rarely surrounded at first by any change of 
color in the skin; they are developed in the form of hard, 
inflammatory-looking papular elevations, about the size of 
a small pea, and of a livid red color; on the second or 
third day after their appearance, purulent matter forms at SYPHILITIC PUSTULE. 
289 
their apex, which is somewhat flattened, this gradually 
increases in quantity, extending into the substance of the 
derma, and at length the pustule giving way at its summit, 
pus is effused, which concretes quickly into a hard, dry, 
brown scab or crust. During the progress of these changes 
the low form of inflammation that is present spreads to the 
integuments around the base of each pustule, which conse- 
quently become hard and thickened, and assume a dull 
violaceous or copper color. After several days’ duration the 
crusts become detached, leaving a small, rather excavated 
ulcer, which, however soon, heals; the peculiar syphilitic 
stain of the surface remains for a considerable time, and 
when it fades* away, a superficial white stain, somewhat 
resembling the pit of smallpox, but smaller, is witnessed on 
the site of the pustule—this is permanent. The pustules 
appear in successive crops, and thus, when the disease has 
existed for any time, they are witnessed on the surface in 
their various stages of development, intermingled wfith 
copper-colored stains or blotches, and the superficial pits 
marking the former site of those which have disappeared. 
When the eruption is situated on the trunk or the extremi- 
ties, the individual pustules often acquire a considerable 
magnitude, equalling in size a small bean; they are, however, 
less prominent than on the face, and contain only a minute 
quantity of pus, surrounded by a hardened, copper colored 
base, which does not undergo resolution usually for a con- 
siderable time, the induration remaining long after the 
disease has been apparently cured. Syphilitic acne may be 
developed at almost any period after the disappearance of 
the primary symptoms, but is generally of early occurrence; 
it is witnessed much more frequently in adults than in 
children, and its duration is usually prolonged for some 
months. 
Syphilitic Impetigo is the least frequently met with of the 
three forms of the pustular syphilides; it may, as regards 
development, assume the characters of the non-specific im- 
petigo figurata or sparsa; in either case a reddish copper- 
colored or violet-tinted patch appears on some part of the 
integuments, most usually of the face, on which the psy- 
dracious pustules are developed on the second or third day. 290 
THE SYPHILIDES. 
These maturate pretty quickly, and, giving way, become 
covered with a dark, greenish-yellow crust or scab, of more 
firm consistence than in ordinary impetigo, and not present- 
ing the same pellucid aspect; these crusts are tolerably 
adherent, in the majority of case3 not falling off for from 
ten days to a fortnight, when superficial ulcerations are left, 
which in healing leave a cicatrix often permanent. An out- 
break of syphilitic impetigo is generally preceded by some 
slight febrile disturbance, and the surface on which it is 
about to appear is the seat of a somewhat tingling and itchy 
sensation, which is alleviated on the coming out of the erup- 
tion. Its duration is seldom much prolonged, and it is wit- 
nessed in children rather more frequently tffan in adults. 
Syphilitic Ecthyma is a very common form of secondary 
cutaneous affection, and almost invariably indicates an ex- 
treme degree of contamination of the system with the 
venereal poison. The phlyzacious pustules which charac- 
terize it are generally few in number, and are developed in- 
dividually on scattered spots or stains, of a livid red color, 
and about the size of a sixpence, or somewhat larger; these 
appear distinctly separated from each other, chiefly on the 
extremities, but they also occur on the shoulders, the front 
of the chest, the face, and occasionally on the lower part of 
the abdomen, and on the scrotum. On the second day after 
the appearance of the stains, the epidermis in their entire 
extent is slightly raised by a sero-purulent effusion; the pus- 
tule thus formed acquires its full development very slowly, 
and becomes surrounded by a dull copper-colored border, 
which enlarges gradually until the entire surface acquires 
nearly the size of a half crown. After some days the pus- 
tule bursts, and the contained matter, exuding, dries into 
a hard, dark-brown, or blackish circular crust, which is very 
persistent; when it falls off, or is removed, a slightly exca- 
vated, indolent ulcer is left, which exhibits an extremely 
slow tendency to heal, the characteristic crust of the disease 
re-forming on it again and again; when eventually it does 
heal, a permanent, uneven cicatrix, of a dull red color at 
first, but gradually becoming white, marks the part which 
had been affected. Little or no constitutional derangement 
immediately attends the outbreak of syphilitic ecthyma, and 
the local symptoms which precede amount merely to slight SYPHILITIC PAPULAE. 
291 
itching, there being neither heat nor pain. It is one of the 
most frequent of the syphilitc eruptions in infants and young 
children, and is witnessed more commonly in old persons 
than in those in the prime of life. 
The Syphilitic Papula are developed always in the 
form of the non-specific Lichen simplex or Lichen agrius ; 
they constitute a very common secondary cutaneous erup- 
tion, and occur usually at an early period after the contami- 
nation of the system with the venereal poison, being often 
present on the skin while the primary symptoms still exist, 
or being developed in a few weeks after they have disap- 
peared. In the former case the affection runs a much more 
acute course than in the latter. 
Lichen syphiliticum is usually preceded by some fever 
and general heat of the skin ; the eruption comes out very 
quickly, the entire cutaneous surface of the body, including 
the face and the extremities, being sometimes covered with 
innumerable, minute papulrn, in from twenty-four to forty- 
eight hours. They are ’placed so close together, often in 
patches or groups of a circular form, as to coalesce and 
present the appearance of large elevations, which require 
the aid of a lens to prove that they are made up of the 
minute papulae which are so characteristic of this eruption. 
At other times they are scattered over the surface perfectly 
distinct from each other, when, however, though less nume- 
rous, they are individually of larger size; in either case 
they present a bright copper color. The papulae generally 
disappear in a few weeks, with slight epidermic desquama- 
tion, as in the ordinary forms of the disease, but the surface 
remains spotted with dull coppery stains, which fade away 
very slowly; and not uncommonly a second outbreak of 
eruption takes place shortly after the first has commenced 
to decline. In some persons, especially those of a full habit 
of body, and in infants, syphilitic lichen assumes more of 
the character of lichen agrius, the papules ulcerate at their 
apex, and a serous exudation takes place, which dries into 
thin, brownish-yellow scales; much itching and well-marked 
constitutional disturbance attend this form of the eruption, 
SYPHILITIC PAPUL2E. 292 
THE SYPHILIDES. 
which is also more persistent. When either variety becomes 
chronic, which, however is rarely the case, psydracious pus- 
tules and copper-colored blotches are mingled with and 
complicate the papular eruption. Syphilitic lichen is wit- 
nessed both in infants soon after birth, and in adults, and is 
amongst the mildest of the syphilitic cutaneous affections. 
It is regarded by some writers as being occasionally a pri- 
mary symptom, and as being not unfrequently a complication 
of blennorrhagia. 
SYPHILITIC SQUAMJE. 
The Syphilitic Squamae constitute rather a frequent 
variety of secondary eruption, rarely making their appear- 
ance for a considerable time after the removal of the primary 
symptoms, and consequently indicating much saturation of 
the system with the venereal poison. The scaly alfection 
of the skin is, in many cases, preceded by a roseolous rash, 
which exists for some time before the scales are developed 
on it. It may present the form of any of the non-specific 
varieties of the eruption, Psoriasis guttata, Psoriasis aggre- 
gata, and Psoriasis leprieformis; and, consequently, a syphi- 
litic psoriasis and a syphilitic lepra are described by most 
writers as distinct affections. 
Syphilitic Psoriasis (Atlas, PI. XI. Fig. 1) is not ushered 
in by any decided constitutional disturbance, nor is it attended 
with local irritation, but the usual general symptoms of 
secondary syphilis always accompany it, and serve much to 
aid the diagnosis. The scales, which are of a dull gray 
color, are developed in distinct spots or small patches, as in 
the ordinary form of the disease, but when the eruption is 
about to assume the aggregate or leproid character, they 
increase in extent pretty quickly. The disease usually 
comes out first on the extremities, to which, however, it is 
not confined, soon appearing on the face, the scalp, and 
the entire trunk, especially affecting the chest and shoulders ; 
the surface of the skin on which the squamous eruption is 
seated is of a dull violet or dark coppery-red color, and is 
elevated somewhat above the surrounding integuments. In 
the leproid form, the edges of the circular patches are much 
raised, and the centres, which are always of a more dingy SYPHILITIC SQUAMvE. 
293 
hue, depressed and free from scales, or with a few thin 
scattered scales on them. In the aggregated variety, the 
outer border of the patches assumes more or less of an 
annular character, and, as Biett has remarked, it is sepa- 
rated in the majority of cases from the surrounding non- 
affected integument by a narrow white rim ; the central 
portions are much more elevated than the edges, and the 
scales on them are thicker, and of a dull gray color. Syphi- 
litic psoriasis differs especially from the non-specific disease, 
in not being more thickly developed around the joints than 
elsewhere on the extremities. In some cases, when the 
eruption has been of long persistence, it presents the tessel- 
lated pavement character described at page 174 ; but fissures 
do not form in the scales, nor is it attended with an ichorous 
discharge or the symptoms of local irritation which cha- 
racterize the inveterate variety of the ordinary disease. 
Syphilitic scaly eruptions are of extreme obstinacy, and 
their duration is invariably much prolonged; when they 
begin to disappear, the desquamation—which, however, is 
never in such quantity as in the non-specific squamrn— 
gradually diminishes, the elevated surface becomes flatter, 
until it at length sinks to the level of the surrounding in- 
tegument, but still retains its peculiar copper color, which 
disappears very slowly, years often elapsing before it fades 
away completely. 
Syphilitic psoriasis is in some cases confined to a single 
region of the body, especially the palms of the hands, when 
it presents most of the phenomena characteristic of ordinary 
psoriasis palmaris, but the scales are thicker, of a duller hue, 
more persistent, and the portion of integument on which 
they are developed is more elevated, drier, and of a copper 
color; the general appearance of the palm of the hand when 
affected with the eruption is such that Biett termed it horny, 
the affection constituting the Syphilide squameuse cornee of 
that dermatologist. 
The squamous syphilides are very rarely seen in children, 
and are still more rarely developed for the first time in old 
persons, being an affection of individuals in the prime of life, 
liable to accompany either the so-called secondary or tertiary 
venereal symptoms. 294 
THE SYPHILIDES. 
SYPHILITIC HYPERTROPHY®. 
In the Syphilitic Hypertrophy® a form of cutaneous 
affection occurs -which has no parallel among the non-specific 
diseases of the skin ; custom has so completely sanctioned 
the application of the term tubercle to its different varieties, 
that it is almost hopeless now to think of changing this de- 
nomination, and for this reason, notwithstanding the great 
objections, so frequently referred to in the preceding pages, 
which exist to retaining this word in the nomenclature of cu- 
taneous nosology, I shall not attempt to substitute another 
for it. Condylomata, which belong to this group of diseases 
of the skin, are, as already noticed, most frequently of syphi- 
litic origin, but as, when of this nature, they fall altogether 
within the domain of general surgery, no further descrip- 
tion of them than what has been given at page 224 is re- 
quisite here. For the same reason warts which result from 
a venereal source will not be noticed. The syphilitic tu- 
bercles will therefore alone engage attention in considering 
this group of cutaneous diseases as symptomatic of secondary 
syphilis. 
Syphilitic tubercles are amongst the most frequent of the 
secondary symptoms of the venereal poison which affect the 
skin ; they may be developed in a very short time after the 
disappearance of the primary disease, or their occurrence 
may be deferred for many months, or even years. The 
tubercles vary much in size and in their apparent pheno- 
mena, and thus constitute different varieties. First, they 
may occur in the form of large papulae, differing from lichen 
chiefly as regards their size, being about equal to that of a 
small pea ; they are rounded, hard, and elevated above the 
level of the skin, appearing in small groups, most usually of 
a circular shape, with healthy skin intervening, and not un- 
frequently forming a centre to each patch. These groups 
are irregularly disseminated over the surface of the face, 
the neck, the trunk, and the extremities, especially the first; 
but are often symmetrical as regards the two sides of the 
body. The individual tubercles, which are of a violaceous 
or dull coppery hue, soon secrete a thin scale at their sum- 
mit, from beneath which, if rubbed off or torn with the SYPHILITIC HYPERTROPHIC. 
295 
nails, a slight watery exudation takes place ; this dries into 
a thin, reddish-brown, persistent scab, which eventually 
falls off, leaving a characteristic syphilitic stain that for a 
long time marks the seat of the eruption. 
Second, the tubercles are of greater magnitude, varying 
in size from that of a nut to that of an olive, of an ovoid 
shape, hard, distinctly elevated, and disseminated over the 
surface ; they may occur on a single region of the body, 
especially affecting the face and neck, or may be generally 
distributed over the surface. In some parts, being more 
closely set together than in others, they sometimes coalesce 
and form a tolerably large tumor, uneven on the surface, 
but distinctly circular at the margin. The tubercles in 
this variety are of a deeper and duller shade of color than 
in that first described; neither desquamation nor serous 
exudation takes place from them; they remain stationary 
for a very long time, not unfrequently for years, and at 
length, being absorbed, often rather suddenly, the charac- 
teristic stain, slow to fade away, marks their site. 
Third, a still larger tubercle than the last appears isolated 
on some portion of the integument, most generally of the 
extremities, but sometimes of the body or face ; it is rather 
soft to the touch, slightly painful, scarcely elevated above 
the surrounding skin, of a dull violaceous tint, with a bronze 
or copper-colored margin. It increases very slowly in size, 
exhibiting an appearance as if about to suppurate, and the 
margin assumes an uncircumscribed erythematous blush. 
At length the most prominent part ulcerates slightly, a 
thick, blackish, adherent crust forms on it, which is very 
gradually detached, usually not for weeks, when the entire 
tubercle falls out, leaving an unhealthy, indolent ulcer, with 
excavated edges, painful and slow to heal. At first rarely 
more than three or four tubercles of this character are de- 
veloped on the body, but they come out in successive crops, 
so as at length to amount to a considerable number. When 
the ulcer which they leave heals, a permanent depressed 
cicatrix results, which for a long time exhibits a rather 
bright copper-red stain. This variety of tubercle rarely ap- 
pears for years after the primary symptoms, is generally 
met with in old persons, or those of a broken-down habit of 296 
THE SYPHILIDES. 
body, and in individuals in whom there exists extreme syphi- 
litic cachexia. 
Fourth and last, several tubercles, about the size of a 
sixpence, but little elevated above the surface and rather soft 
to the touch, are developed, distinct from each other, on 
some special region of the body—usually on the scrotum in 
males, and the pudendal region in females, on the face, par- 
ticularly on the lips and nose, and around the arms; they 
are perfectly circular, and of a dull reddish tint. Small 
superficial ulcers soon form on them, appearing first at the 
outer margin, these gradually extend, so as to cover the 
entire surface of the tubercle, retaining, however, their super- 
ficial character, and from them there exudes an extremely 
fetid, sanious liquid, which irritates and inflames the neigh- 
boring integument over which it may flow. Eventually 'the 
discharge ceases, copper-colored crusts form, and the parts 
heal without any marked cicatrix. By many modern 
writers, particularly of the French school, this form of sy- 
philitic tubercle is regarded as constituting in some cases 
one of the varieties of primary symptoms. 
SYPHILITIC MACULJS. 
Under the head of Syphilitic Maculjb some of the 
forms of secondary roseola are not unfrequently described, 
hut they should not be confounded with the peculiar pig- 
mentary alterations of the cutaneous structure which in 
many cases accompany other secondary eruptions, and in 
some constitute the only affection of the skin present. They 
resemble most in their apparent phenomena ephelis hepatica, 
but differ from it in being developed in the majority of cases 
on the legs, or in the region of the genital organs, occurring 
only in a few instances on the face or the trunk of the body. 
They are also characterized by their color, which is distinctly 
of a copper shade, at times approaching to black, and in as- 
suming from the first a w'ell-marked circular form spreading 
from the circumference in ring-like patches. These morbid 
alterations of color do not appear on the cutaneous surface 
usually until several months or even years have elapsed 
after the cure of the primary symptoms ; they are invaria- 
bly attended with well-marked syphilitic cachexia, and are SYPHILITIC MACULiE. 
297 
extremely obstinate to treatment, sometimes remaining for 
life. Syphilitic maculae occur at all ages, both in persons 
in the prime of life and in old age, and are a not unfrequent 
result of congenital syphilis. 
Diagnosis.—Under this head little remains to be said after 
the observations which have been made in the commence- 
ment of the chapter on the general characteristics of the 
secondary eruptions. The history of the individual case, 
where it can be arrived at satisfactorily, which, however, in 
the majority of instances is quite impossible, is the aid chiefly 
to be relied on ; in doubtful cases assistance is often gained 
by an examination of the glans in males, and the external 
organs of generation in females, when the cicatrix or indu- 
ration resulting from a chancre, if it had previously existed, 
will afford satisfactory evidence; inspection of the throat 
and back of the pharynx also should never be omitted, the 
characteristic venereal ulceration existing there usually in 
connection with the eruption on the skin. 
The 'prognosis in secondary cutaneous affections must be 
guided much by the degree of syphilitic cachexia present, 
by the length of time which they may have previously 
existed—for in proportion to their duration is their obstinacy 
—by the severity and extent of the concomitant symptoms 
in other structures of the body, and by the nature of the 
eruption itself: the latter point has been noticed in the de- 
scription of the individual forms. 
Treatment.—As in all other affections which have their 
origin in the absorption of the syphilitic poison into the sys- 
tem, the secondary eruptions of the skin demand a specific 
mode of treatment, directed to the eradication of the con- 
stitutional taint on which they depend. Formerly it was 
believed that this could alone be affected by the action of 
mercurials, but the discovery of iodine and of its medicinal 
properties has wrought a complete revolution in the thera- 
peutics of the consecutive symptoms of the venereal disease. 
This has in some respects, however, been attended with an 
evil result, that of inducing many practitioners to discard 
mercury altogether as a remedial agent in the treatment of 
the syphilides, and to trust to the employment of such sim- 
ple measures as may be indicated by the local and general 298 
THE SYPHILIDES. 
symptoms, independently of their specific character; or to 
rely solely on the administration of preparations of iodine 
to correct the constitutional contamination. But as in nearly 
every other disease to -which man is subject, it should be 
always kept prominently in view that an exclusive system of 
treatment, cannot be expected to be invariably successful, 
for the same affection often requires the use of even the 
most opposite remedies in different individuals, or in the same 
person under different circumstances. 
The remedies to be employed in the treatment of the 
syphilides may be conveniently considered under three heads: 
the general, the specific, and the topical. 
The general treatment consists in the employment of 
means, calculated to meet the indications dependent on the 
special symptoms which may arise or be present in individual 
cases. Thus, when the outbreak of an eruption is attended 
with distinctly febrile symptoms or well-marked local inflam- 
matory action, the employment of antiphlogistics is demanded 
before the administration of specifics can be commenced. 
Under such circumstances, in young plethoric persons, gene- 
ral bleeding will be resorted to with advantage, and topical 
abstraction of blood by means of leeches is almost invariably 
necessary. Active saline purgatives should be given also, 
and in no case should they be omitted ; with very few excep- 
tions their effects are productive of the most beneficial 
results in the early stages of every syphilitic eruption: the 
only instances in which they occasionally prove injurious 
are when the syphilitic cachexia is extreme in very old per- 
sons or individuals of a broken-down habit of body. They 
seem to act chiefly by determining to the intestinal mucous 
tract, and thereby diminishing excessive cutaneous action, 
the quantity of the eruption, and consequently the local 
inflammation, being thu3 checked; but they also lessen the 
general febrile symptoms. The neutral purgative salts are 
best adapted to fulfil these intentions, and their administra- 
tion will be advantageously preceded by a full dose of calo- 
mel or blue pill. 
On the other hand, should the vital powers be low, and 
the depression of the system very manifest, the vegetable 
tonics must be given ; and if there are deep-seated pains 
present, especially the nocturnal pains so characteristic of SYPHILITIC MACULAE. 
299 
the disease, opiates in full doses should be prescribed in 
combination, or if the suffering is extreme, their use may 
precede the employment of the tonics. No preparation 
relieves the deep-seated pains which so frequently accom- 
pany secondary symptoms, whether of the skin or not, as 
crude opium: it may be given in the dose of a grain, made 
into a pill, three or four times or even oftener in the twenty- 
four hours, according to circumstances. Of the vegetable 
tonics, those which determine to the skin, such as the elm 
bark, are especially useful, or cinchona bark or quina may 
be combined with the tonic or stimulating vegetable diapho- 
retics—dulcamara, mezereon, sarsaparilla, guaiacum, &c.; 
the mineral tonics, especially the stronger acids, and iron 
and its preparations, are also often highly serviceable in the 
syphilides, when the employment of this class of remedies 
is indicated. The former were largely given by Biett in the 
syphilitic exanthemoid and papular secondary eruptions, 
much reliance being placed by him on the nitric and sul- 
phuric acids: the latter are especially indicated when much 
anemia is present, and they are often usefully prescribed in 
combination with iodine, as in the chemical compound of the 
iodide of iron, or of the iodide of iron and quina. When 
a specific eruption occurs in an individual of a scrofulous 
diathesis, or with a strumous tendency, cod-liver oil will be 
administered with decided benefit, and should the debility be 
extreme, preparations of iron are usefully given at the same 
time. 
The specific treatment of the syphilides consists in the 
employment of the preparations of mercury, of gold, or of 
silver, and of iodine alone or in combination with any of 
them. Mercurials are unquestionably the remedies on which 
most reliance is to be placed, but the amount of benefit to 
be derived from their use depends much on the manner in 
which they are administered, and the preparation that is 
employed. They should not be given on the first appearance 
of the eruption, the more especially if its outbreak be con- 
nected with general febrile symptoms—these must be previ- 
ously removed by the means already referred to ; and in all 
cases the state of the digestive organs requires special at- 
tention before their employment is commenced. The several 
forms of the secondary eruption serve as indications as to 300 
THE SYPHILIDES. 
what preparation of mercury is best suited, but it may be 
laid down as a general rule that those which have the pro- 
perty of producing salivation quickly or freely, such as 
blue-pill, calomel, and the allied compounds, are rarely 
adapted for these consequences of the venereal disease. 
For the scaly and tubercular syphilides, corrosive sub- 
limate and the red iodide usually prove the best preparations 
of the metal; either may be given in pill with opium, in 
doses of from l-12th to l-8th of a grain, three times daily, 
the quantity of opium being proportioned to the degree of 
the characteristic venereal pains which may attend; or the 
former may be preferably prescribed in some vegetable de- 
coction, such as that of dulcamara, of elm-bark, of meze- 
reon, of sarsaparilla, &c., as in the following formula :— 
R. Corrosivi Sublimati, gr. j. 
Decocti Dulcamarse, fl siv. 
Dccocti Mezerei, 11 sxij. 
Infusi Sassafras, fl 3viij. Misce. 
“A wine-glassful to be taken three times a day.” 
When these or any other of the syphilitic eruptions be- 
come chronic, or return frequently after they have been 
apparently removed, it will be necessary to have recourse 
to the administration of arsenic, in combination with the 
mercury and iodine, and under such circumstances Dono- 
van’s solution—the liquor arsenici et hydrargyric hydrio- 
datis of the last Dublin Pharmacopoeia—proves singularly 
beneficial. It is for the chronic forms of secondary dis- 
eases of the skin that this combination is especially adapted, 
and in these cases its therapeutical efficacy is undoubted; 
indeed, in my hands, it has very rarely failed to effect a 
permanent cure, but it must be given in moderate doses, 
from ten to twenty minims three times daily—the quantity 
increased very gradually, and its use continued for a long 
time, even after the disappearance of the eruption. It may 
be administered in some of the vegetable tonic or diapho- 
retic decoctions, according to individual circumstances. 
For the pustular and papular syphilides the green iodide SYPHILITIC MACULA. 
301 
of mercury of the Dublin—the iodide of the London—Phar- 
macopoeia, has proved, in my experience, the best preparation 
of the metal. It may be given in pill combined with opium, 
should circumstances indicate the use of that drug, in the 
dose of from half-a-grain to three grains three times daily, 
but its effects must be carefully watched, as it is in some per- 
sons apt to produce salivation, even in small doses, and in 
the treatment of any form of syphilitic eruption it is most 
important to administer as little mercury as possible, and to 
introduce it very gradually into the system ; the precise 
quantity requisite can only be judged by watching the effect 
produced in each individual case, but the mildest action on 
the mouth is always an indication that for the time enough 
has been given. An excellent way of prescribing this pre- 
paration for adults is to substitute it for the calomel in 
Plummer’s pill, and the vegetable decoctions before referred 
to may be given at the same time. 
The syphilitic exanthemata do not require the employ- 
ment of specific remedies in their acute stages; but should 
they exhibit a tendency to become chronic, the green iodide 
of mercury is the preparation best adapted to them. The 
occurrence of maculae as a secondary symptom indicates 
the necessity for a prolonged administration of a mercurial, 
and, therefore, either the bichloride or the red iodide should 
be used. 
When any of the forms of syphilitic eruption appear on 
infants at the breast, it is desirable, when practicable, to in- 
troduce the specific medicine into the system of the child by 
means of the nurse’s milk ; but as in the majority of cases 
it is essential to change the nurse, and it is, consequently, 
often requisite to wean the infant, the hydrargyrum cum 
magnesia,, or hydrargyrum cum creta, may be given in doses 
of from one to two grains daily, according to the age, and 
with each dose from a twelfth to an eighth of a grain of the 
green iodide of mercury may be combined when the erup- 
tion is extensive. 
The preparations of gold and of silver were at one time 
proposed by the French school as substitutes for those of 
mercury; but they were found not to possess at all the same 
efficacy, and they have, consequently, fallen now into almost 
complete disuse for the treatment of secondary symptoms. 302 
THE SYPHILIDES. 
The former were supposed to be especially adapted for per- 
sons of a scrofulous diathesis, with whom mercurials very 
generally disagree, and their effects are highly spoken of by 
Legrand and Chrestien, but they have not, that I am aware, 
been employed in this country. 
Iodine or its preparations should not be trusted to alone 
with the intention of producing a specific action in the 
treatment of the secondary eruptions; from what has been 
already said, it is evident that their combination with mer- 
curials is of especial service; but unless thus prescribed, 
they usually disappoint. In scrofulous habits, their admi- 
nistration should never be omitted—still, a mercurial must 
be given with them, and the more decided the evidences of 
scrofula are in any individual case, so much the more must 
the proportion of the iodine preparations predominate in the 
treatment. The administration of iodide of potassium is 
attended with the best results as soon as the preparation of 
mercury which may have been given evidences its action on 
the system by the mouth being affected, and it is also most 
valuable when given to nurses, with the view of treating 
a venereal eruption in an infant at the breast; in the latter 
case, it often suffices to cure the disease, whether the nurse 
is at the same time affected with secondary venereal symp- 
toms or not. 
The employment of topical remedies in the treatment of 
the syphilides is of much less importance than in the non- 
specific eruptions; little more being requisite, in the majority 
of cases, than the use of the tepid bath every second or third 
day, to allay any local irritation or inflammatory action 
which may arise, and also to restore the healthy functions 
of the skin. When ulceration occurs in the progress of any 
of the secondary eruptions, the black-wash is the best appli- 
cation which can be used, if it takes place on the scalp, the 
trunk or the extremities; but on the face, an ointment con- 
taining a drachm of calomel to an ounce of simple cerate is 
more easily applied, and is more efficacious. In infants, the 
local symptoms are usually more severe than in adults, but 
they are easily calmed by the employment of a dusting 
powder, containing twenty grains of the carbonate of lead, 
half a drachm of the oxide of zinc, and an ounce of starch, 
reduced together to a state of the minutest division; a tepid SYPHILITIC MACULiE. 
303 
bath of fresh water, containing from two to four ounces of 
size, should be at the same time employed every night, or 
every second night, according to circumstances. The dis- 
persion of the stains in syphilitic maculae is much hastened 
by inunction with mercurial ointment while the constitutional 
treatment is being followed out. 
In all cases of secondary syphilitic eruptions, as soon as 
the first inflammatory symptoms, if any occur, are subdued, 
the diet should be nutritious, and wine and other stimulants 
should be allowed; if the syphilitic cachexia be extreme, 
and much debility present, the chief points to be attended 
to are, to support the strength, and at the same time to 
allay both general and local irritability. Change of air, 
especially to a dry and warm climate, is an aid to the treat- 
ment of the utmost importance in chronic and obstinate 
cases. 304 
DISEASES OF THE HAIR. 
CHAPTER XIII. 
DISEASES OF THE APPENDAGES OF THE SKIN. 
In this Chapter I shall describe affections of the hair and 
of the nails. They constitute a class of morbid changes, 
concerning which the regular medical practitioner is but 
rarely consulted, and therefore a short notice of them must 
here suffice, yet the former, especially, are not uncommonly 
a cause of as much anxiety to those who suffer from them, 
as a really grave cutaneous disease. 
DISEASES OF THE HAIR. 
The Diseases of tiie Hair consist in alterations of its 
natural color or characters, and in its partial or total loss. 
Some few cases have been recorded in which the hair has 
undergone a sudden change of color from a light to a dark 
hue, or the reverse, without any apparent cause, or after 
some acute disease; and not unfrequently, when it is re- 
produced after it has been removed for some febrile or other 
affection, it grows of a much darker color than it had been 
originally; this is usually the case when it has been kept 
cut close for any length of time in the treatment of any of 
the eruptions of the scalp. Loss of color in the hair,— 
Canities,—is one of the natural results of old age, but it 
often occurs at a comparatively early period of life, either 
from constitutional causes, or from extreme mental anxiety. 
The effect of the latter is often well marked, and some cases 
have been witnessed in which the hair has become perfectly 
white in the space of a few hours, while an individual was 
laboring under some violent emotion of the mind : these, 
which have often furnished a theme for the poet and the 
popular writer, demand no other notice here than that of a 
mere reference. The most important of the constitutional 
causes of canities is hereditary predisposition, and examples 
of premature grayness of the hair descending through 
several generations in several families are very numerous. DISEASES OF THE HAIR. 
305 
Blanching of the hair is sometimes associated with debility 
of the vital powers, but that it is very rarely so, is evident 
from the fact of its being so seldom witnessed in those 
who die young of consumptive or other lingering diseases. 
Treatment, whether topical or general, has in my opinion, 
no effect over any of the forms of canities except that last 
described, and in it the indications are manifestly to restore 
the system to a state of robust health, if practicable, by the 
use of such remedies as may be appropriate for the indi- 
vidual case. But numerous local applications and other 
means have been and still are recommended, with the view 
of preventing the hair from turning gray: should it be dry 
and crisp, and the surface of the scalp appear bloodless, any 
gently stimulating pomade may be used: cutting the hair 
short, or removing it altogether by shaving the scalp occa- 
sionally, proves useful. The preparations which are used 
for dyeing the hair are very numerous, and formulae for them 
are given in all druggists’ or perfumers’ receipt-books. 
The occurrence of white hair in patches on the scalp has 
been already described. (See Yitiligo.) 
The only alteration in the character of the hair which 
can be strictly regarded as a disease is that peculiar felting 
and matting of it together which constitutes the singular 
affection that has been named Plica Polonica; but inasmuch 
as it does not occur in this country, and as, from having 
never seen a case of it, I can add nothing to the account 
contained in the several works in which it has been described, 
I shall not notice it farther here. 
Loss of hair, or baldness, termed “Alopecia” by the 
ancient writers on medicine, would appear to have been of 
much more frequent occurrence and to have attracted more 
attention formerly than at present; it may be either partial or 
general on the hairy scalp, or on the other parts of the body 
which are naturally covered with hairs. In the former case, 
it was termed Porrigo decalvans by Willan, but then it is 
manifestly due to the occurrence of Yitiligo on these regions 
of the skin, as before described. General baldness is in 
many persons the accompaniment of old age, being usually 
associated with gray hairs, nor can it be regarded as a dis- 
ease except when it occurs in comparative early life: some S06 
DISEASES OF THE HAIR. 
few cases have been recorded as being congenital, in which, 
however, it was due to non-development of the hair follicles. 
Permanent baldness, as has been remarked in the preceding 
pages, is also at times a result of the eruptive diseases of 
the scalp, especially of Porrigo, and is then a consequence 
of the inflammatory action which may exist extending to 
the bulbs: after most diseases of the scalp, however, although 
the hairs falls out, it is reproduced. Loss of hair, partial 
or general, is also a not unfrequent sequence of fevers and 
acute inflammatory affections, and of syphilis ; in the former 
case it generally grows again, but in the latter the baldness 
is usually permanent. Loss of hair from natural causes at 
an early age is, like the premature change of its color to 
gray, hereditary in the majority of instances, is also caused 
by violent emotions of the mind, or prolonged mental anxiety, 
and is connected pathologically in some individuals with 
general debility, or diminished vital action. 
Congenital and senile baldness are incurable, as is also 
that form of it which is hereditary. In other cases, repeated 
shaving of the head, or keeping any hair that may remain 
constantly cut close, and the application of stimulating 
spirituous washes, such as either of the following, sometimes 
prove useful:— 
R. Spiritus Yini Rectificati, . . . . fl 3vj. 
Ammoniae Hydrochloratis, ... gr. xxx. 
Olei Rosmarini, fl 3ss. 
Infusi Armoraciae compositi, . . fl 3vj. 
Misce. Fiat lotio. 
R. Tincturae Cantharidis, fl 3ij» 
Aquae Florum Sambuci, fl 3xj. 
Essentiae Rosmarini, fl 3vj. 
Misce. Fiat lotio. 
The turpentine pomade, as ordered at page 240, not un- 
frequently proves of service also, and each time previously 
to its application the scalp should be washed with an alka- 
line lotion, containing a drachm of carbonate of potash to 
eleven ounces of water, and one ounce of rectified spirit or DISEASES OF THE NAILS. 
307 
of rum. The following pomade, as recommended by Dr. 
Copland, I have frequently used with excellent effect:— 
R. Adipis praeparati, §ij. 
Cerae Albae, 3ss. 
Lento igne simul liquefac, tunc ab igne remove et ubi pri- 
mum lentescant, 
Balsami Peruviani veri, 5\j- 
Olei Lavandulae, m.xij. 
adjice, et assiduh move donee refrixerint 
In all forms of alopecia the scalp should be kept warm, and 
consequently wearing a wig is often of service when the hair 
first begins to fall off'. 
DISEASES OF THE NAILS. 
Most of the Diseases of the Nails are of such a nature 
as to demand surgical interference, and are consequently 
described in the works of surgical writers. Perhaps the 
most important of them all is that in which the nail of some 
of the toes grows into the surrounding fleshy integuments, 
and by the irritation it thus occasions, gives rise to the 
formation of a foul, unhealthy ulcer. It would not be in 
accordance with the plan of this work to say anything here 
of the surgical treatment requisite to cure this most obsti- 
nate and painful affection; but I cannot avoid remarking on 
the importance of preventing the ingrowing, as it is termed, 
of the nails, by always cutting them straight across, parallel 
with the extremity of the toe, as when they are cut at the 
edges, the pressure of the boot or shoe not uncommonly 
gives rise to this disease. The nails both of the hands and 
feet are also subject to inflammation attacking their matrix, 
to hypertrophy, and to atrophy, and they occasionally fall 
off completely, and are not reproduced. This last affection, 
which has been termed by the French writers Alopecia un- 
guale, is sometimes congenital, children being born without 
nails, but such cases are extremely rare. When the nails 308 
DISEASES OF THE NAILS. 
become hypertrophied, the application to them of caustic 
potash, and the daily use of a strong lotion of carbonate of 
potash is often useful; the nitrate of silver is the best 
application when the nails, being brittle, split and break 
readily; and it is also productive of much service should a 
foul discharge continue from beneath the nail, as a conse- 
quence of previous inflammation of the matrix. As has 
been remarked already, the nails at times become engaged 
in some of the eruptive diseases of the skin, more especially 
psoriasis and eczema, when, however, they require no further 
treatment than that applicable to the existing affection. THERAPEUTICS. 
309 
CHAPTER XIV. 
THERAPEUTICS OE DISEASES OF THE SKIN. 
In describing the individual eruptions of the skin, I have 
spoken of the treatment adapted for each, yet there are 
some general points in therapeutics specially applicable to 
this class of affections, which require a separate notice, and 
to their consideration I propose to devote this chapter : it 
will, therefore, consist in a review of the remedies most 
generally used in cutaneous diseases, and the manner in 
winch they should he employed; a few formulae which may 
prove suggestive in prescribing will also he appended. The 
remedial measures ordinarily required may for convenience 
of description he considered in twro divisions—the topical 
and the constitutional; it is true that some of them, baths 
for example, produce their effects by acting both locally and 
on the system generally, but as their mode of application is 
external, they will be considered in the first division. 
Several objects are in general expected to be fulfilled by 
the employment of topical medication in the treatment of 
cutaneous eruptions. It may be used with the view simply 
of cleansing the skin from the scales or crusts which form 
on the surface, so as to permit the direct application of 
remedies to the diseased parts: for this purpose cataplasms, 
baths, alkaline washes and soaps are usually had recourse 
to. It may be employed with the intention of protecting 
the affected portions of the integument from the action of 
the air; or a directly therapeutical effect may be expected 
from its application. Some topical remedies fulfil only one 
of these indications, while the benefit derived from the use 
of others depends on their mode of operation combining the 
three. 
The treatment of diseases of the skin by the total exclu- 
sion of air has within the last few years, more especially 
since the discovery of collodion, been much employed and 
highly recommended by some practitioners, while in the 
hands of others it has completely failed. The practice is 310 
THERAPEUTICS. 
chiefly applicable to local eruptions, and to those which are 
not attended with much discharge. Its employment in 
erysipelas has been referred to when speaking of the treat- 
ment of that disease ; but it has not as yet been sufficiently 
tested by experience to enable a satisfactory conclusion as 
to its therapeutical efficacy to be arrived at. So far as re- 
gards the application of collodion to form an impermeable 
covering, it has been productive rather of injury than of 
benefit in any cutaneous eruptions in which I have used it; 
this appeared to me to depend chiefly on the uneven com- 
pression and contraction of the integument which is occa- 
sioned, causing much local irritation, and sometimes even a 
degree of inflammation. Such effects being due principally 
to the rapidity of evaporation of the ether in which the gun- 
cotton is dissolved, these resulting injurious consequences 
will probably be prevented by the recent proposal of Dr. 
Graves1 to employ a solution of gutta percha in chloroform 
for this purpose. Moreover, the gutta percha forms a less 
brittle, firmer, and thicker, though still transparent, cover- 
ing to the skin, and exerts an even and more complete com- 
pression on the surface; the latter effect also being regarded 
by Dr. Graves as of importance with reference to its bene- 
ficial action. In his paper on the use of this substance re- 
ferred to in the note, Dr. Graves illustrates its therapeutical 
efficacy by the narration of some cases in which it proved 
remarkably successful; but whether it will be of such 
general application as he predicts, experience alone can 
decide. 
The advantage to be derived from the application of 
Bandages to either the upper or lower extremities, when 
they are the seat of cutaneous eruptions, is too often over- 
looked ; they fulfil to a certain extent the indication of ex- 
cluding the action of the air, but they also prove beneficial 
by exerting an equable amount of compression on the over- 
loaded and congested vessels, as has been already noticed 
when speaking of erysipelas; and they afford in addition a 
useful means of applying medicated lotions, as referred to 
in describing the treatment of eczema. 
1 Dr. Graves’ paper on this subject, which I have had the advantage of 
reading in manuscript, is to appear in the number of the Dublin Quarterly 
Journal of Medical Science for August, 1852. THERAPEUTICS. 
311 
The various remedies which are employed topically for 
the treatment of diseases of the skin may be applied to the 
surface in the form of baths, cataplasms, caustics, lotions, 
ointments, powders, and soaps. These will now be con- 
sidered in succession. 
Baths, both simple and medicated, have at all times been 
very extensively used as remedial agents in cutaneous erup- 
tions, and have by many been supposed to be sufficient for 
their cure, without the administration of any internal re- 
medies. To the reader of the foregoing pages it must be 
evident that I place but little reliance on their efficacy, and 
that I recommend a resort to their employment with the in- 
tention of acting, so to say, medically on the disease in but 
few cases: yet it cannot be denied that abundant testimony 
exists to prove that persons affected for years with chronic 
eruptions, more particularly those of a scaly character, 
have been cured by the prolonged use of medicated vapor, 
steam, or water baths. But they are not at present em- 
ployed to at all the same extent they were formerly, and 
modern writers do not recommend baths in the same lauda- 
tory terms as those who preceded them—a proof that their 
efficacy was, to say the least, somewhat overrated. As a 
cleansing agent, and to promote the discharge of the healthy 
functions of the skin, and a return to its normal state, the 
fresh water tepid and warm baths are of especial service in 
many cutaneous eruptions, chiefly those in which the surface 
is dry and hard, as in the exanthemata, the scaly diseases, 
and ichthyosis ; and when these affections are local, they are 
often advantageously employed in the form of douche; but 
they seldom agree with those cases which are attended with 
a discharge, whether it be serous or purulent. In addition 
to their cleansing effects they also often prove useful, as an- 
tiphlogistics, in allaying local irritation and inflammation. 
Vapor baths, being slightly stimulant, are not indicated 
until the chronic stages of cutaneous diseases are fully es- 
tablished, when, in consequence of their possessing this pro- 
perty, they are frequently used with advantage. Salt water 
bathing, in my experience, proves injurious in most diseases 
of the skin, for although it often appears at first to produce 
a beneficial action, the eruption usually returns afterwards 
with greater obstinacy, and is much more rebellious to treat- 312 
THERAPEUTICS. 
ment; but usually, and always when the affection is of an 
inflammatory tendency, it aggravates the disease: the only 
cases in which I have seen it almost invariably serviceable 
are when maculae or stains of the integument become per- 
sistent after the removal of any of the syphilitic eruptions. 
The following are formulae for some of the medicated baths 
usually employed :— 
GELATINE BATH. 
R. Gelatinii (vulgo dicti 11 size”) Ibvj. 
Aquae, (Caloris gradu, 75° ad 92° F.), C. xxx. Solve. 
This bath is employed with excellent effect to allay local 
irritation and itching, and is especially useful in the cuta- 
neous diseases of children. The temperature must be pro- 
portioned to the indications in each case. The above are 
the quantities requisite for a bath for the entire body in the 
case of adults. 
R. Sodas Carbonatis, oviij. 
Aquae Pluviae, (Caloris gradu, 84° ad 96° F.), C. xxx. Solve. 
R. Potassae Carbonatis, 3vj. 
Aquae Pluviae, (Caloris gradu, 84° ad 96° F.), C. xxx. Solve. 
R. Sodae Carbonatis, 3vj. 
Sodse Sub-boratis, 3ij. 
Aquae Pluviae, (Caloris gradu, 75° ad 98° F.), C. xxx. Solve. 
ALKALINE BATHS. 
These alkaline baths are often usefully employed as deter- 
gents of the surface when it becomes covered with thick 
crusts of adherent scales. They should be used with caution 
when any tendency to inflammatory action exists in the skin. 
They are also of service in chronic scaly eruptions, espe- 
cially pityriasis, and in ichthyosis. 
IODINE BATHS. 
R. Iodinii, 5ss» 
Iodidi Potassii, ,?ss. 
Glycerinae, fi |ij. 
Aquae, (Caloris gradu, 86° ad 94° F.) C. xxx. Solve, THERAPEUTICS. 
R. Iodinii, 3.j- 
Liquoris Potassae, .... fl sj ad fl §ij. 
AquaePluviae (Caloris gradu 86° ad 96° F.), C. xxx. Solve. 
R. Brominii, m. xx. 
Iodidi Potassii, Jij. 
Glycerinae, fl 3j. 
Aquae (Caloris gradu, 86° ad 94° F.), . C. xxx. Solve. 
Iodine baths are used in very chronic cutaneous eruptions, 
when there is much hypertrophy of the integuments. They 
may also be employed in aggravated cases of prurigo. 
SULPHUR BATHS. 
R. Potassii Sulphureti, ....... §iv. 
Aquae Pluviae (Caloris gradu, 86° F.), C. xxx. Solve. 
R. Potassii Sulphureti, 
Sodae Ilyposulphitis, aa ,$ij. 
Aquae Pluviae (Caloris gradu, 86° F.), C. xxx. Solve. 
Either of these baths may be used in the treatment of 
chronic scaly diseases of the skin, but their efficacy is much 
inferior to that of the natural sulphurous mineral waters. 
MERCURIAL BATHS. 
R. Corrosivi Sublimati, Sij. 
Glycerinae, fl 3ij. 
Aquae Pluviae (Caloris gradu, 96° F.), C. xxx. Solve. 
R. Iodidi Ilydrargyri rubri, . - 5j* 
Sodii Chloridi, 3ij. 
Aquae (Caloris gradu, 96° F.), . . . C. xxx. Solve. 
Mercurial baths are applicable for the treatment of ob- 
stinate syphilitic cutaneous diseases. They have also been 
used in very chronic scaly eruptions. 
Cataplasms are employed chiefly to remove hardened 
incrustations, for which purpose those prepared with linseed 
meal and smeared over with fresh lard or olive oil are best 314: 
THERAPEUTICS. 
adapted. But they are also very serviceable in allaying 
local inflammation or irritation : when used with this inten- 
tion they should consist of white bread steeped well in hot 
water, then squeezed dry, and moistened with some cooling 
wash, as recommended before for the treatment of eczema 
and of herpes. 
Caustics are used principally with the intention of de- 
stroying the affected integuments and arresting the morbid 
process in lupus, and their use in it has been spoken of in 
the description of the treatment of that disease. But many 
practitioners employ them also in the chronic stages of 
several cutaneous eruptions, with the view of exciting a new 
action in those portions of the skin on which they may be 
seated: caustics have been thus used, especially in the treat- 
ment of the eruptive diseases of the scalp and in squamous 
affections ; my experience of their effects, however, is not in 
accordance with the opinion of those who report favorably 
of their application. Besides nitrate of silver—which is 
the favorite caustic in skin diseases—chloride of zinc and 
caustic potash, some practitioners use a strong solution of 
iodine, which may be prepared as follows:— 
R. Iodinii, 3SS* 
Aquas destillatae, 3V* 
Iodidl Potassii, quantum sufficit ut fiat solutio. 
The following formula for a compound caustic solution is 
contained in the Pharmacopoeia of the London Hospital for 
Diseases of the Skin:— 
R. Zinci Chloridi, 3iv- 
Antimonii Chloridi, 3’j* 
Pulveris Amyli, 3j* 
Glycerinae, quantum sufficit. Misce. 
Whether caustics be resorted to or not in the treatment 
of diseases of the skin, they should never be used to the ex- 
clusion of other remedial measures. 
Lotions, were it not for the difficulty of applying them 
effectually in many cases, and on certain regions of the body, 
constitute the best form for using topical medication in the THERAPEUTICS. 
315 
treatment of a great number of cutaneous eruptions. Their 
special application has been described when treating of the 
individual diseases in which they are to be used, and several 
formulae for their prescription have been given. They are 
most readily applied by means of bandages kept constantly 
wet with them; but as this method is applicable for the 
extremities only, when the eruption is situated on any other 
portion of the integument, they may be applied on a double 
fold of old linen or lint, covered with a thin sheet of gutta 
percha, which is preferable for this purpose to oil-silk, as it 
does not keep the surface so hot, in consequence of its per- 
mitting a certain degree of evaporation. In the cases of 
spirituous or other cooling lotions, neither covering is at all 
admissible, and then the linen or lint must be moistened 
with the wash as often as it becomes dry. The addition of 
glycerine to lotions is of especial service, as in consequence 
of its non-evaporating properties, it keeps the part to which 
they are applied in a constant state of moisture; this is 
peculiarly useful as respects alkaline lotions, which tend to 
render the surface harsh and dry, an evil that in many 
cases would counterbalance the good effects that might 
result from their employment. Independently of their use 
with the intention of producing a direct medical action, 
lotions and washes are also employed beneficially to cleanse 
the diseased surface, previously to the renewed application 
of ointments, and for this purpose they are applied by 
means of a sponge; or should the crusts or scales that form 
be hard and firmly adherent, a roll of lint wet with the 
wash may be brushed over the part. When the ordinary 
alkaline or lead lotions which are used for these purposes 
are found too irritating or astringent, they will be advan- 
tageously diluted by adding to them an equal part of new 
milk. In addition to the formulae for lotions which are 
contained in the several preceding chapters, the following 
may also be employed for the purposes indicated:— 
R. Liquoris Ammoniae fl sj. 
Glycerinae fl 3vj* 
Spiritus Lavandulae fl 3ij* 
Aquae destillatae. fl Misce. 
STIMULATING ALKALINE LOTIONS. 316 
THERAPEUTICS. 
R. Liquoris Ammoniae Carbonatis . . 11 .?x. 
Glycerinas . . ' 11 3ij. Misce. 
R. Sodae Carbonatis gr. xx. 
Spiritus Rosmarini fl 3j. 
Aquae Rosae 11 3vij. Misce. 
These lotions are adapted for all eruptive diseases in 
which the external application of alkalies is indicated; 
when their chronic stage is attended with atony of the 
cutaneous surface. 
SEDATIVE ALKALINE LOTIONS. 
R. Sodae Sub-boratis 3\j- 
Aquae Florum Sambuci ... 11 .?xj. 
Aquae Lauro-Cerasi .... 11 5j. Misce. 
R. Sodae Bicarbonatis gr. xxx. 
Aquae Florum Aurantii ... 11 ,?xj. 
Succi Conii 11 §j. Misce. 
Chiefly useful in eruptive diseases of a dry nature which 
are attended with much itching. 
GLYCERINE WASH. 
R. Glycerinae fl 3ij. 
Misturae Amygdalae 11 3vj. 
Aquae Rosae fl viij. Misce. 
ASTRINGENT LOTIONS. 
R. Tincturae Acetatis Zinci . . . . fl %\x. 
Aquae Rosae 11 Iviiss. Misce. 
R. Acidi Tannici gr. xl. 
Aceti Gallici 11 §ss. 
Aquae destillatae 11 sviiss. Misce. 
R. Creasoti m. viij. 
Tincturae Krameriae fl 3>j* 
Acidi Ilydrocyanici m. viij. 
Aquae destillatae 11 §iv. Misce. THERAPEUTICS. 
317 
In using this lotion, the bottle in which it is contained 
should be well shaken before it is applied to the surface. 
SULPHUROUS LOTION, 
R. Sodae Ilypo-Sulphitis, 3ss. 
Potassii Sulphureti, 5j- 
Aquae destillatae, fl gxiss. 
Aquae Lauro-Cerasi, fl 3ss. Misce. 
STIMULANT WASH. 
R. Tincturae Nucis Vomicae, . . . . fl §ss. 
Essentiae Camphorae, 
Essentise Carui, aa fl 5>j- 
Aquae destillatae, fl 3vij. Misce. 
This last wash is sometimes a useful application in the 
chronic stages of lichen simplex—when the disease is very 
obstinate, of porrigo, and in inveterate psoriasis, provided 
there is no tendency to local inflammatory action. 
Ointments, under which appellation I include cerates and 
pomades, are more generally employed than any other form 
for the application of topical remedies in the treatment of 
diseases of the skin ; this is owing chiefly to the facility with 
which they can be used, and the readiness with which their 
strength may be increased or diminished;—both matters of 
great practical convenience and utility: yet they have the 
disadvantage of being easily rubbed off, of affording but 
little protection to the diseased surface, and of soiling the 
clothing with which they may come in contact. In some 
cutaneous eruptions the application of any greasy matters 
disagrees remarkably, but this appears to depend, in the 
majority of cases, rather on some constitutional cause in the 
individual affected, than in a speciality of the eruption which 
may be present; it also seems to be to a certain degree in- 
fluenced by the region of the skin on which the disease is 
situated : thus, I have seen them prove injurious more fre- 
quently in the eruptions of the scalp than in those of any 
other part of the body. With affections which are accom- 
panied by excessive serous discharge, as in most forms of 318 
THERAPEUTICS. 
eczema, they also, in my experience, generally disagree more 
than with any others. We can, however, seldom ascertain 
the existence of this peculiarity except by direct trial; but 
when it is once discovered to exist, the use of ointments 
should then be carefully avoided. Prepared axunge, in con- 
sequence of its greasy nature, does not, therefore, form a 
good basis for ointments to be used in the treatment of cu- 
taneous diseases, except in cases attended with much hyper- 
trophy of the integuments, as in ichthyosis, and in the chronic 
stages of some obstinate eruptions which are not accom- 
panied by copious discharges ; and the white wax ointment 
—which is employed for the preparation of nearly all the 
ointments contained in the last edition of the Dublin Phar- 
macopoeia—is often not well adapted for this purpose in con- 
sequence of its firmness and consistency. I have, there- 
fore, latterly used in almost every ease either cold cream or 
the cucumber pomade of the French pharmaceutists, as the 
basis of whatever ointment I prescribe ; the latter prepara- 
tion, as already remarked when speaking of the treatment 
of intertrigo, is in itself a useful local application, possess- 
ing calmative and healing properties. As formulas for either 
of them are contained in but very few English works on 
Materia Medica, it will be well, I think, to give them here:— 
ceratum galeni (Cold Cream)} 
R. Olei Amygdalae, . . . . fl 3xvj. 
Cerae Albae, Siv. 
Aquae Rosae, fl 3xij. 
“ Melt the wax in the oil with a gentle heat, in an earthen 
vessel; pour the mixture into a marble mortar, previously 
heated, and stir it constantly until it is nearly cold : then, 
by beating up the cerate briskly, incorporate with it the 
rose water, added in small quantities at a time.” 
Yellow wax may be substituted for the white wax in hospi- 
tal practice. 
1 French Codex. THERAPEUTICS. 
319 
ceratum cucumis (Cucumber Pomade).1 
R. Axungiae Sbij. 
Adipis Vituli (Calf’s Suet), Ibss. 
Liquefac simul, dein adde, 
Succi Cucumis Sativi, . fl Ixxiv. 
“Mix and bruise them well with the hand; set aside for 
twenty-four hours; then pour off the juice and replace it by 
a similar quantity of fresh juice, and repeat this process ten 
times, adding fresh juice each time. As soon as the pomade 
has acquired a well-marked odor of the cucumber, melt it in 
a water-bath, and add an ounce of finely powdered starch, 
which will combine with the water and precipitate it. Allow 
the entire to settle, and then pour off the pomade into small 
vessels. To render it more white and smooth, the French 
pharmaciens usually prepare it for use by melting again in 
a water-bath, and beating it for two hours or even longer 
with a wooden spatula, but when submitted to this treatment 
it does not keep fresh for a longer period than a month; 
while in the former case it will keep for a year, or even 
longer, in a cool place.” 
I shall now append some formulae, in addition to those 
contained in the preceding chapter, for ointments which are 
ordinarily employed in the treatment of diseases of the skin. 
And first, I may mention that an excellent calmative oint- 
ment, especially useful in the cutaneous eruptions of chil- 
dren which are attended with heat and itching, may be pre- 
pared by substituting cherry-laurel water for rose water in 
the above formula for cold cream. 
SEDATIVE OINTMENTS. 
R. Chloroformi, m. vj. 
Cerati Cucumis, Ej. Misce. 
R. Carbonatis Plumbi, 3ss. 
Cerati Galeni, §j. 
Chloroformi, m. iv. Misce. 
Henry and Guibonrt. 320 
THERAPEUTICS. 
R. Glycerinae, fl 3j* 
Unguenti Cerae albae, 5vij. 
Chloroformi, m. viij. 
Cyanidi Potassii, gr. iv. Misce. 
The great advantage derived from the employment of 
chloroform, alone or in combination with other sedatives, as 
an external application in the treatment of cutaneous dis- 
eases, has been frequently referred to in the foregoing pages. 
In the preparation of ointments it should always be the last 
ingredient added, in consequence of its volatility, and for 
the same reason the ointment should be dispensed in bottles 
and not in boxes or pots. 
R. Carbonatis Calcis praecipitati, . . . 3ij- 
Cerati Galeni, 3ij. 
Extracti Belladonnae, . . . . gr. xx. 
Glycerinae, fl 3ij* Misce. 
ASTRINGENT OINTMENTS, 
R. Oxydi Zinci, gr. xx. 
Cerati Galeni, §j. 
Tincturae Myrrhae, fl 3ss. Misce. 
R. Creasoti, ra. x. 
Adipis praeparati, 3ij. 
Pulveris Opii, gr. viij. Misce. 
R. Carbonatis Plumbi, gr. xij. 
Acidi Tannici, * . . gr. viij. 
Cerati Galeni, sj. Misce. 
R. Camphorse rasse et redact®, . . gr. viij. 
Tincturae Conii (Ed. Ph.), . . . fl 3ij- 
Unguenti Cerae albae, 3j. Misce. 
CAMPHOR OINTMENT 
R. Fructus Conii, in pulvere subtilissimo 3ss. 
Unguenti Sambuci, fij. 
Glycerine, fl 3j- Misce. 
HEMLOCK OINTMENT, THERAPEUTICS. 
321 
A hemlock ointment thus prepared I have found very use- 
ful in allaying the painful sensations which attend on some 
forms of cutaneous eruptions. 
Powders are used externally, chiefly in cutaneous dis- 
eases attended with copious serous discharge, as in eczema, 
and in those accompanied by marked local inflammatory 
action, as in erysipelas. They are applied to the surface 
by being shaken from a small bag made of fine muslin, and 
should be dusted over it pretty thickly. Whenever powders 
of different specific gravities are employed in combination 
for this purpose, they should be intimately mixed, and well 
shaken up each time before they are applied. Forms for 
different compound dusting powders have been given in the 
preceding chapters : the following will be found useful when 
an active astringent is indicated, as in the superficial ulcer- 
ations which result in some cases of pemphigus and of ec- 
thyma :— 
R. Kramerire Pulveris, Iss. 
Carbonatis Calcis prmcipitati, . . . 5ij* 
Amyli, 5X* Misce. 
When dusting powders are employed, the affected parts 
should be cleansed every day or every second day, by the 
use of gelatine or size baths, or by sponging the surface 
with equal parts of a weak alkaline wash and new milk 
warmed. This is not requisite in the treatment of erysipe- 
las or of erythema, in which diseases their efficacy, as has 
been before remarked, is partly due to their effect in exclud- 
ing the air. 
Soaps.—The use of ordinary soaps, as detergents, is seldom 
admissible in cutaneous diseases in consequence of their 
irritant properties on the skin when it is at all inflamed, 
and they should, therefore, never be employed except in 
the chronic stages of the non-inflammatory affections and 
in which there is no breach of the surface, and even then 
their effects must be carefully watched. In eruptions situ- 
ated on the scalp, or on other regions of the body which are 
ordinarily covered with hair, I have almost invariably seen 
them productive of injury, and, moreover, in such cases the 322 
THERAPEUTICS. 
incrustations and scales which form are more easily and 
more effectually removed by the application of weak alka- 
line washes as already recommended. The employment of 
medicated soaps in the treatment of eruptive diseases of the 
skin was at one time much resorted to, particularly on the 
Continent, and latterly their use has been revived by Sir 
Henry Marsh, who speaks in very high terms of their effi- 
cacy, but I must confess that, in the few cases in which I 
tried them, they did not produce any good result; nor is it 
likely that a soap should prove a good form for the appli- 
cation of remedies in the topical medication of cutaneous 
affections; for whatever substance constitutes the active in- 
gredient of the soap is left but a short time in contact with 
the skin, being almost immediately washed off ; and it wTould 
be very difficult to regulate its strength, as this must vary 
with the amount of water used each time in the application 
of the remedy. Sir Henry Marsh has recommended four 
different forms of soaps, which contain respectively sulphur, 
white precipitate, red precipitate, and corrosive sublimate, 
the first two in the proportion of a drachm, the third of 
half-a-drachm, and the fourth of ten grains to the ounce. 
The formula for this preparation, which originated with 
Dr. W. D. Moore, of this city, consists in beating up in 
a marble mortar, in the above proportions, white Windsor 
soap and the active ingredient, with half a fluid drachm of 
rectified spirit, a few drops of oil of roses being added as a 
perfume. 
Those remedies which are administered internally in the 
treatment of eruptions of the skin, with the view of acting 
generally on the system, require but little notice here, as 
they have been so fully described and several formulae 
given for their prescription, in the preceding chapters when 
treating of the individual diseases. The chief point to be 
kept in view in the constitutional treatment of cutaneous 
eruptions, one which has been before referred to, is, that 
they require, in most cases, a prolonged administration of 
the remedy which may be employed, and that, consequently, 
it should be given at first in rather small doses, and its 
strength increased afterwards very gradually and slowly. 
This is especially evident with respect to those powerful THERAPEUTICS. 
323 
alteratives, arsenic and iodine, which are such valuable 
agents in these affections, yet which often produce injurious 
consequences hy exciting local irritation, and a tendency 
to local inflammatory action from being given at first in too 
large doses ; the same holds true of cod-liver oil and of 
many other medicines which are of daily use in the the- 
rapeutics of diseases of the skin. During the employment 
of any of these remedies, their administration should be 
occasionally omitted for a day or two, whether they cause 
constitutional manifestations of their effects or not, and the 
bowels freely acted on by purgatives, those of a saline na- 
ture being preferred if the patient’s strength admit of their 
use. 
The following formulae may, in addition to those already 
given in the preceding chapters, serve to aid the practitioner 
in prescribing the medicines which are ordinarily used in the 
treatment of this class of affections:— 
DIAPHORETIC PILLS. 
R. Antimonii Oxydi, gr. xc. 
Morphise Muriatis, gr. iss. 
Confectionis Posse, quantum sufiicit ut fiant pilulse xxiv. 
“ Two to be taken every sixth hour.” 
R. Antimonii Sulphureti prsecipitati, 
Pulveris Ipecacuanhse compositi, . aa 5.j* 
Guaiaci Iiesinse, 3ij* 
Theriacse, quantum sufiicit ut fiant pilulse sexaginta. 
“ One to be taken every sixth hour.” 
ALKALINE MIXTURE 
R. Liquoris Potassse, fl Sss. 
Decocti Dulcamarae, .... . fl 3xj. 
Tincturse Chirettse, fl 3ss. Misce. 
“ Two table-spoonfuls to be taken three times a day.” 324 
THERAPEUTICS. 
R. Solutionis Alkalinae (Brandish), . . . . fl 3j* 
Potassae Sulpkatis cum Sulphure, (Ed. Ph.) 3iss. 
Aquae destillatae fl lij. 
Tincturae Aurantii, fl 3j- 
Misce. Fiat haustus. 
ALKALINE CATHARTIC DRAUGHT. 
“ To be taken in tlie morning before breakfast.” 
DIAPHORETIC MIXTURES. 
R. Tincturm Guaiaci Ammoniatoe, . 11 3y- 
Mucilaginis Gummi Tragacanthae, 11 3vj* 
Misturse Amygdalae, . . . . fl siij. Misce. 
“ Two table-spoonfuls to be taken every sixth hour.” 
R. Sarsaparillae Radicis incisae, . . . siss. 
Aquae destillatae ferventis, . . . . 0 j. 
per horas duodecim in vase clauso macera, subinde agitans, 
dein cola, et 
R. Ilujus infusi, . . . . fl 3xij. 
Infusi Sassafras, 
Decocti mezeri, . . aa fl 
Syrupi Hemidesmi, . . fl sj. Misee. 
“ A wine-glassful to be taken three or four times a day.” 
ALTERATIVE MIXTURES 
R. Ilydrargyri Bromidi, . . . gr. ss. 
Decocti Dulcamarae, . . . fl Sviij. Misce. 
“ Two table-spoonfuls to be taken three times a day.” 
This preparation may be administered in obstinate cases 
of secondary syphilitic eruptions; in its action it is nearly 
allied to the red iodide of mercury. THERAPEUTICS. 
825 
R. Hydrargyri Iodidi Rubri, . . . gr. v. 
Spiritus Yini rectificati, . . . fl 3j. 
tere simul dein adde, 
Aquae destillatae, fl giss. 
Iodidi Potassii, 5\j» 
Syrupi Aurantii, fl §ss. Misce. 
“ Twenty drops to be taken three times a day in a wine- 
glassful of infusion of sassafras.” 
This is a preferable form to that of pill for the adminis- 
tration of the red iodide of mercury in venereal eruptions, 
R. Ferri Bromidi, 5j* 
Liquoris Arsenicalis, .... m. lx. 
Syrupi Florum Aurantii, ... 11 gss. 
Aquae Florum Aurantii, . . . fl 3iss. Misce. 
“A tea-spoonful to be taken three times a day in a wine- 
glassful of decoction of fresh elm-bark.” 
A useful form for the administration of arsenic in chronic 
cutaneous eruptions, attended with enema or much debility. 
Before concluding, a few words are requisite as to the 
hygienic measures best adapted for cutaneous diseases. As 
a general rule, the diet must he, of course, regulated accord- 
ing to the individual requirements of each case, but as these 
affections are usually evidences of constitutional debility, 
though so frequently attended with tendency to local inflam- 
matory or irritative action, it should be nutritious but not 
stimulating. Restriction to an almost purely milk and fari- 
naceous diet is attended with the best results in the majority 
of instances, and should be almost invariably enforced with 
infants and children. Change of air to a dry, elevated posi- 
tion, is often of great service, but extremes of cold and heat 
should be avoided as much as possible. For the latter 
reason, the surface of the body should be kept as far as can 
be of an uniform temperature by attention to the clothing 
worn, which, however, should never be such as to check the 
insensible perspiration, or tend to condense it on the integu- 326 
THERAPEUTICS. 
ments. That worn next the skin should be soft and unirritat- 
ing, and therefore woollen should be avoided, soft calico or 
silk being preferred for under-clothing. In referring to 
change of air, I wish to record it as the result of my expe- 
rience, that a residence at the sea-shore usually proves inju- 
rious in cutaneous eruptions, the fine saline particles which 
float about in the atmosphere appearing to aggravate the 
disease by exciting local irritation: the climate of those dis- 
tricts which are situated a short distance inland is, however, 
well adapted for persons afflicted with them. 
Great objections are often raised to the cure of cutaneous 
eruptions, particularly those which are attended with a 
copious secretion, more especially if they have been of long 
existence, for fear of their sudden removal or the stoppage 
of the discharge with which they may be attended causing 
some grave internal disease; but I have never seen any ill 
consequences result when they were removed by constitu- 
tional treatment, not even in the case of infants or children 
who may be teething ; on the contrary, I have invariably 
witnessed the general health to be much improved in all 
respects thereby; but the sudden cure by the employment 
of topical remedies only, such as caustics or powerful 
astringents or stimulants, is certainly not advisable unless 
the eruption is of small extent and has been of short dura- 
tion. INDEX. 
Acarus folliculorum, 119. 
scabiei, 107. 
Achorion Schonleinii, 268. 
Achroma congenitale, 238. 
■vitiligo, 238. 
Acne, 117. 
indurata, 121. 
molluscoides, 209. 
punctata, 119. 
rosacea, 120. 
sebacea, 118, 213. 
simplex, 118. 
syphilitic, 288. 
varioliformis, 209. 
Acrodynia, 34. 
Albinoes, 237. 
Albinoismus, 237. 
Alibert’s classification, 18. 
Alkaline baths, 312. 
cathartic draught, 324. 
lotion, 56, 61. 
sedative, 316. 
stimulating, 315. 
mixtures, 323. 
Alopecia, 305. 
Alterative mixtures, 324. 
Appendages of the skin, diseases of, 
304. 
Artificial classifications, 16. 
Arsenic, ioduretted solution of the 
iodide of potassium and, 185. 
Asiatic pills, 186. 
Astringent lotions, 316. 
ointments, 320. 
Author’s classification, 24. 
Baker’s itch, 153. 
Baldness, 305. 
Bandages, 310. 
Barbadoes leg, 218. 
Baths, 311. 
alkaline, 312. 
gelatine, 312. 
iodine, 312. 
mercurial, 313. 
sulphur, 313. 
Bennett’s classification, 22. 
Bleb, 17, 63. 
Brandy-face, 120. 
Bulla, 17. 
Bullae, 63. 
Burnt holes, 97. 
Callositates, 223. 
Camphor ointment, 320. 
Cancrodes, 28, 246. 
Cancrolde, 261. 
Canities, 304. 
Cantharides, tincture of, in psori- 
asis, 188. 
Carbonate of ammonia in psoriasis, 
187. 
Carbuncled face, 120. 
Cataplasms, 313. 
Caustic of chloride of zinc, 314. 
of iodine, 314. 
solution, compound, 314. 
Caustics, 314. 
Cazenave’s classification, 20. 
treatment of lupus, 260. 
Ceratum cucumis, 319. 
galeni, 318. 
Chelo'id tumor, 261. 
Chloasma, 192, 264. 
Chloride of zinc caustic, 314. 
Classification, 13. 
artificial systems of, 16. 
author’s, 24. 
Alibert’s, 16, 18. 
Bennett’s, 22. 828 
INDEX. 
Classification, 
Cazenave’s, 20. 
Willan’s, 17. 
Wilson’s, 19. 
natural systems of, 19. 
regional system of, 17, 21. 
Clavus, 222. 
Cold cream, 318. 
Collodion in skin diseases, 309. 
use of, in erysipelas, 47. 
Condylomata, 224. 
syphilitic, 294. 
Corns, 222. 
soft, 222. 
Corrosive sublimate soap, 322. 
Couperose, 120. 
Cream, cold, 318. 
eucumber, 319. 
Crusted tetter, 126. 
Cryptogamia of favus, 267. 
of sycosis, 275. 
Cucumber cream, 319. 
Dandruff, 193. 
Dermatophytae, 28, 264. 
Diaphoretic mixtures, 324. 
pills, 323. 
Donovan’s solution, 300. 
Draught, alkaline cathartic, 324. 
Dry scale, 169. 
tetter, 169. 
Ear, herpes of, 80. 
Eating hive, 97. 
tetter, 246. 
Ecchymoses, 226. 
Ecthyma, 139. 
acutum, 139. 
cachecticum, 141. 
chronicum, 140. 
infantile, 141. - 
luridum, 141. 
syphilitic, 290. 
Eczema, 63. 
capitis, 68. 
chronicum, 66. 
faciei, 67. 
impetiginodes, 66, 133. 
mercuriale, 70. 
rubrum, 65. 
simplex, 64. 
solare, 70. 
syphilitic, 286. 
umbilicale, 69. 
Elephantiasis, 217. 
Elephantiasis, 
Arabum, 218. 
Graecorum, 217. 
ligneales, 243. 
Ephelis, 241. 
Ephelis, hepatica, 242. 
lenticularis, 241. 
syphilitic, 296. 
violacea, 244. 
Epidemic of erythema, 34. 
of pemphigus, 97. 
Erratic erysipelas, 40. 
Erysipelas, 37. 
contagiousness of, 42. 
erratic, 40. 
gangrenous, 39. 
idiopathic, 38. 
metastatic, 40. 
phlegmonous, 39. 
symmetrical, 40. 
true, 38. 
traumatie, 40. 
treatment of, 44. 
Erythema, 31. 
circiunatum, 32. 
fugax, 32. 
intertrigo, 32. 
lmve, 32. 
marginatum, 32. 
nodosum, 33. 
papulatum, 33. 
simplex, 31. 
syphilitic, 284. 
tuberculatum, 33. 
Esthiomanic scrofula, 253. 
Esthiomanos ambulans, 248. 
serpiginosus, 248. 
Evanescent urticaria, 51. 
Exanthema, 17. 
hemorrhagica, 231. 
Exanthemata, 24, 30. 
syphilitic, 284. 
Face, acne of, 120. 
eczema of, 67. 
impetigo of, 130. 
Favus, 265. 
268. 
en cercles, 268. 
Fire, sacred, 81. 
St. Anthony’s, 37 
Fish-skin disease, 200. 
Flux, sebaceous, 212. 
Freckles, 241. INDEX. 
329 
Galen’s cerate, 318. 
Gelatine baths, 312. 
Glycerine wash, 316. 
Graves on gutta percha in skin 
diseases, 310. 
Gray hair, 304. 
Grocer’s itch, 70, 153. 
Gruby on mentagra, 276. 
Gum, 149. 
red, 149. 
white, 150. 
Gutta percha in skin diseases, 310. 
Gutta rosacea, 120. 
Hair, diseases of, 304. 
falling out of, 304. 
grayness of, 304. 
Hardi’s treatment for the itch, 114. 
Heat, prickly, 151. 
Helmerich’s itch ointment, 113. 
Hemlock ointment, 320. 
Hemorrhagise, 27, 226. 
Herpes, 78. 
auricularis, 80. 
capitis, 84. 
circinnatus, 83. 
iris, 86. 
labialis, 80. 
phlyctenodes, 78. 
prseputialis, 80. 
pudendalis, 81. 
squamosus, 84. 
tonsurans, 84. 
zoster, 81. 
Higginbottom’s treatment of erysi- 
pelas, 48. 
Huile de cade, 76. 
Humid tetter, 63. 
Hydrargyria, 70. 
Hypertrophise, 27, 199. 
syphilitic, 294. 
Ichthyosis, 169, 200. 
cornea, 201. 
hysterix, 201. 
papillary, 202. 
scutellata, 201. 
simplex, 201. 
spinosa, 201. 
squamosa, 201. 
Idiopathic erysipelas, 38. 
Ignis sacer, 81. 
Impetigo, 126. 
capitis, 131. 
Impetigo, 
erysipelatodes, 129. 
figurata, 128. 
granulata, 131. 
larvalis, 131. 
lupiformis, 133. 
pilaris, 132. 
purifluens, 132. 
r odens, 132. 
scabida, 130. 
sparsa, 130. 
sycosiformis, 132. 
syphilitic, 289. 
Impetiginous eczema, 72, 133. 
Inflammatio folliculorum, 213. 
Inflammatory blush, 31. 
Intertrigo, 32. 
Iodine baths, 312. 
caustic, 314. 
Ioduretted solution of the iodide of 
potassium and arsenic, 185. 
Itch, 106. 
baker’s, 153. 
grocer’s, 70, 153. 
insect, 107. 
washerwomen’s, 70, 153. 
Jacob’s ulcer, 252. 
Kelois, 261. 
Leper hospitals, 218. 
Lepra, 169, 175, 217. 
alphoides, 176. 
nigricans, 176. 
syphilitic, 292. 
vulgaris, 175. 
Leprosy, 217. 
Leucopathia, 238. 
Lichen, 146. 
agrius, 150. 
circumscriptus, 148. 
gyratus, 148. 
lividus, 147. 
pilaris, 148. 
simplex, 146. 
solitarius, 148. 
strophulus, 149. 
syphilitic, 291. 
tropicus, 151. 
Lips, herpes of, 80. 
Lotion, alkaline, 53, 61, 315. 
astringent, 316. 
glycerine, 316. 330 
INDEX. 
Lotion, 
stimulant, 317. 
sulphurous, 317. 
Lupoid impetigo, 132. 
Lupus, 246. 
devorans, 250. 
exedens, 247. 
non-exedens, 247. 
serpiginosus, 248. 
superficialis, 247. 
non-tuberculosus, 248. 
vorax, 251. 
Maclagan, Dr., on the urine in urti- 
caria, 54. 
Macula, 18. 
Maculae, 27, 237. 
syphilitic, 296. 
Mark, mother, 224. 
Marsh’s soaps, 322. 
Melasma, 192. 
Melitagra, 128. 
Mentagra, 275. 
contagiosum, 276. 
Mermaids, 203. 
Mercurial baths, 313. 
eczema, 70. 
Mixtures, alkaline, 323. 
alterative, 324. 
diaphoretic, 324. 
Molluscum, 208. 
acutum, 209. 
ehronicum, 210. 
contagiosum, 209. 
non-contagiosum, 209. 
pendulum, 210. 
Mother-mark, 224. 
Naevus, 224. 
araneus, 225. 
Nails, diseases of, 307. 
ingrowing of, 307. 
Natural systems of classification, 19. 
Nettle rash, 49. 
Nirles, 78. 
Nitrate of silver-stain, 244. 
Noli me tangere, 250. 
Ointment, camphor, 320. 
cucumber, 319. 
Helmerich’s, 113. 
hemlock, 320. 
scrophulai'ia, 101. 
stavesacre, 115. 
Ointment, 
■white hellebore, 115. 
Ointments, 317. 
astringent, 203. 
sedative, 319. 
Pachydermia, 219. 
Papula, 17. 
Papulse, 26, 145. 
syphilitic, 291. 
Papulous scall, 139. 
Pemphigus, 94. 
acutus, 95. 
chronicus, 97. 
foliaceus, 99. 
contagiosus, 100. 
gangraanosus, 97. 
infantilis, 96. 
simultaneus, 94. 
successivus, 94. 
syphilitic, 287. 
Petechise, 226. 
Phlegmonous erysipelas, 39, 
Phlyzacia, 26. 
Phthiriasis, 162. 
capitis, 162. 
corporis, 162. 
pubis, 162. 
Pills, Asiatic, 186. 
diaphoretic, 323. 
Pimples, 17, 26, 145. 
Pityriasis, 190. 
capitis, 193. 
diffusa, 191. 
labioram, 192. 
localis, 192. 
nigra, 192, 215. 
oris, 192. 
palmaris, 192. 
palpebrarum, 192. 
plantaris, 192. 
prseputialis, 192. 
pudendalis, 192. 
rubra, 190. 
versicolor, 190, 264. 
Plica Folonica, 305. 
Pomade, cucumber, 319. 
Helmerich’s, 113. 
turpentine, 240. 
Pompholyx, 94. 
benignus, 96. 
diutinus, 97. 
solitarius, 96. 
Porcupine men, 203. INDEX. 
331 
Porrigo, 264. 
decalvans, 305. 
favosa, 265. 
lupinosa, 268. 
Powders, 321. 
dusting, 321. 
Prepuce, herpes of, 81. 
Prickly heat, 151. 
Prurigo, 159. 
formicans, 160. 
mitis, 159. 
palmaris, 163. 
pedicularis, 162. 
podicis, 163. 
preeputialis, 163. 
pubis, 163. 
pudendi, 163. 
scroti, 163. 
senilis, 162. 
urethritis, 163. 
vulgaris, 160. 
Psoriasis, 169. 
aggregata, 172. 
annulata, 177. 
capitis, 174. 
centrifuga, 175. 
confluens, 172. 
diffusa, 172. 
guttata, 170. 
infantilis, 177. 
inveterata, 173. 
labialis, 174. 
lepraeformis, 175. 
orbicularis, 177. 
palmaris, 174. 
centrifuga, 175. 
syphilitic, 293. 
palpebrarum, 174. 
preputialis, 174. 
pudendalis, 174. 
scrotalis, 174. 
syphilitic, 292. 
unguium, 175. 
vulgaris, 172. 
Psydracia, 26. 
Pudendum, herpes of, 81. 
Purples, 226. 
Purpura, 226. 
cachectica, 231. 
contagiosa, 231. 
febrilis hemorrhagica, 230. 
simplex, 227. 
hemorrhagica, 229. 
senilis, 228. 
Purpura, 
simplex, 227. 
urtieaus, 228. 
Pustulse, 18, 116. 
syphilitic, 288. 
Pustules, 18, 26, 116. 
Rainbow ringworm, 86. 
Rash, 17. 
nettle, 49. 
rose, 57. 
tooth, 149. 
wildfire, 150. 
Red gum, 149. 
Red precipitate soap, 322. 
Regional classification, 17, 21. 
Rheumatism and urticaria, 53. 
Ringworm, 83. 
of the scalp, 84. 
rainbow, 86. 
Robin’s description of porrigo, 267. 
Rose rash, 57. 
Roseola, 57. 
sestiva, 58. 
annulata, 58. 
autumnalis, 58. 
cholerica, 60. 
febrilis, 60. 
idiopathica, 57. 
infantilis, 58. 
miliaria, 60. 
punctata, 59. 
symptomatica, 59. 
syphilitic, 285. 
Yaccina, 60. 
variolosa, 60. 
Rosy drop, 120. 
Rupia, 102. 
escharotica, 97, 103. 
prominens, 103. 
simplex, 103. 
syphilitic, 287. 
Sacred fire, 81. 
Sarcoptes hominis, 107. 
Scabies, 106. 
cachectica, 110. 
lymphatica, 110. 
papuliformis, 110. 
purulenta, 110. 
Scald head, 265 
Scale, 17, 168. 
dry, 169. 
Scall, 63. 332 
INDEX. 
Scall, 
head, 265. 
papulous, 139. 
Scalp, eczema of, 68. 
herpes of, 84. 
impetigo of, 131. 
psoriasis of, 174. 
ringworm of, 84. 
Scrophularia ointment, 101. 
Scrofula, esthiomanic, 253. 
Sebaceous flux, 212. 
Secondary eruptions, 281. 
Sedative alkaline lotions, 316. 
ointments, 319. 
Shell-fish, urticaria caused by, 53. 
Shingles, 81. 
Silver, nitrate of, stain from, 244, 
Skin, diseases of appendages of, 304. 
Soap of corrosive sublimate, 322. 
red precipitate, 322. 
sulphur, 322. 
white precipitate, 322. 
Soaps, 321. 
Marsh’s, 322. 
Soft corns, 222. 
Solution of iodide of potassium and 
arsenic, 185. 
Spedalskhed, 218. 
Squama, 17. 
Squamce, 26, 168. 
syphilitic, 292. 
St. Anthony’s fire, 37. 
Stains, 18. 
syphilitic, 296. 
Stavesacre ointment, 115. 
Stearrhoea, 212. 
flavescens, 213. 
nigricans, 214. 
simplex, 212. 
Steatozoon folliculorum, 119. 
Stimulant wash, 317. 
Stokes, Whitley, on pemphigus, 97. 
Strophulus, 146. 
albidus, 150. 
candidus, 150. 
confertus, 149. 
intertinctus, 149. 
volaticus, 150. 
Sudamina, 71. 
Sulphur baths, 313. 
soap, 322. 
Sulphurous lotion, 317. 
Sun burn, 241. 
rash, 70. 
Sycosis, 274. 
mentis, 275. 
Sypliilide squameuse corn6e, 293. 
Syphilides, 28, 281. 
Syphilitic acne, 288. 
condylomata, 294. 
ecthyma, 290. 
eczema, 286. 
ephelis, 296. 
eruptions, 281. 
erythema, 284. 
exanthemata, 284. 
herpes, 286. 
hypertrophise, 294. 
impetigo, 289. 
lepra, 292. 
lichen, 291. 
maculae, 296. 
papulae, 291. 
pemphigus, 287. 
psoriasis, 292. 
pustuloe, 288. 
roseola, 285. 
rupia, 287. 
squamae, 292. 
tubercles, 294. 
urticaria, 285. 
vesiculse, 286. 
Tetter, 78. 
crusted, 126. 
dry, 169. 
eating, 253. 
humid, 63. 
Therapeutics, 309. 
Tinea, 265. 
favosa, 265. 
Tooth-rash, 145. 
Topical medication, 309. 
Traumatic erysipelas, 40, 
Tropical lichen, 151. 
Trouts, 243. 
Tubercle, 17, 294. 
Tubercles, syphilitic, 294. 
Tubercula, 199. 
Tumor, cheloid, 261. 
Turpentine pomade, 240. 
Ulcer, Jacob’s, 252. 
Urticaria, 49. 
conferta, 51. 
evanida, 51. 
febrilis, 50. 
intermittens, 51. INDEX. 
333 
Urticaria, 
perstans, 51. 
subcntanea, 51. 
syphilitic, 285. 
tuberosa, 52. 
Velpeau’s treatment of erysipelas, 49 
Venereal eruptions, 281. 
Verrucae, 221. 
Vesicle, 17, 63. 
Vesiculse, 25, 63. 
syphilitic, 286. 
Vibices, 226. 
Vitiligo, 238. 
Yitiligoidea plana, 215. 
tuberosa, 215. 
Warts, 221. 
Washerwomen’s itch, 70, 158. 
Water-blebs, 94. 
White gum, 150. 
hellebore ointment, 114. 
precipitate soap, 322. 
Wild-fire rash, 150. 
Willan’s classification, 17. 
Wilson’s classification, 19. 
Wolf, the, 246.