NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland £l WR 140 dp IS VI f? e V'_— • ^ ...vr^r .,.* r-* _„.._, Lv a BOYLSTON PRIZE ESSAY, 1871. ^ ^ *» W w *S Diseases of the Skin; THE RECENT ADVANCES EST THEIR PATHOLOGY AND TREATMENT. BY B. JOY JEFFRIES, A. M., M. D. REPRINTED FROM THE AMERICAN JOURNAL OF SYPHILOGRAPHY AND DERMATOLOGY. BOSTON: ALEXANDER MOORE. 18 7 1. BOYLSTON PEIZE ESSAY. RECENT ADVANCES IN THE PATHOLOGY AND TREATMENT OF DISEASES OF THE SKIN. BY B. JOY JEFFRIES, A.M., M.D., FE1XOW OF THE MASSACHUSETTS MEDICAL SOCIETY I MEMBER OF THE AMERICAN OPHTHALMO- LOGICAL SOCIETY ; OPHTHALMIC SURGEON TO THE MASSACHUSETTS CHARITABLE EYE AND EAB INFIRMARY ; OPHTHALMIC SURGEON TO THE CARNEY HOSPITAL J LECTURER ON OPTICAL PHENOMENA AND THE EYE, AT HARVARD university; LATE LECTURER ON DISEASES OF THE SKTN AT BERKSHIRE MEDICAL COLLEGE. „2Ber Ijoiuftg mlt ben SDtitteln ttec&felt, rofrb fld)er ntc&t fo fd>nett jum 3tele gelangen ali Setter, fcer kai in bem betrejfenbett gatte Slngejeigte ntit ©ebulb unb 53e^arrli(^feit antoenbett laft."—Hebra. Translation : " He who is always changing his plan of treatment is sure not to attain his object so quickly as one who steadily and patiently applies whatever remedy seems best suited to the case." BOYXSTON MEDICAL PRIZE QUESTIONS. The Boylston Medical Committee, appointed by the President and Fellows of Harvard University, consists of the following Physicians:— John Jeffries, M.D. J. B. S. Jackson, M.D. D. H. Storer, M.D. Chas. Q. Putnam, M.D. MORRTLL "WYMAN, M.D. Henry J. Bigelow, M.D. Richard M. Hodges, M.D. Calvin Ellis, M.D. Samuel Cabot, M.D. At the Annual Meeting of the Committee, it was voted that the Prize of One Hundred and Fifty Dollars be awarded to B. Joy Jeffries, M.D., of Boston, Mass., for a dissertation on the subject, "Recent Advances in the Pathology and Treatment of Cutaneous Diseases." By an order adopted in 1826, the Secretary was directed to publish annually the follow- ing votes: 1st. That the Board do not consider themselves as approving the doctrines contained in any of the dissertations to which premiums may be adjudged. 2d. That, in case of publication of a successful dissertation, the author be considered as bound to print the above vtte in connection therewith. RICHARD M. HODGES, SeCy. AYIS. To avoid repeated and confusing references, all works referred to were added in a numbered fist at the end, so that in the text the first number denoted the book, and the rest the special date and year, et cetera. As these references have in the printing been omitted in the text, the author can only request his readers, should they desire, to write him for any special reference they need to know. This article being written anonymously, alUspecial personal experience of the writer, and reference to his published articles, had naturally to be omitted. It must be remembered that the subject is only brought down to January of this year. Diseases of the Skin; THE RECENT ADVANCES PATHOLOGY AND TREATMENT. INTRODUCTION. • That there have been advances made in dermatology, and that these are recent, seems admitted }?y their considera- tion being offered as a subject for a thesis. This thesis is, however, limited to the " recent advances in the pathology and treatment" of cutaneous affections. We may therefore omit all reference to the classification of diseases of the skin, , winch at present is not only a vexed and most unsatisfactory question, but one that every writer of even a twenty-page monograph seems to consider must occupy a large, and often the most important part of his special publication. The more extensive works, also, are liable to be thickened by the not unfrequently prolix views of the individual au- thor on this entirely unsettled topic of classification. We have sometimes thought it would be better for some thorough clinical observer and teacher to master sufficiently the details of dermatology, and draw up a classification that would meet the wants of the practitioner, and yet not so (7) 8 RECENT ADVANCES IN THE PATHOLOGY AND far out of the way as to embarrass the special teacher of der- matology in his work of education. Such a classification might lit in better with general medicine, and thus prevent derma- tology being pushed aside as so much of a specialty as to ren- der its neglect a matter of course, or of necessity. It seems to us the time has hardly arrived for a classification of cutaneous affections. They have as yet been studied too little, principally from the lack of educated observers, trained in noting and recording symptoms and the effects of fcfemedies, and who are truthful and unbiassed in their deductions. Moreover, till quite recently the pathological anatomist and histologist paid but little attention to the diseases and disturbed functions of the common integument of the body, perhaps because the clinical teachers did not bring them so prominently before him. Thus we hold that, in the present state of knowledge, and in the pres- ent lack of any very defined and fixed classification of diseases in general, to attempt to build one up for dermatology, that shall be at all lasting, seems, a simple waste of time. Pathology and histology will^eak off the boughs, or cut through the trunk of the most ingeniously contrived dermatological tree. We would not, by any means, be understood as depreciating the value of a truthful classification, if it could be got at, or worked out of our present knowledge. For ourselves, we do not quite recog- nize the necessity of any classification in our study and prac- tice. A teacher may, most usefully for tha student, devote hours to a thorough and practical description of the symptoms and treatment of the various phases of eczema, without once alluding to where it, as a whole, or its several appearances, be-* long in any one's classification. Some general order of bringing cutaneous diseases before his class is, of course, necessary for a teacher; but the less the student hears of the special order or classification, and the more of the particular disease, the more successful will be the treatment of his cases, and the better will he be enabled to classify for himself, whilst at the same time he has become trained in observation. Trained and truthful observation are particularly required in the student and prac- titioner of dermatology, who has to learn to believe his eyes against his ears, or, perhaps, make both yield to his experience. TREATMENT OF DISEASES OF THE SKIN. 9 The lack of the cultivation of these qualities even in men of talent, has seemed to us to explain the comparative worthless- ness of so much that has been recently published in derma- tology, quite outside of the desire or necessity of the particular author inducing or forcing him to write a treatise or mono- graph. Without, then, the long experience of trained and truthful observers, and the comparing their several results, and grouping llfteir work as a whole, by the highest talent, we shall not soon reach any satisfactory or well-based classification of the diseases and perverted functions of the skin. Let it be remem- bered, however, that the lack of such classification should not prevent special study, as it does not in way hinder it. Nat- urally enough, it is regarded as a reproach to dermatology, and, in a certain way, is merited, although its importance is thus exaggerated. These few remarks explain our willingness to comply with the strict limitation of the subject, and omit all further mention of classification. We would gladly do the same with nomenclature, equally uncalled for by the terms of the subject, were it not that no- menclature is, as it were, the language agreed upon to speak in between writer and reader; and if one set of names for cutaneous diseases is used at one time, and another at another, then, as often as they occur, they must be mutually translated, to the annoyance of both writer and reader. Some years ago, we re- member hearing a distinguished professor saying, ex cathedra, substantially, that ophthalmology was nomenclature. Yet, if we may trust to the positive results arrived at, we may conclude that this specialty has already got beyond such a state in spite of itself, so to speak. It is somewhat so at present with derma- tology, which is in a sort of nomenclature condition. Want of experience and trained methods of study are, unfortunately, only too often and too successfully covered up by the manufac- ture of names, or the odd and curious misuse of those longest established. Perhaps no more striking proof of the necessity of adhering to well-founded and long-used nomenclature can be adduced, than that we aye obliged, at this very point, to Refine what we mean throughout this paper by certain terms that have been sadly bandied about and abused in some of the more re- 10 RECENT ADVANCES IN THE PATHOLOGY AND cent treatises. Bor instance, by psoriasis we mean the scalv affection generally known by this name, and not a stage or phase of eczema, as Wilson uses the term. Again, by leprosy we mean elephantiasis Grcecorum, and not psoriasis, Wilson not- withstanding. Again, by the generic word herjpes we mean cir- cles or groups of papules, or vesicles, or both together. It does not designate a special disease, unless having attached to it a specific name. By the word pruritus we mean simply itching. By the word prurigo we mean a disease that we shall have something to say about in its place. There are, of course, many other instances of misuse and abuse of nomenclature, but those we have mentioned are among some of the worst that recent authors have indulged in, either from in- dividual idiosyncrasy, ignorance, or from a desire to appear pecu- liar, and thus attract attention. We desire here at the outset to say that we have the greatest respect for Prof. Erasmus Wilson, of London, both as a dermatologist of vast experience and as a man of independent thought and acute observation. For this reason we all the more regret his individual idiosyncrasy, in de- siring to multiply and alter nomenclature without due regard to other teachers—not to speak of the profession at large—and his irresistible impulse to change established modes of spelling, arising, as can be seen, from his ripe scholarship in the languages of the Greeks and Latins. But for his imitators, who have not his experience or trained observation, and who but follow his classical knowledge, we have as students of dermatology no sim- ilar respect, and we cannot, in any truthfulness or independence, regard their words and writings with the same consideration.' Let this, therefore, be our apology for any seeming harshness that, as we hold, a just indignation may induce us to indulo-e " in. Every day makes us realize more and more how much Wilson, as a high authority and teacher, has hurt the progress of dermatology by his individual idiosyncrasy, adhered to with national persistency. His'followers have, unfortunately, also sup- posed they were like him when they imitated him."' That to the'general profession, at least, dermatology is simply nomen- clature, is perhaps truer of it now than was the same remark in reference to ophthalmology some fifteen years ao-o. TREATMENT OF DISEASES OF THE SKIN. 11 For the present admitted importance of the specialty there have recently appeared in dermatology more publications than general practitioners and readers can well comprehend. A mass of literature has been heaped up in a specialty little studied, and but slowly and reluctantly recognized. We freely admit that it is the fault of the specialty itself and its adherents, that has driven off those-who would otherwise have gladly availed them- selves of its acknowledged success, to benefit their patients and save themselves from discomfort. There is not, for instance, any book in English which a student or a practitioner can study whilst he follows the clinique and the lectures at any hospital where these are to be found. Certainly, for the subject of cuta- neous diseases there have appeared a large number of treatises, monographs, and journal articles, a majority hi which are worse than Hebrew to any but professed specialists, and very generally of little or no benefit to* them. The more a practitioner endeavors to study almost any of these publications, the more he becomes lost, mystified, and the sooner disgusted, unfortu- nately not with the author, but with dermatology. The secret of all this matter in print, and the constant reports of cases, etc.— in other words, the recent great increase in dermatological liter- ature, is well understood by those who have followed the spe- cialty, but, we think, perhaps not by the profession at large. Now, a knowledge of this so directly concerns the appreciation of the advance, or otherwise of the pathology and treatment of cutaneous diseases, that we offer no apology fo»making known and dilating upon it here. .For the past twenty or five-aud- twenty years tlere have been at work a number of shrewd, practical, intelligent, if not highly scientific, and truthful ob- servers, mostly clinical teachers having immense fields of study. Wilson represents this number in England; the St. Louis staff, in Paris; and above all, in Germany, Hebra at Vienna. The re- sult has been, that they have learned, by diligent observation and careful experiment, how to cure successfully many diseases of the skin utterly out of the reach of the therapeutics of the gen- eral practitioner as he learned his profession at almost any of the schools ten years ago. These observers, where they have been clinical teachers,have taught their hearers also how to ob- 12 RECENT AD VANCES IN THE PATHOLOG Y AND serve, how to diagnosticate, ancLhow to treat cutaneous affec- tions. Such knowledge, in anyitteld large enough, is of great practical value, and would soon bring its possessor reputation and practice, since almost all general practitioners have plenty of cases of cutaneous diseases which have baffled their best ef- forts, and which they gladly turn over to the specialist, after they have learned to trust his ability and experience. Thus it is that the students of the Paris and Vienna schools of derma- tology have spread a knowledge of the specialty, and by suc- cessful practice, both in England and America, attracted, par- ticularly during the last five years, no inconsiderable attention to cutaneous medicine. The schools also are gradually recog- nizing the need of some teaching in this department, and have here and there made appointments in accordance. These stu- dents of the continental schools have also spread their teachers' views by a few treatises, many monographs, and innumerable journal articles, nearly all of which, no matter how ingeniously concealed, are but nitrations of the master's knowledge, more or less perfect according as the writer's sieve was more or less retentive. In proportion as these publications truly and clearly represented the master's thoughts and experience, they have done good. In proportion, however, as these were not well put, and the writer's own ideas and inexperience brought more promi- nently forward, they have done harm. There has been plenty of motive, but little necessity, for a great deal of dermatological literature. Cutaneous medicine arid surgery cannot be learned from books alone. Dermatology is comparatively a simple spe- cialty, but, like a foreign language, it can only "be thoroughly mastered where it exists, i. e., where a competent teacher has the necessary material to teach from. When once thoroughly mastered, however, it is, like a foreign language, readily em- ployed, not easily forgotten, and always of the greatest practical value. There remains to be told, however, another part of the secret —why dermatology is, and will for a long time continue to the majority of medical men, to consist of only an unintelligible and unmeaning classification, and a more or less heathenish nomenclature, affording apparently quite sufficient excuse for TREATMENT OF DISEASES OF THE SKIN. 13 tipping the whole overboard. Success naturally calls forth imi- tation, and nothing is more natural than that an apparently suc- cessful specialty, we mean as regards reputation and practice, should induce many to take it up and attempt to follow it with- out any previous training in it, or perhaps even study of it. Such "imitators soon find that the medical man's only advertise- ments—namely, cured cases—do not increase, and something has to be done to acquaint the profession and laity of the author's intention to follow out a special practice. A book or mono- graph is soon patched up—the more unintelligible and the less clear and concise the better—and through it a reputation is soon gained; for cutaneous medicine is so little understood in the profession at large that a book means an author, and the idea pf an author means a knowledge of the subject. The more outre" the thoughts the more learned does the writer naturally seem, particularly if a little of other people's original ideas are ingeniously interwoven so as to appear striking and new. Of course, we recognize this as one of the curses of medicine at large, but we must confess that it does seem as if unfortunate dermatology had to bear more than its fair share of pretenders' efforts in all three of the principal languages. The profession at large, however honest and anxious to decide, are not in a position to discriminate between one man's work and another's, in this specialty. For the dermatologist there is no more thank- less task than that of going over and showing the mistakes and inexperience of the many authors who have rushed into print because they have found something new to themselves. Did all this stop here, we should not feel quite so indignant, or have thought it necessary to have so freely ventilated the secrets of the specialty; but there has been recently such a quiet monopolizing and adopting, to use no stronger expression, of the ideas of the masters in dermatology, that it is quite time for the profession to understand it, and thereby be able to.discrimi- nate. Another point must be alluded to—namely, that when the students of the European schools have settled down in Eng- land and America, and commenced to practise what they have learned, a little experience has soon shown that they, to their , own surprise, were not so very much more successful than their 14 RECENT AD VANCES IN THE PATHOLOGY AND older confreres in the neighborhood, to whom they had not accorded, perhaps, any scientific knowledge, at least of cutaneous medicine. Diseases of the skin are often so loathsome or so troublesome as to force the country practitioner, and still more so the city one, to hunt up or hit upon some successful remedy, in order to save himself and his patient. Thus, shrewd medical men will be found carrying out quite independently very much the same line of treatment. In this country, the graduate of the European school, in attempting to prescribe the same reme- dies in the same manner as he has seen done the other side of the water with such good results, finds that he has another peo- ple to treat, whose common integument as well as general sys- tem will by no means bear a similar amount or strength-of either external or internal remedies. Lack of like success dis- courages and disappoints him, giving rise to a doubt in the minds of his professional brethren at the same time as to the advance in treatment of the specialty. If he is shrewd he will let time and experience again teach him. Here, once for all, we desire to disclaim any apparent ignoring of the French school and the Paris teachers. No matter how much they may talk in their lectures and theorize in books, yet the success of the St. Louis staff will, after all, be found to de- pend on methods of treatment but little different from what is seen in Vienna or London. The great clinique of the General Hospital of Vienna, including the syphilitic aitf cutaneous wards, has, however, been a well of knowledge into which many pumps have been successfully inserted. One difference in the two schools is that, as in all other departments of medicine Germany teaches the student how and what to see, puttino-him in the best position to practise what is preached to him; whilst there is in France at present a national tendency to theorize brilliantly to the pupil without that steady plodding over him #■• so essential to solid progress. If one is thoroughly conversant with cutaneous medicine, and has seen as well as heard much the French works from the hands of the Paris dermatologists 1 will afford him interesting reading, because it is always pleasant to recognize old friends among strange people in a foreign 1 land, and as soon as one can get accustomed to and remember * • TREATMENT OF DISEASES OF THE SKIN. 15 their names, fellow-travellers at least serve pour passer le temps In all seriousness, however, the lack of practical dealing with the subject, and attempting to teach the reader what can be done for this or that affection, or what cannot be done if such is the case, is perhaps the true cause of French works on derma- tology being almost without exception most unsatisfactory, and perhaps not unreliable, but of no practical .value for reference. There seem, also, to be a number of invisible and intangible cords, one end attached to the word dartre and the other to the pens of all French dermatologists, so that these cannot move except under some reference to that potent spell. This is getting to be very much the case with the word or idea neurosis and the English writers and their imitators. It is but'fair to warn where pathology and treatment are not advancing. It has been anything but a pleasant task to thus expose the present weaknesses of a branch of medicine already become a decided specially. We think, however, it was called for, and we believe that nothing but so con^»ete a showing of the derma- tological hand could explain our willingness to comply with the 'strict letter of the subject as proposed, and omit what we are free to confess has its attracftons for discussion, namely, the present classification and nomenclature of skin diseases. We can also now recognize the judiciousness of the wording of the question, namely, recent advances in the pathology and treat- ment of diseases of the skin. To these now we gladly pass, taking them up in definite order, so as to avoid confusion, but following no special classification, and of course omitting those affections concerning which nothing is to be said. The exanthems, scarlet fever, measles, and small-pox, belong rather to general medicine, that is, these cases do not come under the dermatologist's care, except perhaps the latter in the great hospitals where a special department exists. This seg- regation, however, is often one of convenience, and not always adhered to strictly. The sequelae or consequences of scarlet fever and measles have been more carefully studied, but are discussed at length in the works on clinical medicine where they belong, and we need not dwell upon them here. One of the sequelae of small-pox and varioloid, namely, pitting of the • 16 RECENT AD VANCES IN THE PATHOLOGY AND integument, comes before the specialist, and dermatology has been called upon, not so much to explain its pathology as to de- vise a ready and perfect preventive of it. To enumerate the remedies proposed and tried, and their proposers' names, would be to pretty nearly fill this article with a list of the materia ' medica and the names of clinical and dermatological writers. The secret lies in the keeping constant moisture of some form in contact with the cutaneous surface, on the principle of th< steady poulticing a forming abscess. The want of success de pends upon the almost utter impossibility of having the whole integument, including the most important part, the face, per- fectly and always moist, during so long a time as is necessary with a patient suffering to the extent a victim of small-pox or varioloid does. The reputed success of this or that remedy, in the hands of one or another practitioner, is also readily ex- plainable by the following fact, quite lost sight of or perhaps unknown except by those dermatologists who kave had large small-pox wards in great epicrefaics, or been attached to hospitals for many years. Not more than a half of the patients who have had variola vera exhibit cicatrices afterwards, and in vario- * loid either none at all or but a "few are formed. This will be found to be true by any one having opportunity to see through some hundreds of cases. Now, any physician having had a few dozen cases, and used some one remedy to prevent pitting in them all, may have met apparently with marked success enough to induce him to publish the results of this special treatment. Another gentleman is naturally induced to try the method and with him it may seemingly utterly fail; the truth being that the remedy had no effect whatever, except that if it was something to moisten and soften the skin the patient was rendered more comfortable. When the pustules are deep-seat- ed in the cutis there is a positive loss of substance that no method of treatment can obviate, and the scar causes a " pit" It seems doubtful whether the pathology and treatment of the venereal diseases should form a part of this article. As they recently have been so well and so thoroughly discussed and as all that is new is early brought before the profession in medical literature, we presume they were not intend ed to be in- TREATMENT OF DISEASES OF THE SKIN. 17 eluded. At present their study is a separate specialty, and although they are brought together in special journals—much as the eye and ear frequently are—yet we propose to avail our- selves of the benefit of the doubt, and omit allusion to them here. Specific inflammation of the mucous membrane of the generative organs produces no cutaneous disease; the chancre sore, also, is not followed by eruptions; but constitutional syphilis imitates, on the common integument of the body, almost every other affection this organ is subject to, even the results of the presence of animal and vegetable parasites. Hence true syphilis has been brought in under dermatology, and hence the teacher of dermatology is obliged to go over and explain and exhibit the results of constitutional syphilis, in order, if for nothing else, to teach his hearers how to diagnosticate one from the other—perhaps the first thing the young practitioner will have to do when dependent on himself alone for guidance, .and on what he has learned for instruction. PSORIASIS. Good strong common sense, a desire for truth, and a wisli to succeed, have enabled Prof. Hebra, of Vienna, to give us in his book the very valuable results which his many years' ex- perience with this incurable affection afforded him. His pathol- ogy does not, however, carry him further than that of Roiitansky, Wedl, and Simon, namely, that the essential nature dPpsoriasis consists in an excessive growth of epidermis, or in a prolifera- tion of the epidermic cells, and their accumulation upon circum- scribed spots at which the papillae of the corium are hyper- aemic. Wertheim found, on examination of spots of psoriasis under the microscope, always enlargement of the papillae, and judges therefrom that the vessels are distended. Neumann obtained sections of psoriatic plaques from living patients, and found the epidermis cells increased, and also the rete Malpighii hyper- frophied. The papillae, especially of the older plaques, en- larged. The corium and papillae were filled with numerous proliferations. These cells appear principally in the upper layers of the corium and on the tops of the papillae, producing 18 RECENT AD VANCES IN THE PATHOLOG Y AND there a little swelling. A cross section through a papilla exhibits plainly the cell-growth filling the stroma and forming a ring, in the centre of which is seen the section of the vessel. From this we must deduce that psoriasis is an inflammatory process of the upper layer of the corium and the papillae, accompanied with greatly increased cell-growth, and with which the papillae are considerably enlarged. These enlargements cannot, however, be considered as characteristic appearances of psoriasis, since they occur in other chronic diseases, as prurigo and eczema. In this last a difference exists, in that the enlargement of the papillae appears only after longer continuance of the affection, whilst in psoriasis it is present from the first. The excessive formation of epidermis is, therefore, but a hyperplasia of the cells of the Malpighian layer, accompanied by an in- creased throwing off of the epidermic layer. It was a study of, and clinical experimentation with this dis- ease, which especially taught Hebra the value of external appli- cations, and in general their use in cutaneous affections. We cannot, of course, enter here into the details of the therapeutical use of soft soap, water-packing, the several forms of prepara- tions of tar, and various stimulating ointments. And this is all the less necessary since the journals of the last half-dozen years have been pretty full of the English, French, and German methodj^-of use. But how few practitioners have learned therebjjjp use external remedies with entire satisfaction to themselves, or the success that attends their application in the great cliniques where they have been most employed. The Vienna school of dermatology has been so practical and so successful, as to have attracted foreigners, both American and English. We are now just beginning to hear how treat- ment and remedies must be modified to be successful with two other quite different peoples. There is no better instance in point than the most practical and valuable contribution of a good observer and truthful recorder, Dr. Anderson, in his "Psoriasis and Lepra" monograph. Hebra, in his immense field, had seen psoriasis in the high and low, rich and poor clean and dirty, fat aird lean, and all its phases in all these • so that with his strong vein of common sense he, as usual, was • TREATMENT OF DISEASES CJ THE SKIN. 19 ft loath to accept this or that or anything as causes of psoriasis, to fill up his etiology with. Neumann follerws him in this respect, neither of them agreeing with Wilson's curious notion that psoriasis is somehow a worn-out syphilis. Squire and also Anderson think that patients are more apt to have psoriasis (which must be latent) appear when they are out of health or run down, like nursing women and over-worked business men, etc. Experience rather points this way, but these same people will also have their curse burst out when they are in the best of health. As psoriasis is not contagious, in the rarest cases ever fatal, pretty amenable to proper treatment, but is hereditary, what are we to say to patients who ask if they may marry ? Here pathology and treatment have really advanced, and we can reply: The wife will not have the disease from marriage, and the children may escape. Comfort and appearance can both be ably assisted by thorough and well-conducted treat- ment. If an equal cause was to stop marriage in general, there would be few divorces. Statistics show, taking England, France, and Germany together, that psoriasis occurs about one in fourteen among all affections of the skin ; the proportion of the sexes, men 143 . to women 156, from the combined results of different observers. It may occur as early as a*t six years, very exceptionally before this time. As we have said, it seems unnecessary to discuss or explain the methods of treatment found so efficacious in the last ten years, and now so generally described and followed. Moreover, all the remedies above mentioned have been pretty fully placed before the profession. Experience has shown that our people bear external and internal treatment to a much less extent than Europeans, as well exhibited, for instance, in the use of arsenic in psoriasis. It is rather an ungracious task to mention with anything like a slur the probably quite truthful belief of this qr that gentleman in reference to one or another remedy for psoriasis. Pathology teaches us that we have an affection that is incurable, *. e., its return cannot be prevented, but it also says that increased or heaped-up epidermis cells form the principal element. Treatment, therefore, points towards the 2& RECENT ADVANCES IN THE PATHOLOGY AND most rapid method of removal of these, and this seems best accomplished by the use of water, irritants, etc., externally, and arsenic internally. Hardy, during the inflammatory stage of psoriasis, prescribed emollient and alkaline baths, and laxative medicines. In the second stage he administers arsenic, and at the end of this period, when the disease has become crfronic and stationary, he has recourse further to ointments containing ^mercury, sulphur, or pitch. Oil of cade he uses, combined with glycerine and starch. Lately he has found benefit from phosphorus. Spender thinks psoriasis, like its congeners, arises from " tissue irritation," which may be aggravated or perpetuated by an un- healthy state of the blood. In anaemia he says arsenic will not act unless combined with some preparation of iron. Lipp has used hypodermic injections of arsenic for. psoriasis, sV to -J- of a grain being employed every second or third day with some advantages, namely, less of the drug, no derangement of the digestive organs, and shorter duration of treatment. No more permanent benefit, however, was obtained than by arsenic used in other ways. McNab has used one part carbolic acid to four of lard melted together, applied at night; and when the scales are removed oxicte of zinc ointment. This with a constitutional course. With him Liveling also concurs. * Passavant writes Pr to it, and with good results, 'since the microscope has shown ue the alterations which take place in the skin, explaining the varied appearances seen in the several phases and stages of this protean disease. Neumann produced artificial' eczema on a rabbit's ear, and watched the changes under a low power. There were rhythmic contractions of the vessels, and finally dila- tation, ending in permanent stasis. The ear that was at first transparent became opaque, swollen, and in a few hours numerous serous vesicles appeared. After forty-eight hours the animal was killed, and the tissue found infiltrated with serous fluid and numerous cell-proliferation. Biesiadecki gives a more extended account of the formation of papules and vesicles. The papillae over circumscribed spots become thickened and elongated by infiltration of cells and serous fluid. The connective tissue corpuscles of the papillaa are increased in number, large and succulent. Numerous spindle-shaped cells are seen in the mucous layer, or one-half still imbedded in the papillae. They force asunder the cells of this layer and reach up to the epidermis. In this mucous layer they often form a thick mesh, permeating it in various directions. Within this mesh are seen the somewhat swollen epithelial cells with their protoplasm less granular. These circumscribed infil- trations of the papillae and mucous layer form the eczematous papules. This cell-proliferation in the papillae increases, and the superficial cells of the mucous layer swell up and burst, whilst the epidermis rising above thus forms the vesicle. The spindle cells are then still more abundant, they act as juice- carrying canals, bringing the nourishing material to the mucous 30 RECENT ADVANCES IN THE PATHOLOGY AND layer. In acutely developed eczema they suddenly appear in great numbers, forming a thick network. With the abundance of these cells in the mucous layer there is a larger amount of the fluid saturating the papillae, so that it often forces up the epidermis in the form of a bulla. If the epidermis is removed the fluid trickles out (we'eping eczema). This explains the way the fluid exuded in the papillae reaches the surface through the mucous layer. Neumann says that Cohnhein and Recklinghausen's experi- ments answer the question where this proliferation comes from, i namely, the wandering cells out "of the blood-vessels. But Recklinghausen also showed that in a piece of cornea cut out and kept alive in oxygen and moisture, the cells continued in- creasing for twenty-four hours without blood-vessels; hence this proliferation must come from other tissue elements. Pagen- stecher, however, in preparations from the living, put while warm into weak chromic acid, found in great abundance spindle- shaped cells, which he identified with the " wandering cells," as Biesiadecki has described in the normal skin when an in- creased epithelial development had preceded (granulating, cica- trizing surfaces, psoriasis, chronic eczema, in the parts around an epithelial carcinoma). He supposes that the epithelium does not originate in a direct multiplication of the epithelial cells, but from these wandering cells, by then* entry into the region of the epithelial formations, becking in some measure infected by the latter, and so changed into epithelial cells. \ When epithelium was increasing he always found these wander- J ing cells in great abundance. The gradual change of these 1 cells into other tissue elements, as connective tissue cells he has ' observed with Hartnack's immersion lens. At this point Fox's remarks are directly in place, and we quote them briefly here. He says: " But this question occurs here—What relation exists '\ between the capillary congestion and the cell-proliferation? Is the vascular alteration the consequence of cell-activity—that is is it the response to a hyper-activity of the cell-elements which acts, if I may say so, as a vis d fronte ? Or is it the reverse? 4 —is the cell-proliferation the result of an increased supply of ' nutrient fluid sent to or retained in the part ? I am much inclined " i i TREATMENT OF DISEASES OF THE SKIN. 31 to think that in eczema both cells and vessels play an important and somewhat independent part in obedience to.a nerve paresis, Mere capillary excitement does not give rise to eczema. If that were the case we should have the erythema overstepping their present limits. Mere capillary changes are unaccompanied by special cell-changes; but these latter involve the former. A priori, one is led to believe that there is some cause at work which directly stimulates the cell-proliferation in eczema, and that the direction which this takes towards pus-formation on the one hand, or fibrillation on the other, depends upon the general nutritive tendencies of the person attacked. The acute cell- proliferation may imply and induce capillary excitement; but it seems that the two things are Coincident. • Now, what can account for this duplicate condition ? I think an alteration in the innervation of the part attacked. Looking to the general mode in which eczema is induced, to its history, and to the results which have recently been published by Heidenhaim, Pfltiger, Eckhard, and others, as to the influence of nerve-irrita- tion in the production of tissue changes, I am quite disposed to agree with Hebra that in eczema " it is faulty innervation which is the most important element in its production." I said that cell-changes of a peculiar character were seen in the rete mucosum ; and not many months since Podeopaew apparently demonstrated that nerves run up and form exceedingly minute plexuses between the rete mucosum and the upper laminate epithelium. Perhaps I ought to say that though Hebra believes that perverted innervation is the prime cause of eczema, he thinks it leads " to congestion and*other disturbances of the cir- culation,'* and does not refer to the influence of nerve-irrita^on in inducing cell-proliferation. The latter is, I think, a neces- sary point to be admitted in explaining eczema. According to the duration of eczema the anatomical changes are of course different. The microscope detects no differ- ence between this exuded gummy fluid and ordinary serum. The follicles, the papillae, and the upper layers of the corium are swollen in acute eczema, but this swelling disappears in the majority of the cases. If the eczema is chronic, then the skin becomes thickened, the lines and furrows deeper, the papillae 32 RECENT AD VANCES IN THE PATHOLOG Y AND enlarged so as to be visible to the naked eye. The older the eczema the larger the papules and the greater the cell-prolifera- tion in the corium, so that this sometimes reaches down into the deepest layers, even to the panniculus adiposus. Fox says: " It has been the rule to regard eczema as an inflam- matory disease, and the expression of a diathesis, styled by the French the "dartrous diathesis"—a convenient term, as Ander- son says, to cloak our ignorance of its nature. T^he word "debility" has been used to characterize the constitutional- condition upon which eczema is thought to depend. What is really meant is, that the local changes in eczema are due to an altered state of the nutritive fluids of the body, and primarily of the blood. Now, I recognize the fact that eczema may be modified by diathesis, but that it is not essentially the result of any special alteration of the blood-current. Speaking in broad terms we should say, moreover, that the cause of eczema is multiple; if is perverted innervation as a sine qua non; but plus—not as causes, but part causes or excitants in a variety of combinations and varying frequency of coexistence— general debility, morbid bloods-states, strumous diathesis, local irritation of the most diverse kinds, disease of important viscera, mental depression, and so on." To Hebra we certainly are indebted for the great improve- ment in the treatment of eczema obtained by external appli- cations. The detail of these we need not of course here enter into, since the journals have lately given it quite fully. We would simply recall the use of water, in baths, douches, and cataplasms; the employmenf of fats and oils to remove the dried products of eczema; the application of soft soafp and its combination with alcohol; the various preparations of tar; the ascertained value of vegetable or mineral powders strewn on to prevent irritation of opposed surfaces; bandaging over eczematous spots; and finally the use of gutta-percha cloth over the whole surface affected, as a limb or both extremities, etc. It seems hardly necessary to here gather together the various recommendations and prescriptions scattered through the special and general journals, as they meet every one's eye, and on TREATMENT OF DISEASES OF THE SKIN. 33 examination will generally be found to be a sort of sedimentary deposit from the clinical discoveries of the masters and teachers in dermatology. Over the rn;any pages in Wilson's Journal of Cutaneous Diseases, written by himself, Milton, and others} and over such articles as Stewart's, we can but join with Auspitz and Pfek in a suggestive shake of the head, and to this will be added a slight blush for dermatology over many articles and pages England and America have produced on the pathology and treatment of eczema. Cantani gives an interesting article on the pathology and treatment of eczema. In reference to the latter, he repu- diates from general treatment when indicated, arsenic and cathartics, highly praising iodide of potash and mineral waters, natural and artificial baths, and other treatment much like that above spoken of. IMPETIGO. The morbid appearances that were formerly designated by this name are now by the best authorities included under eczema; and even those who resist this, describe an eczema impetiginodes and an impetigo eczematodes. The only erup- tion apparently which could be called impetigo, is that of va- riously sized pustules which form during processes of inflam- mation resulting from injuries, burns, chemical or otherwise, cutaneous poisons, etc. Concerning these nothing specially new as to pathology or treatment has been very recently brought forward. A contagious impetigo has been described by Fox, who claims Allbutt and Anderson in his support. His reason for pressing this disease upon the notice of the profession, is the fact that when once recognized as a pustular eczema—an ordinary impetigo—and treated as such, it may and generally does last for a long time, not yielding to the remedies usually employed for eczema and its allies. He describes the disease as often epidemic, varying in severity both as regards general and local manifestations at different times. It is pyrexial, markedly uniform as to its eruption, which is at first coarsely vesicular, the vesicles or minute bullae being distinct and * 34 RECENT AD VANCES IN THE PATHOLOG Y AND separate, quickly enlarging into flattened bullae, which are replaced by flat yellow crusts. The mucous membranes are not unfrequently implicated, vesi^o-pustules developing upon them* especially those of the eye. The disease tends to run a definite course. It is contagious, the secretion furnished by the eruption being capable by inoculation of producing the disease in unaffected and healthy subjects. He found no difficulty in treatment, which consisted of a weak ammonio-chloride of mercury ointment applied to the ulceration beneath the scabs. It certainly alters the character of the secretion, which is no • longer inoculable, and disappears rapidly. Internal remedies avail but little. Occasionally salines are needed at the outset, and tonics in weakly and strumous subjects; but as a rule the ointment suffices for all purposes. We have never seen such a disease sui'generis. It corre- sponds to what in old days would have been called impetigo larvalis. We cannot, of course, deny its existence, but the inoculations reported are not strong enough proof for us. Pick and Reder obtained similar results from inoculation from simple scabies pustules. We hold with Auspitz that the exist- ence of impetigo contagiosa must be further determined be- fore accepted as proved. ECTHYMATOUS PUSTULES AND BULL.E Are found with many cutaneous troubles as results of inflam- mation, injury, or irritation. They may be due to internal or "i external causes. The word ecthyma does not convey to our mind the idea of a distinct or separate disease, but only the i phase or appearance of some affection in which the skin exhibits ecthymatous bullae or pustules, large or small. As to treatment, 1 a good step in advance has been made in the common-sense way of looking at pustules of whatever size, namely, that they are local abscesses, and the rules of surgery for these apply to the former. RUPIA. Large, thick, dirty, more or less conical crusts, not from burns and not psoriatic masses of epidemis, are always* due to syphilis This Hebra long ago insisted on, and like all truth, it is gradu* {TREATMENT OF DISEASES OF THE SKIN. oo ally fighting its way into belief. As, therefore, it belongs to syphilis, we for reasons above stated pass it by. Wilson lately agrees with Hebra: the other English and French authors still recognize a non-syphilitic rupia. PEMPHIGUS. • The several very interesting cutaneous diseases now included under this name have recently been more or less carefully ob- served by one and another. It would seem as if we must admit an ordinary form, pemphigus vulgaris, and quite a different one, pemphigus foliaceus. Neumann gives four species, whose names explain their differences : 1st, p. benignus in children, lasting six to eight weeks, and not returning; 2d, p. malignus or cachecticus, fatal, croupy exudation forming over the cutis When the bullae burst; 3d, p. gangranosus, described by Stokes as occurring among poor children of three years or under. Bullae appear behind the ears or on the hands and feet, gradually con- fluent with others close by, and a sphacelus forming, death occurs in ten or twelve days. Neumann, however, suggests the name purpura scorbutica as more in accord with tjie morbid process. 4th, p. pruriginosus, great itching with only small vesicles, de- stroyed by scratching. Vesicular formation also on the mucous membrane of mouth and fauces, and when bursting, leaving ex- coriated spots. Pemphigus bullae contain at first serum, then pus or sometimes blood. Their contents react neutral, later weakly alkaline. At first the cells of the rete Malpighii are lengthened out so that the bullae seem fan-like in structure (no{;, however, so marked as in burns, where Biesiaaecki found these cells quite thread-like); later the whole bulla is filled with fluid only. Chemical analy- sis of the bullae and of the urine does not explain the cause of the disease. And pathological anatomy lias but in one instance found amyloid degeneration of the liver and spleen. The result of many shrewd observers careful record shows that quinine checks the fever preceding an eruption, and also the eruption itself. Iron, arsenic, etc., are of no use. Water in baths, packing, etc., tar ointments and tar baths, emollient salves on the surface, and powdering it over, are what afford V 36 RECENT AD VANCES IN THE PATHOLOG Y AND relief if not cure. Hebra reports no good from internal reme- dies. With continued baths, i. e., the patient kept under water night and day, he obtained an apparent permanent cure, after respectively 100, 76, 47, and 26 days' immersion. We here omit, of course, all mention of syphilitic pemphigus, merely again saying that constitutional syphilis imitates on the' skin, pemphigus, as it does almost every other true cutaneous affection. The brief sketch we have above given of non-syphili- tic pemphigus, although so meagre, yet constitutes our present knowledge of the disease. Etiology, pathology, and even the anatomy of. the affection, are so little understood that any re- ported cases throwing the slightest light on it are worth bringing together. Hardy noticed pemphigus like bullae after copaiba ordered for gonorrhoea. The eruption lasted six weeks. Copaiba is eliminated by the perspiration, or rather the sweat is saturated with it, and this drug as we know affects the skin in a peculiar manner. There was in his case cutaneous anasarca. Malherbe reports two cases: one produced by external irri- tants and ending fatally, hardly perhaps to be called pemphigus; the second, a case of chronic pemphigus terminating fatally by intestinal perforation. The author thinks these ulcerations of the intestine are like those seen in extended burns of the cutaneous surface. i Luithlen reports a case of haemorrhagic pemphigus in a new-born infant, which he states was not syphilitic. But the mother had " scrofula of the bones and general cachexia." The child was born August 10th and died September 14th. Steiner gives a clinical study of pemph%us in children. He holds that the disease exists as an acute one in children. Chronic pemphigus as seen in them corresponded to Ilebra'sp. vulgaris; p.foliaceus he never*saw in children. He attempted inocula tion with the contents of pemphigus bullae, but obtained only such results as would be by inoculation with any pus. His ob- servations taught him to believe that a pemphio-us existed with children not of syphilitic origin, and he holds that without some other symptoms of syphilis a case of pemphigus in infants cannot be held to be of specific origin. He found the course TREATMENT OF DISEASES OF THE SKIN. 37 and result of pemphigus in children to depend on whether it was acute or chronic, and on the condition of the patient, Acute pemphigus ran its course in.two or three weeks. Chronic pem- phigus lasted months or years without affecting the patient otherwise. Twelve of his fifty-seven patients died, and of these twelve, seven had syphilitic pemphigus, four p. cachecticus, and one p. pyaemicus. Post-mortem showed only signs of hereditary lues or general atrophy, nothing definite to explain the pemphi- gus itself. As to treatment, Steiner can give us nothing dif- ferent from that above spoken of. Pribram describes very carefe.lly the clinical and post-mor- tem appearances of a case of febrile pemphigus in a phthisical young man of 17, where death from tuberculosis occurred dur- ing the eighth week. Kobner discusses the existence of an acute pemphigus, from which, however, we gather nothing new of pathology or treat- ment. Thomas reports a case of acute pemphigus in a child 1^ years old. There were several complications in the case, and he says the patient had been formerly under his care with a more chronic form of pemphigus. This case, therefore, like many others reported, fails to absolutely decide the question of an acute pemphigus, i. e., not chronic or returning. Klein reports a case of severe pemphigus, lasting during the better half of pregnancy and rapidly recovering after confine- ment. Such cases have also been observed by others. Steffen reports having seen an outbreak of acute pemphigus at Stettin, seven cases together in a children's hospital, and one in private practice. He therefore believes against Hebra that an acute pemphigus does exist. Six of the patients died. We think, however, what-was observed should rather have been called, " some epidemic disease with pemphigus-like bullae." Chatagnon reports a case of chronic gastralgia being followed by acute pemphigus. Erysipelatous patches were covered with large hullae. Desquamation occurred in large thick scales, par- ticularly on the palms and soles. Again we rather question the correctness of calling such an affection pemphigus. There are, of course, many cases of cutaneous appearances accompanying 38 RECENT ADVANCES IN TEE PATHOLOGY AND other diseases which are reported as pemphigus. Those we have spoken of are such as seem of most importance. MILIARIA AND SUDAMINA Are now pretty generally considered not to be cutaneous dis- eases, but symptoms of some definite general disorders. Except to be referred to, they are gradually being dropped from lists of diseases of the skin. PRURIGO. Considerable advance has be'bn made in the pathology and treatment of this formidable disease. But before we speak of these, it is absolutely necessary to explain that by prurigo we mean a distinct disease, and that the word pruritus does not convey the idea of a disease, but only expresses th&t there is itching. We have pruritus or itching in prurigo. These two words have recently been so carelessly and unscientifically mis- used, that attention must be called to it here, otherwise we may be misunderstood. " Fox in his clinical remarks is obliged to again warn against this mixing of these two terms, which from their sounding alike are constantly interchanged, whilst in reality one means a fortunately rare disease, and the other designates a common symptom. Teachers of dermatology on both sides of the water have made repeated protest against it. It would, of course, be out of place for us here to say more than that in accordance with the highest and best authorities, we mean in this article by prurigo a disease, and by pruritus sim- ply the sensation of itching. In no dermatological work we know of will there be found more good strong common sense than in the five-and-twenty pages Hebra devotes to prurigo in his book on cutaneous dis- eases, which a year or two of study and observation at his clinique will satisfactorily prove to any one. Pruritus senilis and pruritus or itching of this or that part of the body, either from hyperaesthesia of the presence of this or that animal* para- site, Hebra carefully separates from the distinct and fearful disease prurigo, that from Will an and Payer's time has been recognized, but under which also, by those observers and their TREATMENT OF DISEASES OF THE SKIN. 39 followers and imitators, has been classed the, so to speak, true pruritus cutaneus. Under the title of prurigo there have been many articles written recently, which, upon the' slightest glance, will at once be seen refer to pruritus cutaneus, due to some of the above-mentioned causes. Notice of these, there- fore, wc of course omit, at least for the present. True prurigo, as seen and described by Hebra, is a fearful and incurable disease, apparently extremely rare in this coun- try as well as in England, but by no means so in France, or especially in Germany. Hutchinson, Milton, Foxtail three English dermatologists, are uncertain whether they have ever seen Ilebra's true prurigo in England, and almost doubt its dis- tinct existence. Wilson has seen and understands it. #At from five to seven years of age the little patient will be- gin to show small subepidermal papules, rather recognizable ]}j the touch than the sight. They are always isolated, and con- stantly leave some regions unaffected. These itch intensely, and the necessary scratching removes the epidermis, showing a little fluid, or, if the papilla has been wounded, then a drop of blood, which dries to a black crust. From henceforw%rd the disease increases and the further changes due to never-ceasing scratching, are, pigmentation up to almost negro blackness, thickening, roughness, dryness, and furrowing of the common integument. There will naturally result pustules and excoria- tions, with enlargement of the glands, particularly the inguinal. Examining a patient with prurigo, we find the head free, the hair dull and dry, the face but rarely affected, but pale and un- healthy. Worse on the extremities, but never perceivable by sight or touch in the arm-pits, elbows, flexor side of wrists and palms, groins, hams, and soles. The disease at times simulates many others, especially eczema, scabies, lice, and it requires a practised eye and careful exclusion of one after another of these to diagnosticate the complaint. At its height the whole complex of symptoms is very striking and definite. Neumann describes these papules above spoken of as con- sisting of circumscribed cell-proliferations in the papillae, ac- companied by aft exudation, not extending to any elementary form, which elevates the epidermis. The rete and epidermis 21 40 RECENT AD VANCES IN THE PATHOLOG Y AND are more developed and pigmented. The pointed cells de- scribed by Schron and Schultze are abundantly developed. These last are seen in patients with excessive epidermis or epithelial growth. The papillae and cutis are enlarged and thickened with connective tissue; the outer root-sheath strongly developed, and the hair-follicle with club-like distention. Fur- ther study of the cutaneous nerves must decide whether an anatomical change in them may cause the disease. Derby, under Biesiadecki, studied the anatomy of several cases of prurigo, and reports as the result of his examination:. 1st. That there exists in prurigo an affection of the hair. From the outer root-sheath there is a prolongation composed of epithelial cells, which thrusts itself between the separated fibres of the arrector pili. 2d. The arrectorespilorum are largely developed, and their pulling on the hair causes it to stand more vertical, goose-skin, besides favoring the bulging out of the inner sheath of the hair-follicle and the outer root-sheath. 3d. Finally, a serous exudation takes place near the hair thus diseased or ab- normal; this permeates the tissue of the corium and papillae, exuding a clear or sanguineous fluid on puncturing the papule. Hence is explained why the prurigo papules do not appear on hairless spots, as the palm and sole, rarely also on the flexor surface of the extremities where the hairs are very few and scattered. As to the treatment of true prurigo, we can, of course, only learn from those under whose care it has come. The result in both the French and German schools has been to show that the disease is incurable, but temporarily relieved by treatment. Rayer long ago said that except in a few cases in which the constitution of the patient may need special attention, he would recommend external treatment exclusively. With this Hebra agrees, saying, "external remedies alone are of any use in prurigo." These remedies are, however, but few, being the same employed in psoriasis, scabies, chronic eczema lichen ruber, et cetera; namely, those which, so to speak, reduce the skin quickest—water, hot and cold, in all the various methods of applying it, soft soap, sulphur-ointments like Wilkenson's, Vleiningkx's sulphide of lime, baths of corrosive sublimate the TREATMENT OF DISEASES OF THE SKIN. 41 various fats or oils, as cod-liver oil, the tarry compounds, as oil of cade, ol. rusci, and lastly, carbolic acid. Xhe details of the use of any and all of these are, of course, not in place here, since we are but to indicate where and how progress has been made in pathology and treatment. URTICARIA. There has not been much advance made either in the pa- thology or treatment of this disagreeable complaint. It has been called a neurosis, but so have several other diseases, which does not advance us. Here and there cases have been reported where some definite cause could be seemingly assigned for its appear- ance different from those hitherto regarded as likely to excite it. Failu has published a well-written pamphlet on urticaria, being a prize essay on this disease, which he well calls " La plus singuliere des maladies cutanees." Nettleship reports a case in a little girl two years of age. The urticaria was first noticed when the infant was three months old, and it has con- tinued. Pigment blotches have resulted on the spots where it was most abundant, namely, the neck and trunk. The London Hospital Reports speak of two cases, one in a boy, the other in a man aet. 44, accompanying erysipelas of the face. Dumontpaltier reports a case of intermittent urticaria where the attacks returned each night for six weeks. Rheumatism and asthma prevailed in the family. The children suffered from intermittent diarrhoea, alternating with urticaria: Wilson reports cases associated with rheumatism, from ute- rine trouble and from mental shock. Gubler reports a case of urticaria coming on the third day of small-pox. It lasted three days, during which time the variolous eruption remained sta- tionary. Jiitte describes as urticaria hemorrhagica a case where itching, red wheals or blotches appeared, some one-half to one inch in diameter. The redness increasing in a few hours, subcutaneous hemorrhage occurred, and the exudation passed through various changes of color. Willan and Rayer have called this purpura urticata. Fouquet saw five cases of urticaria tuberosa, swellings the size of a walnut or hen's egg, of whitish color, appearing especially on the extremities of 42 RECENT AD VANCES IN THE PATHOLOG Y AND women, lasting a day, and disappearing with slight epidermal desquamation. Villan describes as urticaria evanida two distinct forms, one that appears spontaneously and rapidly vanishes, whilst the other is called out only by rubbing or energetic muscular ac- tion; this last form he never saw associated with the first. Writing with a blunt point a name or figure on a skin disposed to this affection, and corresponding raised sharply defined wheals appear. This muscular sensibility is more or less pres- ent in all people, but may arise to a positively morbid condi- tion, so that even washing with a sponge brings it out. The wheals are caused by contraction of the cutaneous muscles. Chloroform and ice prevent their formation and relieve them. Manteggazza speaks of a new alimentary nervous excitant called guar ana, something like chocolate. It comes from Bra- zil. In the human subject it seems to produce, in large dose, sometimes slight strangury and urticaria. ERYTHEMA. Much the same in reference to pathology and treatment must be said of this disease as of urticaria. It is nevertheless now better understood how the affection produces such different ap- pearances on the skin as concentric rings or segments of circles, that it may also appear as papules, that it comes where two surfaces rub together, and that it may cause very large tuber- cles or lumps, all of which quite different symptoms are due, perhaps, to the same unknown cause. The idea is gaining ground that the erythemata, for instance, erythema iris in cir- cles, is connected with, or may be regarded as, less developed herpes iris. Erythema in a peculiar form has been noticed in large numbers of cholera patients. Hutchinson saw a case of erythema annulare (herpes iris) in a boy aet. 5, where the attacks recurred in three successive years. A rather more doubtful case, i. e., whether it could be considered true erythema multiforme, was in a lad aet. 15 where the trouble repeatedly occurred for fifteen years after vaccina- tion, and where over some points vesications were developed. Bohn attempts to prove that erythema nodosum and pur- TREATMENT OF DISEASES OF THE SKIN. 43 pura rheumatica are caused by the same process. He holds that every nodule in erythema nodosum is due to a circum- scribed hemorrhagic inflammation, an inflammatory infarctus of the skin caused by an embolic process in the finer cu- taneous arteries. As he could find no disease of other organs (as heart or arteries) to account for this embolus, he refers it to embolic formation by blood and fibrine clots in the patient's blood. He goes on to show how purpura rheumatica is not to be connected with rheumatism, but much rather allied to ery- thema nodosum, dependent on this embolic process. He , also explains away by this theory the generally received views of some dermatologists in reference to the rheumatic character of purpura rheumatica and even of erythema nodosum. . Illicit, under the name of erythemapapulatum urosmicum, describes a peculiar eruption, appearing very often, if not con- stantly, in uraemic poisoning, and of prognostic value. Numerous papules show themselves, surrounded with more or less halo, or on an erythematous portion of the skin. They come all over the body, but especially at first on the palm and sole, fore-arms and face. They do not seem connected'with sebaceous or sweat- glands, as they are no more common where these latter exist in abundance. These red papules are sensibly elevated to the touch, last but a few days, and flatten down, the halos spreading wider and wider till they meet, and thus form a large erythe- matous patch. After about two weeks a slight desquamation occurs, 'these light red spots change to a darker red, violet, and finally blue-black. The injection disappeared on pressure ' of the finger; now it no longer does so, and we have petechias. Itching he noticed in but three of the fifteen cases. After death the-spots disappear, except the petechiae. Once he noticed vesi- cles in the erythematous spots. These appearances he saw in uraemic poisoning, in the last stages of Bright's disease. He regards it as an uraemic symptom, and connects it with the kid- ney degeneration in chronic parenchymatous nephritis. Of 224 cases under his care during seven years, 123 died, and among them this eruption showed itself 19 times, i.e., in 15 per cent. of the fatal cases. He recognizes and makes a careful distinc- tion between this and what Fuchs called cnesmus vulgaris. 44 RECENT AD VANCES IN THE PATHOLOG Y AND HERPES LABIALIS, OR BETTER, FACIALIS. This affection is now recognized as accompanying febrile dis- eases. The groups of vesicles will also be seen on the mucous surface of the mouth and pharynx. As to whether such her- petic eruptions in febrile diseases are of good or bad augury, authorities differ. They of course are not of special interest to the dermatologist. Similar sorts of herpetic eruptions occur in otherwise perfectly healthy persons on the forehead, lids, nose, and ear; and in young persons, at certain definite periods of the year, herpetic eruptions recur with febrile symptoms over the exten- sor surface of the elbow and knee-joints, and after a few days similar groups of vesicles show themselves on the cheeks or per- haps other parts of the body. These facts, if not new, are now at least settled by recent clinical observation. Not much light has been thrown on the pathology or treat- ment of this form of herpes. Nothing has been gained by call- ing every case of it by the name of a quite different disease, herpes zoster or zona. Wilson observed a case of bilateral her- pes liabalis accompanied with catarrh and slight stomatitis. The locality of the eruption would, if it depended on it, imply irri- tation of the dental branch of the inferior maxillary in the right side, and filaments of the infraorbital branch of the superior maxillary on the left side. He mentions a case where repeated attacks, every four to six weeks, of herpes, occurred in a lady aet. 28, on the nose, but the vesicles, so to speak, aborted, com- ing only so far forward as. to form a blotch". Another case was where a tender tooth in the upper jaw, second left bicuspid, after inflammation, seemed to be the cause of an herpetic erup- tion on the skin of the lower lip, close to the mucous border. Bertolle reports cases of herpes of the soft palate, in which, during perfect health, there was suddenly fever, severe head- ache, difficult swallowing, raised pulse, and hot skin. On the first to^econd day the pharynx and tonsils were very red and swollen, and the latter covered with miliary yellow spots • occa- sionally these were seen on the soft palate or gums. They never appeared on the posterior pharynx, and even in Motet's case no TREATMENT OF DISEASES OF THE SKIN. 45 vesicle was seen beyond the isthmus faucium, although in this the lips and cheeks were studded with herpetic eruption, and finally also the extremities. The vesicles are not confluent— leave a flat ulcer that quickly heals. When herpetic eruption follows on the commissure of the lips and nose, it indicates rapid termination of the trouble and quick recovery. Jn women it appears about the menstrual period, or when the menses are de- layed or suddenly checked. Gerhardt explains the origin of herpes facialis thus:—The small arteries which run in the bony canals next the fine tri- geminal twigs, become at the commencement of the febrile at- tack contracted, and during the hot stage again dilate, so as to press on the nerves and irritate them, hence a^vqsicular dermati- tis. He thinks h. facialis occurs between the chin, ear, and eye- brow. HERPES PROGENIALIS comes, as is now agreed, on all parts of the penis, and on the female external genitals. It is simply ridiculous to attribute it to venereal, or to contact with venereal sores or discharges. Many a perfectly chaste male or female will have repeated attacks of it for years. Whether, when the disposition is present, the irri- tation and excitement of coitus tends to call it forth more often, is an open question. It has nothing to do with any form of ve- nereal disease. When the crusts fall off, after the vesicles dry up, there is sometimes quite a little ulcer, which, when irritated by walking, etc., assumes the appearance of a chancre, and time alone can decide between them. Of course those who suffer repeatedly from herpes progenialis are more likely on contact to take chancre or syphilis, or both, because they have a num- ber of excoriated spots denuded of epidermis. Recurrent h. progenialis has been here and there noticed, and Doyon, in a recent monograph, proves he has seen it very often, and understands its periodicity, etc. With true French in- stinct, however, he attributes»its cause to a dartre constitution- ally, and a venereal sore locally. That it occurs and is more likely to be noticed in those with venereal, is true, but plenty of observations prove it has nothing to do with that disease. In 46 RECENT AD VANCES IN THE PATHOLOG Y AND the sulphurous and chloro-saline waters of Uriage, Doyon thinka will be found the best derivative, alterative, and tonic treat- ment needed; but a sojourn of many weeks is required for sev- eral successive years. He is medical inspector of these waters at Uriage. As to the, treatment of herpes progenialis we are but little advanced, except to know that nothing will prevent it; and all irritating substances applied to the surface after the vesicles break, serve to render them more like ulcers and hard chancres, to the annoyance of patient and physician. To bring herpes progenialis and cold sores under herpes zoster, or call it a neu- rosis, is no advance, but simply fends to confuse student and teacher. HERPES ZOSTER, OR ZONA, is a disease which has been known and suffered from for ages, but what at present concerns us is, that its pathology has re- cently been studied and its treatment attempted. It remains, however, still a " game we do not understand." New facts about it are, that it has been now seen on all the different re- gions of the skin from the head to the feet, on the inside of the nose, and on the tongue. It has been noticed to occur repeat- edly in the same individual. It not very infrequently appears on both sides of the body at the same time, and then perhaps not over corresponding nervous tracts. It affects one side of the body as often as the other. It is more common in April, May, October, and November. It may occur as early as at five, seven, or ten months; is not uncommon in children. It may be accompanied or followed by paralysis. It may leave lasting or permanent neuralgia, and that of an intense charac- ter. It may be followed by dangerous sloughing, and finally in the aged it may cause fatal prostration. When affecting the ophthalmic nerve it has naturally attracted the attention of ophthalmic surgeons who have especially studied it, and report that it may greatly injure or destroy the eyeball. The disease seems sometimes to be almost endemic. We have thought it best to give this little sketch with the references to establish the statements, rather than encumber ■ TREATMENT OF DISEASES OF THE SKIN. ' 47 ourselves" with quotations from the various authors it is culled from. A single*etiological point is Mr. Hutchinson's idea that zoster may at times be called forth by arsenic. We have made a pretty thorough study of what has been written in reference to the etiology and pathology of zoster, and our index holds all the authors' names and articles indi- cated, but it would be too long a list to introduce here. Such men as Barensprung, Bohn, Thomas, Vernon, Hutchinson, Bow- man, Emmert, Weidner, Johnen, Gerhardt, Hebra, Woakes, and many others, have dissected, studied, speculated, and theorfzed over this nosological riddle, and we have done the same with what they have reported, but fairly give it up. We have, how- ever, arrived at this conclusion, namely, that the same cuta- neous, morbid appearances may be called by irritation of the cutaneous distribution of a nerve or by irritation of its termi- nal, connection with the nervous centres. We agree with Mr. Hutchinson, that whoever may succeed in unravelling the mys- tery which at present surrounds zoster, must at the same time make a discovery in physiology. As to the anatomy of zoster, some light has been thrown on its apparent erratic appearance by Voigt's minute dissections of the terminal distribution of the cutaneous nerves. He has shown that tracts of skin that we thought zoster should not have invaded, are in reality supplied .by prolongations of the nerves we recognize as implicated. Biesiadecki found the papules and vesicles were formed in the same way as in eczema. When pustules form, the cell elements increase in the papillae and permeate the whole corium and a part of the subcutaneous cellular tissue. The papillary blood-vessels are enlarged and crowded with blood. From the papillae spindle-shaped cells push into the mucous layer, they subdivide, pushing apart the epithelial cells, as series of round cells. The epithelial cells are thus compressed and seen lying vertically towards the epidermic layer as slim threads.^ In the centre of the pustufe there is a considerable cell-proliferation, and collections of pus are found in the mucous layer in a net- - work composed of the compressed and altered epithelial cells of the middle and upper mucous layer. The epithelium of the 48 RECENT AD VANCES IN THE PATHOLOGY AND lower mucous layer takes part also. in the process by subdivi- sion, often mother-cells holding several nucle^ lying above the flattened and cell-infiltrated corium, but here and there reaching into the network. The network passing through the pustules consists of the epithelial cells pushed asunder and compressed, of the middle and upper mucous layers, and the cells of the sebaceous and sudoriparous follicles. Both take part in the for- mation of the pit or scar. Arourid and in the neurolemma there is evident cell-proliferation in herpes zoster, like the sim- ilar- proliferation in neuroma and carcinoma around the trunk. Every remedy found to relieve even a single case, of zoster is an advance in treatment, and should therefore be here recorded, since the physician's repertoire -and the patient's endurance is likely to be sorely tried. A physician suffered six weeks with severe neuralgia after zoster on the trunk, and reports finding relief from painting the parts with a solution of iodine and collodion, and taking the syrup of iodide of iron internally. This "acted magically." He continued with citrate of iron and quinine, and soft extract of opium and belladonna smeared on the parts where the zoster had been. A writer reports having seen numerous cases during the hot summer of 1868, and he recommended painting the vesicated patches with flexible collodion, as the cleanest and most effec- tual means of preventing the rupture of the vesicle, and suita- ble at every stage of the disorder, even in cases where superfi- cial ulceration has taken place. Crepinel says that he found great benefit in the treatment of zoster neuralgia by applying chloroform and oil (one part to five) several times a day, increasing the proportion of chloroform with the severity of the pain. The remedy to be used at as early a stage as possible. Chegnon records an instance of the good effect of blisters in arresting zoster and preventing the persistency of the distressing neuralgia. Chaussit also thinks blisters are most useful. Forget finds that blisters do not hinder, but may even promote the erup- tion, but they are one of the best means to relieve the succeeding neuralgia. Bandon recommends smearing the affected pari early with a solution of chloride of iron mixed with laudanum. TREATMENT OF DISEASES OF THE SKIN. 49 Bowman, in one case, relieved the persistent neuralgia after h. zoster ophthalmicus by dividing the supraorbital nerve and subsequently the branches of the infratrochlear. At present, of course, besides opium plasters, we have subcu- taneous injections to "fall back on. And those who have ex- perienced in themselves or witnessed in others the sometimes fearful pain of zoster, will readily grasp at anything to obtain or give relief. On the trunk, where there will be motion of the skin, application of unstimulating plasters in large pieces gives some relief by steadying the parts and preventing dragging. We omit here, of course, all the list of remedies tagged on to the account of zoster in nearly every book or monograph, so often apparently simply copied from one to another. HERPES IRIS AND CIRCTNATUS, the latter being a change of form of the former. We spoke of the suggestion made by Hebra, that h. iris was perhaps only a further development of erythema iris. He has seen both on the same patient. In regard to the time of the.year when most prevalent, their involution, duration, etc., it seems highly probable this is the case, and then h. iris and its form, h. cir- cinatus (i.