325 NATIONAL L:b»AB¥ 0' MtDlClNE NLM DD57bM31 D .oi_oo- Surgeon General's Offic. S : v. y\ ill! ?/i''■ *■ ^ * .»* >*"<• ^, "■*. .vs?7i* «* $fcfa*$^ &'&&*',■ *>" SKIN DISEASES DESCRIPTION, PATHOLOGY, DIAGNOSIS, AND TREATMENT. TILBURY £px, M.D., Lorn, M.B.C.P. FELLOW OF UNIVEBSITY COLLEGE, PHYSICIAN TO THE SKIN DEPARTMENT OF UNIVERSITY COLLEGE HOSPITAL. FIRST AMERICAN FROM LAST LONDON EDITION. EDITED BY M. H. HENRY, M.D., SCBGEON TO THE NEW YORK DISPENSARY—DEPARTMENT OF VENEBEAL AND SKIN DISEASES. FELLOW OF THE NEW YOBK ACADEMY OF MEDICINE. **' % «* LIBRARY. 9 NEW YORK: WILLIAM WOOD AND COMPANY, 27 GKEAT JONES STEEET. 1871. VMR FlHs IS'J I PREFACE TO THE AMERICAN EDITION. I have, with the consent of the author—whose engagements would not permit him at this time to revise the last edition of his work—prepared the present volume for the American Student and Practitioner. The undeniable want of such a work in this country is, I think, sufficient apology for offering this edition to the profession. I know of no work on Dermatology in our language that combines eo completely the results of a thorough knowledge of the pathology of skin diseases, such sound clinical observation, and so rational a system in the application of therapeutics. The attractive manner in which the book is written will, I feel assured, be the means of conveying a better knowledge of a large class of interesting diseases which have not in this country, until recently, received the attention which their character and importance deserve. The book is a good one; so good that I have refrained from tres- passing on its pages or the patience of the reader with many " notes and additions." With the exception of a short account of a new disease (rhino- scleroma) described by Hebra, and a more systematic arrangement of the formulae, I have done little more than follow out the sugges- tions of the author contained in notes, and in the Appendix to the last English edition. M. H. H. 157 West Thirty-foubth Stbeet. New Yobk, September, 1871, PREFACE. Stimulated by the very favorable reception which the profession has accorded to my two previous works,—the one on the special sub- ject of "Vegetable Parasitic Diseases," and the other "Skin Dis- eases in General," and guided by the kindly suggestions of my critics, and by the experience gained in my special department for Skin Diseases at Charing Cross Hospital, I have attempted, I hope not unsuccessfully, to produce a book which I believe to have been really wanted—a book containing a concise and practical account of Diseases of the Skin for general use. The present work may be regarded as a second and condensed edition of my two former works combined, re-written and re-cast, so as to suit both practitioners and students. In addition there is given the substance of a course of lectures recently delivered at Charing Cross Hospital. The various licensing bodies are wisely showing an increasing dis- position to demand from the student a definite knowledge of diseases of the skin. This is the case particularly with the University of London, and also, of late, with the College of Physicians, the Col- lege of Surgeons, &c. Keeping prominently in view the wants of the student in this respect, I have given a pretty full account of the elementary lesions, the description, the pathology, the diagnosis, and the principles of treatment of skin diseases. Moreover, I have incorporated with the Index a Glossary containing the derivation and meaning of terms, in the belief that it will be of much service to the reader. A large number of students enter the public services, and have to undergo special instruction preparatory to foreign service—at Netley for instance. I have therefore sought to aid them by including in the work an account of diseases affecting the skin which they will be called upon to treat in India, China, and other parts: ex. gr., vi PREFACE. Delhi boil, Bisbra bouton, Framboesia, Leprosy, Bucnemia tropica, Guinea-worm disease, the Madura foot (India), Ngerengere (New Zealand), Cochin-China ulcer. Some very interesting matter will be found in the Appendix relative to the so-called " Army Itch." It has seemed to me possible likewise to meet the requirements of the practitioner by amplifying the sections on diagnosis, and provid- ing a special Formulary, containing 200 selected prescriptions. At the end of the sections on treatment reference is made by number to various formulae of use in particular diseases. The formulae are classified, and to each is appended the name of the disease in which it is useful. Whilst the student, therefore, may use the book as a whole, including the Glossary, the practitioner may, if he desire, merely refer to the sections on diagnosis and treatment, and to the Formulary, where I believe he will find what he requires. The classification of diseases is simplified, I hope; it is new, and in accordance with the plan proposed by the College of Physicians in its new nomenclature report, and with my own strong convictions. The whole of the subject of Parasitic Diseases is fully illustrated by woodcuts ; and amongst others is a representation of the Madura foot, not figured as yet in any English work. In another part of the work is a representation of Delhi boil. My thanks are due to Mr. Erasmus Wilson, F.R.S., Dr. Lionel Beale, F.R.S., Dr. McCall Anderson, and Dr. Purser, for the use of illustrations; and to Dr. Lawson, C.B., Dr. Gordon, C.B., Mr. Perry, R.A., Dr. Marston, R.A., and others, for valuable information. 43 Sackville Street, Piccadilly, W., October 1, 1868. CONTENTS. CHAPTEB page I. INTRODUCTION—IMPORTANCE OF STUDY OP SKIN DISEASES—A KNOWL- EDGE OP GENERAL DISEASES REQUIRED—WILLAN'S RESEARCHES. . 1 II. GENERAL PATHOLOGY—ELEMENTARY LESIONS....................... 5 III. ETIOLOGY—BLOOD TISSUE AND NERVE CHANGES—INFLUENCE OF SEX, AGE, OCCUPATION, FLANNEL, SCRATCHING—CONDITIONS THAT DE- TERMINE THE LOCAL DEVELOPMENT OF DISEASE—COMPARATIVE FREQUENCY IN KIND OP SKIN DISEASE........................... 14 IV. CLASSIFICATION.................................................. 21 V. GENERAL DIAGNOSIS—PROGNOSIS—TREATMENT..................... 25 VI. ERUPTIONS OF ACUTE SPECIFIC DISEASES.......................... 32 VII. ERYTHEMATOUS DISEASES.......................................... 44 VIII. CATARRHAL INFLAMMATION, OR ECZEMA........................... 64 IX. PLASTIC INFLAMMATION, OR LICnEN............................... 79 X. SUPPURATIVE INFLAMMATION, OR PUSTULAR DISEASES.............. 91 XI. BULLOUS DISEASES................................................ 112 XII. ALPHOUS DISEASE................................................. 123 XIII. STRUMOUS DISEASES.............................................., 130 XIV. CANCEROUS DISEASES............................................. 136 XV. SYPHILITIC ERUPTIONS............................................ 142 XVI. LEPROUS DISEASES................................................ 157 XVII. HYPERTROPHIC AND ATROPHIC AFFECTIONS......................... 166 XVIII. PARASITIC DISEASES............................................... 190 XIX. NEUROSES OP THE SKIN........................................... 233 XX. HEMORRHAGES.................................................... 242 XXI. CHROMATOGENOUS DISEASES—PIGMENTARY.......................... 244 XXII. DISORDERS OP THE GLANDS........................................ 248 SUMMARY............................................................... 264 FORMULARY............................................................. 269 MINERAL WATERS IN SKIN DISEASES...................................... 295 GLOSSARIAL INDEX...................................................... 297 CHAPTER I. INTRODUCTION—IMPORTANCE OF THE STUDY OF SKIN DISEASES--A KNOWLEDGE OF GENERAL DISEASES REQUIRED--WILLAN's RESEARCHES. Diseases of the skin deserve to be more carefully studied than they are, for many reasons. They are excessively common, and amongst the first to test a man's self-dependence both in public and private practice amongst the poor, in workhouses and hospitals, as well as private patients. They are specially calculated to educate the faculty of minute observation. Their occurrence affords ample opportunity for gaining the confidence of patients, because these ailments are seen as well as felt; their inveteracy and dis- figuring character often affect in a peculiar manner the personal comfort and vanity of men and women, so that relief is estimated at a comparatively high standard, whilst the good or bad effect of treatment, in the majority of cases, can be readily appreciated by the attacked. Many cutaneous mis- chiefs are contagious, and transmissible from one subject to another. It is highly important to be able to speak positively on this point in regard to individual cases. One of the commonest opinions demanded from a medical man concerns the necessity for isolating one or more members of a family, with the view of preventing the spread of skin diseases. An error of diag- nosis may allow the dissemination of ringworm throughout a school, bring discredit to the practitioner, and serious loss to the proprietors. This is but one of many examples that might be adduced to show that he who has a fair knowledge of diseases of the skin has an immense advantage in the practice of medicine. And there are other considerations. Foremost is this, that accurate ob- servation of the morbid changes that go on in the skin is destined to throw much light upon the pathology of internal organs. But the truth of the statement I started with must be self-evident. The successful study of skin disease necessitates a knowledge on the part of the student, whoever he may be, of diseases in general—and the only efficient treater of cutaneous ail- ments is he who is master of the details of general therapeutics. The same disease, as it occurs in persons of different diathetic tendencies, requires to be handled in a somewhat varying manner : eczema, for instance, in an old and gouty, a young and pallid, or a scrofulous subject, requires not the same, but a modified treatment. The rank specialist or mere empiric would diag- nose the eczema, pay no heed to the diathesis, and employ a therapeute, which he has stereotyped, as suited to all cases, under all conditions. The 2 INTRODUCTION. philosophic practitioner, bringing into use his knowledge of medicine in general, would be careful to take advantage of known specifics; but he would treat any constitutional condition which tended to prevent reparative action, and rectify errors of function or departures from healthy action in organs and parts which bear relation by interdependence of function, and so influ- ence the diseased skin. There is also, it must be remembered, a certain unity of character about diseased actions in various parts of the bod}r, which justifies us in instituting a comparison between the morbid processes in dif- ferent organs. A recognition of the changes in one, will not unfrequently throw light upon the nature of those occurring in another organ, about which, however, some doubt exists. There is also a more definite relation than this between the skin and internal organs. The ability to detect mis- chief of different kinds in the body in which a skin disease exists, often- times enables one not only to unravel more completely the nature of the latter, but to remove a cause of general debility, or one that checks elimi- nation, or that in other ways interferes with the due play of the vis medica- trix naturae in the cure of skin disease. The removal of a stomach, a kidney, a uterine, a liver derangement, gives a patient a much better chance of get- ting well under treatment intended to cure a coexisting skin disease, and to effect this—i.e., to be a successful dermatologist—one must be a well-in- formed physician. One of the most important relationships which should be considered is that of the skin and kidney functions. In no book, in no teaching, in no practice, is any prominence given quoad the treatment of skin diseases, to the importance of our being guided by a consideration of that which the physiologist impresses upon us with peculiar emphasis—the relation which subsists between the functions of skin and kidney. The dermatologist practically ignores the fact in the pathology to which he pins his faith and the therapeutics he adopts. On the face of it, this total abnegation of a great physiological fact can but be, as my experience teaches me, an egregious blunder: but cutaneous medicine is the slave of empiricism. The skin is often made to relieve kidney disease with the fullest success; why, then, is the converse not more frequently and confi- dently effected ? Remembering that the kidneys form the safety-valve by which a proper balance of fluid (and waste) is kept in the system (the amount secreted de- pending in some degree upon the state of the 'fluids, the cutaneous exhala- tion, etc.), and that there is not necessarily any relation between the quan- tity of urine and that of its solid contents—it may be affirmed that deficient action of the kidneys (as to solid and fluid) may (in old people especially) very materially affect the occurrence of skin disease. Eczema may be taken as an example. Speaking generally, deficient kidney elimination may—(1) Determine the occurrence of disease. The skin will have more work to do where there is a sluggish action of the kidneys, and the blood circulating in and through it may consequently be charged with more nitrogenized matter than usual, especially in gouty and rheumatic subjects; and if disease have INTRODUCTION. 3 a tendency to show itself, its manifestation will be at once encouraged or excited. Therapeutics proves this indirectly in the familiar instance of the influence of colchicum and diuretics in eczema, in such cases accelerating the cure in many instances ; whilst the presence of an excessive amount of urea in the urine in eczema supports the proposition laid down. (2) It intensifies the obstinacy of existing diseases. This follows from what has been said, and will be found to be clinically true. There are two classes of cases : in one, the total urea formed in the body is above the average, and in the other it may be normal; in either case the deficient excretion (com- paratively speaking) produces to a certain extent a like result—the presence in the blood of an excess of effete products. But deficient excretion may further be explained by the non-transformation into urea of the waste prod- ucts of the body by an arrest in the change of complex into simpler com- pounds. Dr. Frank Smith's observations relative to indican in the urine in eczema are conclusive on this point as to a deficiency of urinary excre- tion. It is our duty, then, when we know excretion is not active, to go further and find the cause of default. It may be an arrest in the normal metamorphoses, or a mere non-excretion of normal waste-products. The treatment is by diuretics in the one, by tonics chiefly in the other. It would seem sometimes as if the waste-products which should be excreted were de- rived from the changes going on in the skin itself, when that is extensively implicated in disease. (3) The deficient elimination of water by the kidney, leads, where gravitation comes into play, to the transudation of fluid in the superficial tissues, and occasionally to the production of blebs. The connection between chronic redness of the face and dyspepsia (particu- larly pyrosis), and between menstrual derangement and some forms of acne, is often marked, and may be cited as showing that our dermatology must be something more than " skin deep." It must comprehend the normal inter- relationship of the cutaneous envelope with internal organs, the deviations therefrom and their results, and the action of diathesis in modifying dis- ease. It must also be in a position to determine, when a given disease is only part of a general one, what the nature and history of that general disease is ; and it must include a knowledge of the pathology and therapeutics of chron- ic visceral disease. The mode in which the latter acts will be noticed again. Enough has perhaps been said to indicate how varied and large an amount • of knowledge the dermatologist should possess. I think it important to call attention to the fact that considerable differ- ences exist in the same diseases, according to the country and people amongst which they occur, and this is only what might be expected from the influ- ence of varying conditions of climate, diet, custom, etc. Nothing shows this more conclusively than an examination of the writings and plates of * foreign authors. Many of Hebra's descriptions (always good) of ordinary instances of disease really represent exaggerated forms of English skin dis- ease—ex. gr., lichen ruber and scrofulosis, and even lupus. In the East— Syria and Egypt—syphilis is by no means so severe as in other parts of the 4 INTRODUCTION. world. Pityriasis rubra and general psoriasis are not common with us, at least to such an extent as on the Continent. Again, fibroma molluscum and rupia are probably much milder in England than in Germany. I was very much struck with the difference as regards scabies in passing through Hebra's wards; it was altogether more ecthymatous ; and, indeed, the ulcer- ative aspect of most diseases in which ulceration is wont to occur, has seemed to me less marked in our own than in many other countries ; I speak not from theory, but actual observation. There is surely a sufficient reason, too, for the more sthenic character of diseases in England. A great truth underlies the contrast. I suppose that the meat-eating and porter-loving Englishman, with his hardy pursuits, acquires a greater amount of stamina, and that degenerations dependent upon constitutional debility are not so marked in his case as in that of the vegetable-feeding black or the fish-eating northerner. It would be out of place to pursue this topic further; let me only add, then, that we must be careful not to trust absolutely to foreign description for learning to recognize, and certainly in treating, English skin affections. I find that, on this point, I am in accord with American physicians. Before passing to the subject of Pathology, I would be allowed to make one reference to Willan. It has become the fashion to depreciate his labors, and even to level a certain amount of ridicule at the class to which I be- long—viz., that of the Willanites. We must remember that we cannot con- ceal, by a platitude of new ideas and high-sounding words, the fact that the essence of our present stock of knowledge, and the recent advances in cuta- neous pathology, have been mainly derived from the hard and solid work of Willan. He undertook the study and rearrangement of a class of diseases at a time when they were in the utmost confusion; he brought to bear upon the question a large amount of very accurate observation, and was enabled to parcel out certain " batches" of diseases, each presenting peculiar charac- ters, to establish a groupage which to this day represents the basis of the best classification for teaching purposes. And I am surprised at some of my dermatological confreres who depreciate the Willanean system as obso- lete and useless, and yet quietly incorporate it amongst the details of their own pet system of classification. Science is progressive, and Willan was not omniscient; naturally, therefore, Willan's system of grouping skin dis- eases requires to be developed; unfortunately there were no workers in the field immediately following Wiilan to carry on the work which he began; but, modified in accordance with the pathology of the present day Willan's arrangement constitutes the true plan upon which cutaneous diseases are to be arranged.. The principle of the system is perfectly right, the details alone defective ; and it is an unfair thing to make one flaw the evidence of the total worthlessness of the whole plan. Willan's labors, gauged by the medical circumstances of the time in which he lived, take the highest clini- cal rank; they gave an impulse to the study of cutaneous diseases in Eng- land, and secured that country an enviable standing in regard to dermatolo- gy which it is to be hoped she will continue to hold. CHAPTER II. GENERAL PATHOLOGY--ELEMENTARY LESIONS. There are certain types of morbid changes occurring in the skin, such as " red blushes," " pimples," solid elevations, collections of serosity or pus, which are termed elementary lesions ; their description will form the subject of this chapter. Now, it is important at once to notice that a large number of cutaneous diseases are inflammatory in their nature. It is just as well, therefore, that we should start with some definite idea of what is meant by inflammation. In the first place, the line of demarcation is by no means well drawn be- tween ordinary nutrition and inflammation. The latter may well be regard- ed in many cases as arising out of an exaggerated action of those processes that are in operation in healthy nutrition. Inflammation does not consist of a special something introduced from without, hut is simply an alteration, in one sense, of the relative activity of conditions that make up healthy nutrition; and it would seem to be excited by disorder of the blood, of the nerves, and even the tissues themselves. The first stage is active congestion; this is followed by the escape of fluid from the vessels, which may be plastic, forming more or less solid ele- vations (papulations); or serous, constituting vesiculation; or the effused fluid may become more or less purulent. The local disturbance which is called inflammation may be induced by an infinity of causes; but con- gestion is the first stage in all cases; consequently, although according to the nature and intensity of the cause, will the degree of inflammation vary—in some instances redness alone occurring, in others papulation, vesi- culation, or pustulation, yet under all circumstances there will be a simi- larity in the aspect of corresponding stages of inflammation, as it occurs in different diseases. One of the prime objects of inflammation is the removal of effete and disorganized matters, and the repair of disordered tissue; this will further explain why the process of inflammation under different circumstances should be similar. Some writers misinterpret this similarity. An attempt has been made to make all skin inflammations stages of the same disease. It is argued, for instance, that lichen, a papular, and eczema, a vesicular disease, are stages of one and the same affection, because, amongst other things, papules are seen to become vesicles; but this argument is untenable until it be shown that the cause and character of the papule of an eczema is the same as that of a lichen. There is close resemblance, because there is inflammation in 6 ELEMENTARY LESIONS. both cases. The difference in the two instances must be found in the differ- ence of cause, in the character of the tissue action, and the inflammatory products. The plastic lymph of lichen, the serosity and cell proliferation in eczema, contrast strongly—in both cases little elevations may occur, but in the one case they are due to the presence of fibrillating lymph, in the other to serosity, and often abortive or undeveloped vesicles—though the two diseases to a great extent exhibit a close similarity in their development, there is a dissimilarity in the general nutrition—lichen is plastic, eczema, catarrhal inflammation. Given inflammation, the result will be modified according (amongst other things) to the blood state—ex., struma, syphilis, etc., the tissue action—ex., tendency to pus formation, etc., or the influence exerted by nerve irritation in accelerating cell metamorphosis. These modifying conditions the phy- sician should strive to understand. My object in making these remarks is to point out that there must neces- sarily be a close similarity between the corresponding stages of inflammatory diseases, though the diseases, as a whole, may be really different; and as I am speaking to the student, critics must not blame me for the absence of an elaborate essay on inflammation. With these introductory remarks I pass to the consideration of ELEMENTARY LESIONS. These are the types of form assumed by morbid changes in the skin. They are generally arranged according to the plan originated by Willan. A correct understanding of their nature is essential to accurate diagnosis. The elementary lesions are as follows: maculae or stains, erythema, papules, squamae, vesicles, blebs, pustules, and tubercula. These are followed by certain other or secondary changes—viz., excoriation, crusts, scales (second- ary), cicatrices, staining, etc. I shall here give a general summary of these various conditions, leaving the minuter details to be filled in in speaking of individual diseases. JSIacnlai are discolorations, mostly of primary occurrence, and often con- stitute the sole change in the skin, They are usually unaccompanied by hyperemia. The term maculae is often limited to pigment alteration, the seat of which is the rete mucosum; but we may here note that there are five groups of discolorations or stains: (1) pigmentary; (2) parasitic, as in chloasma; (3) syphilitic ; (4) hemorrhagic, as in purpura; and (5) chemi- cal, for instance, that induced by nitrate of silver, or by carbazotic acid. Now, the hsemorrhagic and chemical groups are readily distincmished. Para- sitic and syphilitic stains are often confounded, especially in the case of chloasma: this is fully noticed in the proper place. The pigmentary stains are those of most consequence here. They may be arranged thus, in three subdivisions:— A. Idiopathic. These are generally excited by external irritants, and are (1) traumatic, including stains induced by pressure in handicrafts, ELEMENTARY LESIONS. i and by the clothing, those following as the result of congestion in many local diseases, as eczema of the leg ; (2) toxic, including the stains which follow the application of heat, the action of the sun, mustard poultices, and the like. B. Symptomatic stains, or those which follow as a consequence of disease or change at a distance, including the pigment deposits which occur in connection with some natural physiological change in the body, as in pregnancy ; those which occur in connection with uterine disorder, in cachexias, cancer, anaemia, liver or supra-renal disease, or nerve disorder, as in leprosy. C. Congenital, including pigmentary moles and naevi. This table should be referred to in reading the chapter on chromatogenous diseases. Erythema, or Capillary Congestion, or simply Hash.—Erythema is due to impeded circulation, and in it the capillary layer of the skin is involved. There are two chief forms of erythema or congestion,—A, active, B, passive. The latter group may be dismissed with a few words. The color of the erythema is dull, bluish, the surface is cold. It is generally of mechanical origin, and produced by venous obstruction. It may be symptomatic of a more general disorder—for instance, a weak heart. The great majority of cases are active forms of erythema. Here the color is more or less of a bright hue, and accompanied by heat, swelling, and pain—in fact, the ordi- nary signs of inflammation. The erythemata of this nature may be ranked under three heads : (1.) Those forms which constitute tlie sole disease, as in local hyperaemia, produced by local causes—ex., irritants of all kinds, and heat. (2.) Those which form the main feature in general disorders, and are so important as really to constitute the disease that requires treat- ment—ex., the ordinary febrile erythemata; in this case the rash is more or less partial. (3.) Those which constitute a prominent feature in more serious and fatal affections—ex., measles, scarlatina, the acute specific dis- eases ; here the rash is general over the skin. We might make only two groups of erythemata, local and general, the latter including groups 2 and 3 in the above arrangement. In these erythe- mata there is (1) redness which varies according to the part of the capillary plexus involved, being punctate when the follicular plexuses are specially concerned, uniform if it be the horizontal vascular surface of the derma, diffused and general if the blood be disordered as a whole, or circular if the vessels under the governance of one or more nerve twigs are alone the sea* of disturbance—the color varies according to the activity of the circulation and the state of the general health ; (2) swelling : this is due to the greater volume of blood present and the escape' of fluid from the vessels into the tissues; (3) arise in temperature; (4) disordered sensation, pain, or tin- gling, or burning; (5) an acute course usually; (G) secondary effects, such, as desquamation, exudation, hypertrophy. 8 ELEMENTARY LESIONS. When the deeper tissues—the connective—in addition to the skin are affected, we have what is called phlegmonous inflammation. The points of importance are the hue of the redness, as indicative of venous or arterial stasis, and the extent of the redness as significant of a general or a local disorder. Papules, or " pimples," are differently explained by different dermatologists. They are little solid elevations of the skin, and are produced by a variety of causes, as follows—(1) Deposition in the skin of plastic lymph ; (2) the turgescence and consequent erection or prominence of the follicles (the perspiratory, the sebaceous, or the hair) ; (3) by collections of epithelium or other substances in these follicles, and the projection of these masses; (4) by enlargement of the papillae ; (5) and (6) by hypertrophous growths of the derma, as in small warts. The true papule, that which occurs in lichen, is due to the effusion into the skin, especially the papillary layer of plastic lymph (plastic inflammation). The papules are palish or white, flesh-colored or dull red, with no appreciable surrounding congestion as a rule, lasting a variable time, and disappearing by resorption and slight des- quamation. On close inspection the papules are seen to be sometimes transparent at the point, from the presence of lymph, which may as yet not have thoroughly fibrillated (solidified), hence on scratching the point of the papule off a little oozing may take place. The lymph comes from the fol- licular plexus as well as the vascular loops in the papilla?, and therefore the papule sometimes looks as if it were a turgescent follicle, but the true papule is essentially non-vascular, pale, and solid. An inflamed follicle is " follicu- litis," not a papule, which as I stated is really a solid lymph formation. There are certain varieties of papules. They are small and hard on the outer surfaces of the body, larger and softer on the inner surfaces, about the neck and the face. They are absent from the palms of the hands and the soles of the feet. They are large in syphilis, large and flat in lichen ruber. They may be scattered, or in groups forming patches, which increase by the development of papules at the circumference. In some cases, the character of the nutrition is such, that scratching is followed by haemorrhage, instead of lymph effusion, as in prurigo, and here at the apex of each papule is seen a black speck, produced by dried blood. Papular disease (and I am speaking of papules that are produced by a deposit of lymph in the skin) is chronic ; it is accompanied by a tendency to, or actual thickening of the skin, and more or less itching. It is fibrous or plastic inflammation. Secondary papules are produced as the result of chronic irritation, and they may be either lymph formation or congested follicles. Large and flat papular elevations occur in prurigo, and are produced by enlargement of the little areas of the skin enclosed by the natural furrows. Vesicles.—As in the case of the papule, properly so called, we have the up- raising of the skin by plastic lymph, so may an elevation result from the effusion of fluid which does not fibrillate, but which raises the skin above it into a minute bladder, and then makes its exit through the cuticle, forming ELEMENTARY LESIONS. 9 " discharge." The little bladdery elevation so produced is called a vesicle. The fluid comes from the capillary plexus of the skin. Some dermatologists think that a vesicle is a modified papule, but it seems to me that in the two cases there is a marked difference in the general nutrition—the one produc- ing plastic, the other serous material—the one leading to a " dry," the other to a " moist" disease. Vesicles are of small size ; they may be isolated (scabies), discrete as it is called, or they may run together, as in eczema, their walls rupturing, and a weeping surface being produced. When the cuticle is thick, the fluid does not escape readily, the vesicle may then enlarge by augmentation of fluid, or by junction with others, and so what are called blebs or bladders are produced; this is common about the fingers. When the fluid does escape, it dries into crusts ; the discharge is often excessive; vesiculation may leave behind a dry, red, fissured surface. The essence of vesicular disease, however, is the free outpouring of fluid which is more or less serous, and tends to elevate the skin into what are called vesicles: it is identical with catarrhal inflammation in other parts. The contents of vesicles are haematoid, pyoid, granular and mucous corpuscles, plastic lymph, fatty matter, and amcebiform cells. The reaction may be acid, neutral, or alkaline. The fluid is at first transparent, but soon becomes quickly opaque or puri- form in those instances where there is a " pyogenic (pus-producing) habit of body " present. An elevation of the cuticle by fluid may occur in consequence of the non-escape of the sweat when this is over-abundant, and this is the nature of sudamina and miliaria, but in such cases the source of the fluid is obvious. 13lebs* are simply large vesicles ; their size is arbitrary, varying from that * The following note on the mode of formation of a bulla or blister, will be read with interest and profit:— " As generally understood, a blister is supposed to be an exudation of fluid, which, discharged from dilated vessels, passes through the rete mucosum or Malpighian layer of the skin, and accumulates between the epidermis, that constitutes the elevation, and the rete mucosum, which is held to remain attached to the surface of the dermis. The difficulty which at once suggests itself here is, why there should be a detachment of the epidermis from the rete mucosum—why the papillae should not be left bare when the raised skin is removed. Some recent investigations by Professor Biesiadecki show that our previous knowledge of the process, though in the main correct, has not been complete or accurate. He has endeavored to fill up this hiatus, and has taken as the subject of his observa- tions the small vesications that are caused by a burn, because these are quickly produced, and are not, as in the case of the minute blisters which occur in disease, accompanied by any previously diseased conditions of the skin. If a subject be burnt with a hot iron, there will be found in the neighborhood of the eschar, after the lapse of a few hours, sundry small vesications; these are well adapted for investigation. If such a blister be cut out with a portion of the adjoining skin, macerated in chromic acid, and imbedded in gum, complete vertical sections may be obtained. It is then found that both the papillae and the stratum. Malpighii have 10 ELEMENTARY LESIONS. of a pea to that of a shilling, usually reaching the latter from the former in a few hours: they are seated upon an erythematous base, are generally associated with ill-health, and come on without premonition. In consequence of their rapid formation and tke resistance offered by the cuticle, the bleb is tense and full, but absorption soon produces more or less flaccidity, the contents become opaque, sometimes sanious and bloody (rupia), and being discharged dry into crusts of yellowish or blackish hue, but sometimes of a raised conical form (rupia) ; beneath the crusts the surface is raw, red, and more or less dirty. Sometimes at the bottom of a bleb is found a disc of plastic matter, and the raw surface may take on a morbid action and secrete a"thick tenacious fluid and even pus. Bullae are solitary or multiple, con- fluent or isolated ; often periodic in old people. Blebs may be formed by the coalescence of vesicles, as in eczema of the fingers; but these are linear elevations rather than circular cuticular elevations. In erysipelas, blebs are common. About the hands and feet of infants they are sometimes as syphilitic. The exact manner in which blebs are produced is a matter of doubt. Through the influence of nerves a sudden dilatation of the vessels may undergone important changes. In the smaller vesicles the papillae are enlarged, their connecting tissue presents lacunae, and the vascular loops are greatly dilated and apparently elongated. The epidermis is altogether detached from the papillae except in the hollows between the papillae, and-the space between the two is occupied by innumerable very fine fibres, which seem to be on the stretch. The fibres do not at first sight give the idea of elongated cells, as they are of equal thickness and have no nuclei, though one or two may be scattered here and there. They readily stain with carmine. When the vesications are larger, and the fluid more abundant, the fibres are torn through, part adhering to the inner surface of the epidermis, part to the outer surface of the papillae. Amongst them, some club-like cellular structures, with nuclei in their interior, may be seen adhering to the papillae by their elongated extremities. In the serous contents of the vesicles a few round nuclei are suspended. Biesiadecki states he was long in doubt respecting the origin of these fine fibres, but he has now convinced himself that they really proceed from the cells of the rete mucosum, as the intermediate forms between the finest fibres and the unchanged cells may with care be seen, whilst the surface of the papillae is well defined, so that they could not proceed from the connective tissue. We may therefore conclude that in the formation of a blister from a burn there is, in the first place, a great dilata- tion of the blood-vessels, which immediately occasions a serous exudation. This permeates the tissue of the cutis and reaches the rete mucosum, the cells of which do not appear to be capable of imbibing fluid. As the deeper ones adhere strongly to the papillae, and as the accumulating serous fluid cannot escape through the condensed cellular layers of the epidermis, the cells constituting the rete mucosum are gradually put upon the stretch, at first being merely elongated, and finally becoming converted into fibres in which no trace of a nucleus can be discerned. These facts appear to us to be of great interest, and they teach that vesicles may be traversed by a -framework of fine fibres, as it is well known is the case with pustules—e. g., those of small-pox."—Lancet, Oct. 10, 1868. ELEMENTARY LESIONS. 11 occur, and fluid rapidly escape; and bullae occur specially in herpes and pemphigus, in the production of which diseases the nervous system is allowed to be greatly concerned. Pii.slv.le8 are elevations of the upper part of the derma, produced by pus, quickly formed, and coming rapidly to the surface. They are, on the whole, accompanied by more inflammation than are vesicles or papules, and by a deeper affection of the tissues. Now, pustules have been divided into pri- mary and secondary. In the former we have hyperaemia, and the direct formation of pus quickly and at once, as in ecthyma; in the latter, the con- tents of the pustule are rather puriform than purulent. The pustules com- mence as vesicles, the contents of which are transparent and serous; by- and-by pus is therewith intermingled. This is the case in scabies, and even variola and vaccinia, and in eczema impetiginodes. It is customary to make three kinds of pustules :—(1), psydracious, viz., those which are hard and pointed, which have a slightly red circumference, and are often seated at the hair follicles ; (2), phlyzacious, which are large, raised, vivid red, have an indurated base, and are replaced by thick dark scales; and (3), achores, a term applied to the small acuminated pustules that occur in the scalp : these are inflamed sebaceous glands (or boils). Boils, or furunculi, are regarded as pustules; they are accompanied by swelling, heat, tension, and the formation of " a core." This core is thought to be produced by circumscribed sloughing, or by strangulation of the tissues, caused by the swelling, or by a special exudation into the skin. Others affirm by an inflamed and suppurating sebaceous gland, and I refer for further particulars to the description of furunculi, in the body of the work. /Sqvamre, or, simply, scales (I don't mean crusts which are the result of the drying of secretions) are of two kinds, epithelial and fatty; the latter occur in affections of the skin, which are described under the head of " seba- ceous diseases ;" the former, epithelial, are found under many different con- ditions. In acute specific diseases, measles, and scarlatina, for instance, the cuticle may, so to speak, die, and then its scales are shed in what is termed " desquamation," or " peeling " of the surface ; a scaliness results from the disordered nutrition which follows the application of local irritants, or the growth of vegetable parasites; and in most inflammatory affections, such as eczema, erythema, lichen, the epithelial formation is seriously inter- fered with, and scales are freely produced. In all these instances the scaliness is secondary to and occurs after the real disease has fully shown itself. It is often mixed with more or less exudation. In another class, however, the excessive formation of epithelial scales is the essential and prominent change in the skin ; here the scales are primary products. We may therefore divide scales into primary and secondary, and into epithelial or fatty. 1. In the epithelial variety we have simply altered epithelial cells, produced by augmented formation or hypertrophic growth. They are thin, fine, branny, opalescent; or thick, hard, dry, whitish, more or less opaque, rarely of a dark aspect, collected together in an imbricated 12 ELEMENTARY LESIONS. manner (lepra vulgaris), with a more or less hypertrophied state of the pa- pillary layer of the derma; or thrown off as soon as produced (pityriasis), or with only slight aggregation, perhaps forming a thin layer. The scales are produced in great abundance and with rapidity, but, histologically speaking, are not so perfectly formed as in the normal condition. In some cases they become granular, even fatty, or invaded by fungi, as in chloasma and ringworms. The over-formation of scales is generally accompanied by itching, slight redness beneath the scales, and in old-standing cases by crack- ing and Assuring of the diseased part, as in lepra vulgaris, producing a dull white, and compact cracked dry surface. When the scales are fine and branny, and constantly shed, what is termed furfuraceous desquamation is present. Sometimes this scaliness may be associated with general inaction, and more or less atrophy of the skin; and in that case the disease is xero- derma, or dry skin; in an exaggerated degree, where the scales form plates, ichthyosis. 2. In the fatty variety there are epithelial scales, but they are loaded and surrounded by fatty matter from the sebaceous glands. These fatty scales are rather plates that are " stuck " on to the part, and can be more or less dissolved up with ether; they are common in ichthyosis and seborrhcea. Sometimes large plates form, as in pemphigus foliaceus, for instance ; at other times the whole epidermis of the hand or foot may peel off in large masses, like parchment. Tubercula.—This word, which sounds so like tubercle, is a very bad one. It is, however, so commonly in use that I am bound to define it, and to de- scribe what it includes according to general agreement. Willan meant it to signify any tumor of smallish size, not defined by the word papule. Here is his description: " A hard, small, circumscribed, and permanent tumor, suppurating partially." Hardy defines tubercula somewhat as fol- lows : Little globular tumors, firm or soft, containing no fluid, formed deeply in the substance of the skin, at times disappearing by an insensible absorption, at others ulcerating, with prior softening, accompanied by loss of substance more or less deep and extensive. Tubercula, which micht be replaced by the term degenerations, includes elephantiasis, keloid, framboe- sia, cancer, lupus, epithelioma, rodent ulcer, the four latter commencing as hard nodules on the derma proper, and having as their especial features, the tendency to enlarge, spread, and ulcerate, with decline of the general health. The tubercules formed by degenerations are solitary (cancer) or multiple (framboesia), at first often subcutaneous, the skin being apparently natural but soon becoming irritated, interfered with as to nutrition, hence, swollen, congested, softened, and at length .ulcerated, when, in the majority of cases, out sprouts the diseased mass beneath. This occurs in elephantia- sis, framboesia, cancer, epithelioma, in lupus, rarely in keloid. The surface then presents a variable aspect; it may be clean, or foul and exuding a dirty fluid (cancer), or scabbed in various degree (lupus). The loss of sub- stance increases either superficially or deeply; one part may heal whilst the ELEMENTARY LESIONS. 13 other ulcerates, as in the varieties of lupus. The edge may be undermined and everted (cancer), or inverted, thickened, rounded off, as in lupus ; and there may be more or less infiltration of the textures beyond the boundary- line of the sore (as in cancer), or congestion and oedema (lupus). Degenerations are chronic in character, often hereditary; but I had better reserve further particulars. Such, then, are elementary lesions. I have incidentally noticed " second- ary changes," but must add one or two additional particulars, (a) As re- gards desquamation, this may result from hyperaemia whenever marked. It should be mentioned that in pityriasis rubra and pemphigus foliaceus the squamation is general, (b) As to crusting, this occurs in all discharging diseases. Crusts vary in appearance with the nature of the secretion, ac- cording as this is serous, purulent, or bloody. If serous discharge exists, the crusts are thinnish and brownish; if pus exists, they are thickish, light yellow, and more or less greenish, as in impetigo and eczema. Crusts are dark and adherent in syphilis, and cockle-shaped in rupia. They may be formed solely of fungus as in favus; then they are dry, powdery, friable. Where discharge is slight and purulent, the crusts are adherent, hard, and dark, as in lupus. Where there is hair, crusting is of course favored, and the hairs help to prevent the falling of scales, (c)- Cicatrices follow especially ecthyma, variola, herpes zoster, furuncle, anthrax, pustula maligna, syphi- litic acne, (d) Distinct ulceration is seen mainly in strumous inflammation, lupus, cancer, syphilis, elephantiasis. Loss of substance without ulceration by interstitial absorption in tubercular syphilis, erythematous lupus, mor- phoea, atrophia cutis, leprosy, the distention of skin in pregnancy, (e) Cysts are formed mostly by the blockage of the follicles and distention of the gland apparatus of the skin, the sebaceous and sweat glands, (f) Conden- sation of tissue which may be newly formed is seen in pityriasis rubra, keloid, morphcea, and scleroderma. Other details will be found (in regard, for instance, to the characters of different ulcers) under the head of Diag- nosis and in the descriptions of individual diseases. CHAPTER III. ETIOLOGY—CAUSES OP BLOOD, TISSUE, AND NERVE CHANGE—INFLUENCE OP AGE, SEX, FLANNEL, SCRATCHING, ETC.--CONDITIONS WHICH DETERMINE THE LOCAL DEVELOPMENT OF DISEASE—COMPARATIVE FREQUENCY IN KIND OF SKIN DISEASE. Now, in the last chapter the general appearances of diseased changes in the skin were discussed. It is now necessary to indicate more distinctly the causes of these changes. To comprehend rightly the nature of morbid process in the skin, it is necessary, of course, that the student possess a correct knowledge of the healthy structure and healthy action of the skin. This I suppose him to possess. He must make it the standard of comparison, of course, in all cases. Now, in order that nutrition may be healthily carried on in any part, there must be—(1) a proper state of the blood; (2) a proper condition and behavior of the tissues to be nourished; and (3) a right exercise of the controlling influence exerted by the nerves. And these three must work harmoniously together. Deviations from health may originate consequently from a flaw in any one of the three conditions above named. The theoret- ical origin, therefore, of diseased changes in the skin may be specially in the blood, as we see in zymotic affections; in the tissues themselves, as seen in the case of warts, cancer, keloid, lepra, etc.; or in the nerves, as in prurigo and pruritus, and, it is thought and now generally taught, herpes. If the exact origin of disease be not as stated, the parts of the system chiefly con- cerned in the production of diseased conditions may be emphatically in one case the blood, in a second the tissues, and in a third the nerves. But of course, inasmuch as the ordinary action of these three agencies is bound up and related in the closest manner in health, in disease the misbehavior of one affects secondarily the proper action of the other of the three agencies concerned in healthy nutrition. So that all are more or less involved in disease when fully developed. Now, we are ready enough to ascribe disease to changes in the blood, but we do not sufficiently recognize the influence of perversions in the inherent cell life of the skin structures, nor the controlling supervision of the nerves in the generation of cutaneous disease. If we want an example of disor- dered tissue-life, we shall find it in cancer; the local tissue changes are not sufficiently explained by any alteration in the blood current, there is no appreciable disorder of it, that is secondary to the cell proliferation, which is the essential disease in the early stage. Take keloid again—hypertro- phous growth of the fibro-cellular tissue of the skin, is the only thing to be ETIOLOGY. 15 detected; it is apparently primary. These are examples of deviations from the normal cell-life of the skin, at present explained by no blood cause; by nothing save a change originating in the tissues. Dr. A. Biesiadecki * has lately published some interesting observations bearing upon this point. He finds that there exist in the normal lamina mucosa, cells which differ entirely from the proper epithelial cells, and resemble connective-tissue corpuscles. In pathological conditions these increase in numbers and play an import- ant part. This has been studied by Biesiadecki in condyloma, in eczema, and in pustular diseases. The commencement of vesiculation, for instance, in eczema, consists, according to our author, in the migration from the papillary layer towards the surface of numerous spindle-shaped cells, which at first are seen to lie partly in the papillary layer, partly among the deepest layers of the mucous layer (that is, in the Malpighian layer). This migration gives rise to the softening and disintegration of the Malpighian layer and epidermis. Dr. Biesiadecki gives very excellent drawings of sections of diseased skin in which these changes are shown. I have seen the same amoeboid cells in molluscum, and Dr. Sanderson informs me that he has met with them in pemphigus. It may be argued that in all these cases the changes in the tissues are due really to a primary alteration and the existence of certain pabula in the blood ; but making due allowance for this, it would still seem as if the tissues themselves originated some morbid processes, or at any rate directed the course of the final result. So is it in some degree with the nerves. It is probable that the origin of some diseases of the skin may really be in the central nervous system, or in the nerves themselves that run to the affected part, at any rate the nerves are mainly concerned, or they constitute the agency by which the morbid changes in the skin are produced. No one doubts that herpes results from irritation of the nerves related to the seat of eruption. It is true that the nerve disorder, which seems to be primary, may result from a blood change, but we know that it may also arise from a local impression, and each day pathology is more fully proving the neurotic origin of certain cutaneous diseases. Hitherto it has been supposed that the influence locally of the nervous system was mainly concerned in altering the calibre of vessels (contraction being under the guidance of the sympathetic and active dilatation, the cerebro-spinal nerves), but recent observations by Eckhard, Pfliiger, and Heidenhaim, have conclusively shown that it does more, especially in the case of glands. Pfliiger states that nerve twigs run directly into the cells of the salivary gland, and connect themselves with nuclei; and Heiden- haim, as the result of his researches, believes that nerve irritation, under * " Beitrage zur Physiol, und Pathol. Anat. der Haut," Sitzungsberichte der Wiener Akad., vol. lvi. p. 223. 16 ETIOLOGY. certain conditions, may induce lively cell formation and metamorphosis. There are then three main ways in which the nervous system may act upon the skin (in addition to altering its sensibility, and through reflex action), first, by inducing changes in the calibre of the vessels, and so influencing the transudation of fluid ; secondly, it would seem by encouraging an hy- peractivity in the cell-life; and thirdly, where there is general debility there is lessened nervous control over tissue, the reparative process is not so active, and the skin cannot resist so well as it should external influences that tend to injure it, or induce disease. I have thus far generalized so as to enable the student to comprehend in some degree the general sources and nature of the changes that occur in skin diseases, and to show that in different morbid process, disorder of the blood in one, of the tissue-life in another, and of the nerves in another, areprinci- pally concerned as causes of mischief. But it would seem that not only are blood-tissue and nerve collectively and individually involved in the production of pathological results as regards the skin, but also the lymphatic system, which, however, one would imagine, from the little notice taken of it by the physician, is a thing out of place and of no service. My reasons for thinking that changes in the fibro-cellular tissue and disorder of the lymphatics are related, will be stated under the head of hypertrophies and atrophies, in speaking of keloid, scleroderma, and their allies. Having thus stated the three main channels through which " causes " work, I may "now give a summary of the more generally recognized influences that induce blood, nerve, and tissue change, and I especially enumerate the causes that produce A. Altered States of the Blood-current. They are— 1. Acute specific diseases (virus action), small-pox, scarlatina, ru- beola, etc. 2. The circulation of special poisons, be they animal, ex., syphilitic : medicinal substances, e.g., arsenic, belladonna, copaiba, nitrate of silver (see Erythemata): or dietetic, such as shell-fish, giving rise to urticaria, roseola, erythema. 3. Hereditary diathesis, as in ichthyosis, psoriasis, syphilis, eczema, and lichen, etc. 4. Dietetic errors, as in wine-drinkers, high livers, non-vegetarians • etc.,s leading to the increase of urea and uric acid in the blood. 5. The tuberculous, scrofulous, and lymphatic habits, giving rise to non-specific eruption—ex., impetigo, acne. 6. The gouty and rheumatic diathesis, as in lichen aorius. 7. Altered and lowered nutrition from such causes as bad living, poverty, misery. 8. The accumulation of excreta in the blood from non-excretion, sup- pression of natural discharges, etc. 9. Convalescence from severe and lowering diseases, by which the body is less able to resist disease. ETIOLOGY. 17 10. Climacteric, or endemic influences, often malarial in nature, which act by deteriorating the system generally, and give rise to the framboesia of the West Indies, the sibbens of Scotland, elephan- tiasis and its allies, the plica of Poland, the pellagra of Lom- bardy, the bucnemia, or Barbadoes leg, the Aleppo evil, and Delhi boil, the carate of New Granada, and the podelkoma, or Madura foot of India, and the guinea-worm disease of the Gold Coast and other parts. The above are the main influences that tend to disorder the blood-current, and to induce the diseases whose elementary lesions have been described. B. There are certain states of mal-nutrition in which disordered tissue life seems to be the most prominent, as lupus, cancer, warts, corns. Local irri- tants that cause destruction of tissue rank here also, such as burns, scalds, parasites, the occupation of bricklayers, masons, and washerwomen. C. Influences that play upon the nerves. Sometimes they are morbidly excitable, as in urticaria. All causes of debility tend to perverted innerva- tion, but as a rule local irritants are those agencies that induce nerve dis- order, and lead to diseases in the skin. Ex. : Want of cleanlmess ; altera- tion of temperature; undue exposure to the sun; the action of ordinary local irritants; occupation, giving rise to special causes of local irritation, as cooks, firemen, etc., who have their faces exposed to great heat. Then chronic visceral disease may be reflected through nervous agency to the skin, and so uterine, gastric, intestinal affections often give rise by " sympathy" to chronic congestion of the face and other cutaneous disorders. It is remarkable that the two leading dermatologists of the day—Wilson and Hebra—should totally disagree in regard to the comparative influence of the two great groups of causes, general and local. Hebra is the advocate of the local origin of skin diseases, Mr. Wilson of the general as well as the local. I am entirely with Mr. Wilson. Hebra says, " Much more potent in the generation of diseases of the skin than the internal causes that have their seat in the organism itself, are those agencies which are external to the body, and which affect the skin directly; thus are produced the so-called idiopathic dermatoses." Among the exter- nal causes which he enumerates are climate, clothing, occupation, mode of life, atmospheric conditions, unwholesome handicraft, pressure, friction, con- tusion, scratching, neglect of cleanliness, too frequent or too energetic wash- ing and bathing, irritants used for medical purposes, such as rubefacients, epispastics, the moxa, etc., and epiphyta, dermatozoa, and epizoa. Now, in the instances of handicraft, pressure, friction, and cleanliness, Hebra can best establish his point; but who will say that parasitic disease is entirely local ? There is a general condition of nutrition which must be present before fungi will flourish. The local cause often produces disease because it acts upon the surface of a debilitated subject. A middle course is the one we must adopt. In the majority of cases there is a predisposed state of system, and the actual disease is evoked by local agencies, . 2 18 THE INFLUENCE OF FLxVNNEL AND SCRATCHING. and these, as I have said, act frequently through the nerves of the affected parts. Some of the causes have been called ephemeral, such as in the acute speci- fic diseases ; some persistent, as in lichen, psoriasis, ichthyosis, cancer, lupus, and the like. Some come into action only once in a lifetime. Some are in constant operation, others only at stated periods; so that certain diseases are wont to appear at particular periods of life. Upon the nature of the cause depends the contagious or non-contagious quality of any disease. It is generally held that parasitic diseases and the acute specific are contagious. I shall describe a form of impetigo which is contagious. The special influence of age, hereditary transmission, occupa- tion, and heat, will be found in the opening of the chapter on general diag- nosis. Sex has some influence on the cause of disease ; for instance, males suffer from sycosis, pemphigus, psoriasis, bucnemia, eczema, and epithelioma; and females from acne, kelis, and lupus especially. The Influence of Flannel and Scratching.—Oftentimes the simplest and most commonplace agencies, harmless in health, become active in the inten- sification of diseased conditions. This is the case with the wearing of flan- nel next the skin. We scarcely need more than a reminder of the fact that some skins are so irritable in health as to be excited to an unbearable de- gree by the use of flannel, to understand that whenever there is a tendency to exaltation of the sensibility of the skin, it may not only be heightened by the irritation of flannel, but that this may also give rise to decided physi- cal alteration. In a very large number of cases of skin disease pruritus is in this way intensified and the disease even protracted, and in proportion to the degree of uncleanliness. Flannel acts as a mechanical irritant, by aug- menting the local heat, and intensifying reflex action. When, therefore, a congestive state of the skin, or any disposition to pruritus exists, the flan- nel should be taken off from next the skin, and placed, if necessary, outside the linen ;—this will prevent any " catching cold." The diseases in which this is advisable are, chiefly—erythemata, roseola, urticaria, certainly syphi- lodermata in their early stages, scabies, and prurigo. A remembrance of this little practical point will sometimes give us the greatest cause to be thankful that we attended to it, trifling though it be. Sera tcldng plays an important part in the modification of skin diseases most of which are accompanied by itching; to relieve which scratching is the natural topical application. What does it do ? 1. When there is no eruption, it may produce one. For example in pruritus, it gives rise to excoriations, an artificial eczema, general enlarge- ment and turgescence of the follicles of the skin, with, perhaps abrasion of the cuticle over and above them; wheals in a nettle-rash subject • ecthv- matous pustules in the ill-conditioned. Of course in all these cases there is a basis to go upon—a tendency to the several diseases produced. Scratch a healthy person, and the local injury is soon remedied. DISEASES DETERMINED TO DIFFERENT PARTS. 19 2. It augments and modifies existing eruptions. See in eczema how it inflames it, and increases the discharge and subsequent crusting; in lichen, the thickening of the derma. In scabies it gives rise to the peculiar " scratched lines " so characteristic of the disease, and many of the ecthy- matous pustules; in prurigo, the peculiar ecchymosed apices of the papules, and helps out the coarse urtication. 3. When the disease is non-contagions, secretion, if present, may be trans- ferred from place to place; and if acrid, set up local inflammation; and when contagious, scratching is the surest method of inoculation, as in the case of contagious impetigo. Children in this way transplant the disease from the head to various parts of the body. Mothers, beyond a doubt, get the disease about their hands from contact with children. There are conditions liable to be overlooked, but which determine the local and immediate development of diseases in different parts of the skin. These are not causes in the true sense of the word. I place them here more for reference than anything else. If there be some repetition, it will be excused for the sake of the completeness which will be given to the general survey of the pathology of disease intended to be contained in this section of the work. DISEASES ARE DETERMINED TO DIFFERENT PARTS, Amongst other things, by— 1. The general or local nature of the cause. The whole skin is affected, of course, in acute specific diseases. 2. By physiological changes, in which the opportunity for the occurrence of disease is presented in the non-performance of some proper pro- cess. For instance, at puberty the hair formation and gland func- tions of the skin are called into activity, and any failure in the due formation of hair or the proper performance of the gland function may be a cause of disease, and this is the case in acne. 3. The predilection of parasites for certain structures or parts—for in- stance, the hair in the case of fungi; the interdigits and wrists on the part of acari, the pubis and the head, in reference to certain varieties of pediculi; the parts kept warm and moist by flannel in the case of the fungus of chloasma. 4. The special exposure of certain parts of the surface to external irri- tants—for instance, the face to the fire in cooks, or the face and the bared arms to the sun in out-door workers; the bared legs in the case of the attacks of dracunculus disease ; the lower lip to pipe-irri- tation, evoking epithelioma; the neck to the friction of the collar, inducing boils ; and various parts to scratching by the fingers. 5. Anatomical peculiarities; such, for instance, as the free circulation in the tissues of the face liable to be influenced by all changes of tem- perature. 20 RELATIVE FREQUENCY OF THE DIFFERENT DISEASES. 6. A failure in the proper correlation of function between the skin and other organs, as when the kidney fails to act properly and throws greater work on the skin, which fails to perform the extra labor demanded of it, and so becomes disordered. The transmission of mischief by reflexion—for instance, from stomach to face, or uterus to the face, should be mentioned here. 7. The contiguity to mucous surfaces, from whence inflammatory mischief may travel to the skin. 8. Auto-inoculation, as in contagious impetigo. 9. Gravitation, as in the legs. 10. The special affection of individual nerve trunks in connection with the seat of eruption, as in herpes zoster. RELATIVE FREQUENCY OF THE DIFFERENT DISEASES. Mr. Wilson has recently published " An Inquiry into the relative Fre- quency, the Duration, and Cause of Diseases of the Skin, as deduced from the Observation of 5,000 Consecutive Cases." * This gives a complete view of the matter as affecting the middle and upper, but not the lower classes. The diseases occurred as follow:—Of 5,000 cases 1,677 (33|- per cent.) were eczema, 435 (8*70 per cent.) rosacea (or red rash of the face, especially in women), alphos (psoriasis and lepra), 314 (6-28 per cent.), acne 245 (4'90 per cent.), alopecia 310 (6'20 per cent.), pityriasis 176 (3-52 per cent.), trichosis (ringworm) and scabies 107 and 184 respectively (2*14 and 3*68 per cent.), lichen 177, area 130, and syphilodermata, 162 (3'62, 2*60, 3*42 per cent.). Then follow erythema 110 cases, chloasma 57, furuncle 50 and sycosis 64 each, prurigo 36, lupus (in all its forms taken together) 77, herpes and scrofuloderma 56 and 21, melasma 27, impetigo 58, xeroderma 29, and naevus 9. Then come cancer 25, kelis 14, urticaria 36, ecthyma 16, purpura 2, pemphigus 8, roseola 5, hordeolum 2, morphcea 5, bucnemia 1. Mr. Wilson further groups them together, and forms a clinical classification. Of the whole number 2,711 were eczematous (eczema, rosacea, lichen, scabies, and impetigo), 597 affections of the hair and hair follicles, 204 phytodermic (vegetable parasitic), psoriatic 314; then come sebiparous affections (acne, etc.) 284, strumous 98, syphilitic 162, alterations of color-function 52, ery- thematous 163, furuncular 72, nervous 71, pemphygoid 64, carcinomatous 25, etc. We may gain a very fair idea from the above figures of the general occurrence of skin diseases. * " Journal of Cut. Med.," Jan. 1868. CHAPTER IV. CLASSIFICATION. The object of classification is so to group skin diseases together that the student may be able to obtain at once a general view of cutaneous maladies in their rough outline, and also to compare one disease with others with a view of tracing affinities between them. Much that has been said in the preceding chapter, will help towards a clear conception of what is the best classification; inasmuch as it gave a general idea of the causes and the agencies operating disastrously on the skin. Skin diseases have been grouped in three chief ways : anatomically, patho- logically, and clinically. In regard to the first two, no complete system has been devised, and it is self-evident that the best mode must certainly be that which collects diseases together, and arranges them side by side, in their mutual relationship, as exhibited in practice—in fact, clinically. Plenck and Willan's classifications formed the first step towards a clinical groupage, Alibert made an advance, and Mr. Wilson has still further developed the matter. The system of Willan and Bateman was follows:— Order 1. Papulce, including strophulus, lichen, prurigo. Order 2. Squamce, including lepra, pityriasis, psoriasis, ichthyosis. Order 3. Exanthemata, including rubeola, roseola, scarlatina, purpura, urti- caria, erythema. Order 4. Iiullaz, including erysipelas, pompholix, pemphigus. Order 5. Pustnla; including impetigo, variola, porrigo, scabies, ecthyma. Order 6. Vesicula>, including varicella, rupia, vaccinia, miliaria, herpes. Order 7. Tubercula, including phyma, sycosis, verruca, lupus, elephantiasis, vitiligo, molluscum, acne, framboesia. Order 8. Maculae, including ephelis, spilus, naevus. It is now quite conceded that some of the details in this arrangement are erroneous, and that the system requires development in accordance with recent advances in pathology. I have turned with no little anxiety to the new nomenclature of diseases prepared by the College of Physicians, to see whether any aid could be obtained towards the establishment of a new classification, but find that the detailed arrangement of diseases of the skin is altogether old and unsatis- factory. We are told in the preface that, after much consideration, the committee have resolved " That the proposed classification of disease should be based upon anatomical grounds," and in subservience to that conclusion, the diseases of the body are found to be classified according as they are 22 CLASSIFICATION. general or local. Now, changes in the skin are found in diseases that rank in both these classes, and the diseases in which they occur may be grouped according to the arrangement recommended by the College of Physicians, as follows:— 1. General diseases, such as affect the whole frame rather than any spe- cial part of it, divisible- into two sections, A and B. Section A, comprising diseases that " involve a morbid condition of the blood, and which present for the most part, but not all of them, the follow- ing characters:— " They run a definite course, are attended with fever, and frequently with eruptions of the skin, are more or less readily communicable from person to person, and possess the singular and important property of generally pro- tecting those who suffer them from a second attack. They are apt to occur epidemically." Under this head are included the acute specific or zymotic diseases,— cholera, plague, dengue, typhus, typhoid, rubeola, scarlatina, yellow fever, small-pox and its allies, cerebro-spinal fever, glanders, farcy, equinia, ery- sipelas, malignant pustule. In the majority of these diseasesj of course, the skin-mischief is of secondary importance. Section B " comprises, for the most part, disorders which are apt to invade different parts of the same body simultaneously or in succession. These are sometimes spoken of as constitutional diseases, and they often manifest a tendency to transmission by inheritance." Here we have both rheumatism and gout, syphilis, cancer, lupus, rodent ulcer, true leprosy, scrofula, purpura, scurvy. The definition of the rodent ulcer, as given in the new nomenclature, is this—" a destructive ulcer, characterized by the extent and depth to which it spreads in the adjoining structures, and by the absence of preceding hardness, and of constitutional affection;" but absence of constitutional affection is one of its prominent features: why place it then with constitutional diseases ? It may be a question whether Delhi boil, the Aleppo evil, and framboesia, which are probably of kindred nature, and endemic in certain districts, should not be ranked under this head : for it is believed they are due to general causes. 2. The second main division, as contrasting with that of general, is local diseases, and here there is a real step made in regard to the plan su^o-ested for the arrangement of all local diseases. The local diseases, in the College of Physicians' scheme, are regarded as severally falling under one of the following heads:—Inflammatory, i.e., catarrhal, ulcerative, suppurative plastic, pyozmic, rheumatic, gouty, (431) syphilitic, (491) scrofulous, and gonorrhceal inflammation. Gangrene; passive congestion * haemorrhage. Dropsy. Fibrinous deposit. Alteration of dimensions, including dilata- tion, contraction, hypertrophy, atrophy, degeneration, fatty and calcareous. Ossification. Fibroid, lardaceous disease. Waxy disease. (431) SypJd- litic disease. (441) Cancer. (451) Colloid. Non-malignant tumor. Cyst. (491) Scrofula, (49°) a. with tubercle, (49b) b. without tubercle. Parasitic CLASSIFICATION. 23 disease. Calculus and concretion. Malformation. (992) Injury. (1014) Foreign body. Functional diseases. The diseases printed in italics are directed to be returned, in any classification of disease that may be made for statistical purposes, not among the local diseases, but under the head- ings refened to by number; which are, in the case of 31, Section A of general diseases, and the others Section B of general diseases before refer- red to. Now, this plan is directed to be applied to the grouping and description of the various local diseases of the ear, mouth, nose, circulatory, digestive, respiratory systems, etc., but this has not been done in the case of diseases of the skin: they are indeed the only exception, and that is why I stated at the outset that the detailed arrangement of diseases of the skin in the new nomenclature report was old and unsatisfactory. I shall supply the omission as far as possible, making catarrhal: plastic: suppurative : gangrenous inflammations of the skin, etc., in agreement with the College plan, as that is entirely in accord with my views of cutaneous pathology. Now, with the aid of these particulars, and in conformity therewith, let us see what are the diseases in which the skin is specially affected. We have the following diseases to deal with :— 1. Eruptions in acute specific diseases. 2. Skin changes in constitutional diseases: syphilis, struma, cancer, lupus (? local), rodent ulcer (? local), leprous (elephantiasis). 3. Local inflammations, which, according to the views I entertain, would be arranged thus: erythematous or congestive : catarrhal (eczema) : plastic (lichen): suppurative or pustular: ulcerative: gangre- nous, etc. 4. Haemorrhages. 5. Degenerations, lardaceous disease. 6. Parasitic. 7. Hypertrophies and atrophies. But these do not include all. We have besides, bullous and squamous diseases, disorders of the special structures of the skin, (a) of pigment for- mation, (b) of the nerve supply, (c) of the vessels, (d) of the glands of the skin. Going a step farther, we may construct the following classification, which is the clinical scheme of Mr. Wilson, somewhat condensed:— 1. Zymotic diseases (eruptions of acute specific diseases). 2. Local dermal inflammations,—erythematous : catarrhal or eczematous: plastic or lichenous: suppurative or pustular : bullous. 3. Diathetic, including strumous, cancerous, syphilitic, leprous (or true leprosy), and alphous (or lepra vulgaris) diseases. 4. Hypertrophic and atrophic diseases. 5. Hemorrhagic (purpura). 6. Neurotic or nerve disorder, pruritus, prurigo, etc. 7. Chromatogenous or pigmentary alteration. 24 CLASSIFICATION. 8. Parasitic, animal and vegetable. 9. Diseases of the glands and appendages of the skin. This is the classification which I recommend the student to adopt. There are those who will miss the group squamous; it has usually in- cluded pityriasis, which ranks with epithelial hypertrophy: ichthyosis, which is only a part of general atrophy of the skin: and lepra vulgaris, which is a very special disease, that I have grouped under the term alphous. It is impossible that three such dissimilar diseases can be classed together under the term, squamous. (See Summary.) CHAPTER V. GENERAL DIAGNOSIS, PROGNOSIS, AND TREATMENT. I. GENERAL DIAGNOSIS. In making a diagnosis we should remember that modifications of disease are brought about by diathesis, by chronicity, by remedies, by scratching, by abortive development, and by the intermingling or coexistence of two or more different diseases. The following are the " points" in diagnosis which we should carefully note in the first instance. THE MODE OF ONSET. The majority of cases of diseases of the skin are not preceded or even accompanied by severe constitutional disturbance; if there happen to be much fever and malaise, especially when the patient takes to bed from a sheer feeling of illness, and an eruption begins to show, we suspect some- thing grave, one of the acute specific diseases probably. However, amongst the occasional exceptions, acute lichen, erythema nodosum, secondary syphilis, acute eczema, pityriasis rubra, acute pemphigus, urticaria, herpes zoster, and erysipelas may be named. Secondary syphilis has been mistaken for the mottling of typhus and measles, acute lichen for measles, and herpes zoster for pleurisy, on account of the pain. It is merely necessary to be aware of these mistakes to avoid them. Occasionally in eczema there may be mai-ked pyiexia. When symmetrical, the disease is usually due to a blood-poison ; when unsymmetrical, to local causes or perhaps affections of the nervous trunks. TEMPERAMENT. We are generally enabled to say at a glance whether our patient is of full habit and likely to have a loaded system: especially the case in women ; whether there be organic disease, or if there be a dyspeptic habit, or an ill- fed system, that signifies debility. If lymphatic, the patient may have eczema, impetigo, intertrigo, the pustular aspect of scabies and ringworm; if gouty, the scaly diseases, chronic eczema, and lichen agrius; if rheumatic, erythema nodosum ; if strumous, eczema, lupus ; if florid, alphos especially. There is also the cancerous cachexia, and in nervous subjects various hyper- sesthesiae engrafted upon ordinary eruptions. Bed-haired subjects get pity- riasis of the scalp. THE DURATION OF THE DISEASE. Hereditary diseases are chiefly—lepra, psoriasis, ichthyosis, lichen, ecze- ma, and syphiloderma. 26 GENERAL DIAGNOSIS. Congenital diseases—syphilodermata, pemphigus, pigmentary, n»vus, and ichthyosis (scales). Chronicity.—The more chronic a disease is the more does it tend to be- come a local disease; and this is the case with hereditary affections (hence in these cases local treatment is the most important). THE RECURRENCE OF THE DISEASE. Lepra and syphilitic diseases are essentially those which recur. OCCUPATION OF THE ATTACKED. Cooks get eczema and erythema, and with bakers, grocers, and bricklayers lichen agrius about the backs of the hands; chimney-sweepers are liable to epithelioma of the scrotum ; cotton-workers to urticaria ; butchers and gra- ziers to whitlow, boils, and malignant pustule; dragoons and shoemakers to eczema marginatum in the fork of the thighs; young women who come from the country and have the full diet fare of the London servants, get an overloaded system that shows itself in erythema papulatum, erythema no- dosum, or impetigo ; butchers frequently get ecthyma. AGE OF THE PATIENT. This is very important. During the first six weeks of life congenital syphilis develops itself; intertrigo, eczema of the scalp, and seborrhoea capillitii also occur about the same time. Syphilitic pemphigus occurs, it is said, before the child is six months old, not afterwards; during the first few months and up to and through the period of dentition, strophulus and eczema are met with. I need only mention important facts. Cancer (epi- thelioma) is a disease of late life—not before thirty ; about sixty : and ro- dent ulcer about the age of sixty and beyond. Lupus is a disease which commences in early and young life, and the same may be said of syphilis. The parasitic diseases occur in the young, rarely after twenty-one years of age. Herpes circinatus (or, as I call it, tinea circinata) is the form seen in adult life. In old people, prurigo, ecthyma cachecticum, pemphigus, and pruritus, with cancer and rodent ulcer, occur. THE SEAT OF DISEASE. On the scalp we frequently have parasitic diseases, kerion, eczema im- petigo, sebaceous cysts, alopecia, and lepra; ears, eczema; forehead, lepra and herpes zoster; near the eye, chromidrosis, rodent ulcer, xanthelasma or vitiligoidea, molluscum; face generally, acne, impetigo, contagiosa, erysipe- las, lichen, syphilitic eruptions, erythema; nose, lupus, acne rosacea; cheeks, lupus, malignant pustule, acne rosacea; upper lip, impetigo sycosiforme herpes labialis ; lower lip, epithelioma; chin, sycosis; whiskers, acne sycosi- forme; angle of mouth, congenital syphilis; chest, chloasma and keloid; under clavicle, sudamina; about the nipples in women, scabies; in the side shingles; outer and posterior aspects of trunk, prurigo and lichen, as dis- GENERAL DIAGNOSIS. 27 tinguished from eczema on the inner and front aspects ; elbows and knees, lepra, psoriasis; interdigits and about vjrists, scabies ; back of hands, lichen and grocers' and bakers' itch ; palm of hands alone, syphilitic lepra and ery- thema ; buttocks and feet of children, scabies; upper line of penis, scabies ; scrotum, eczema, psoriasis, and epithelioma in chimney-sweepers ; front of leg, erythema nodosum, and in old people, eczema rubrum; about the anus in children, congenital syphilis ; travelling or developing, and affecting gen- erally over the body, pemphigus foliaceus and pityriasis rubra; in the bend of joints and armpits, eczema rubrum ; and limited to the hair follicles, lichen and pityriasis pilaris ; and to these and the sebaceous glands, lichen scrofulosus and lichen ruber. It is important to ascertain if the eruption be persistent or evanescent (urticaria), developed pretty much at once (acute specific diseases, herpes zoster, herpes), or consecutive, and particularly if uniform or multiform: the latter being the character especially of scabies and syphilodermata. It is (rarely) seen in the complication of scabies by impetigo contagiosa ; urti- caria, and scabies, or purpura; scabies and prurigo, eczema and scabies, ec- zema and lichen (eczema lichenodes), eczema and psoriasis, oftentimes in the fork of the thighs and about the bend and front of the elbow. This fact of the intermingling of diseases is one of the most important to remember ; to forget it is to lay one's self open to one of the commonest sources of error. We scrutinize closely the character of the eruption to ascertain the j»rt«i£- tive elementary lesion. This is the clue to the nature of the eruption. I will now give the DIAGNOSTIC FEATURES OF ERUPTIONS. Macula} (see pp. 6 — 20). Erythemata.—There is no need to particularize that of the acute specific diseases. Mistakes generally occur with roseola, which is confounded with erythema papulatum and rubeola; but it is never accompanied by distinct catarrh; it is rose-colored at first, gradually getting duller, non-crescentic, occurring in circular patches from half an inch to an inch in diameter ; not on the face ; it is often very partial. In acute diseases erythema oftentimes occurs about the arms and limbs, as in cholera or rheumatism. Ordinary erythema is of a darker hue than roseola: it has a bluish tinge at its edge, and is not so well defined—i. e., is more diffuse. Erythema may also arise from friction; from tension, as in oedema; from medicinal substances, as henbane, arsenic, belladonna, copaiba; and after operations, when it is often pyaemia The erythema of erysipelas is accompanied by tension, shining, smarting, and swelling. E. scarlatiniforme presents all the characters, as regards the rash, of scarlatina, but lacks its general throat symptoms and the peculiar appearance of the tongue. The rash is seen about the neck, the flexures of the joints, and the trunk; it lasts five or six days, and is often more or less evanescent. The rosalia of authors—rubeola notha, or rubella—holds the same relation to rubeola that E. scarlatiniforme does to 28 GENERAL DIAGNOSIS. scarlet fever—that is to say, there is an absence of the general symptoms, whilst the eruption is similar. In all these cases of acute febrile erythe- mata desquamation is observed. In every instance the redness disappears or is removable by pressure, unlike that of purpura or pellagra. In lupus erythematodes an erythema like chilblains is common; it occurs in summer as well as in winter, and is connected with loss of hair, etc. The erythema of urticaria is very easily diagnosed : a slight scratching with the nail will produce a wheal. Papula?, on the outer aspect of the limbs, with a thickened dull state of skin, constitute lichen; those with slightly dark apices (coagulated blood), occur on the arms and anterior aspect of the trunk, as a complication of scabies and of strophulus (pruriginosus) in children; to a marked extent seen in pru- rigo, accompanied mostly by an inelastic state of skin and the " broad" papules formed by an exaggeration of the little areas enclosed by the natural furrows of the skin: intermingled with vesicles and pustules in scabies; soft and red, and with erythema in children, in strophulus; flat and reddish, collected together in little parcels, though discrete, lichen ruber ; aggregated and confluent, lichen circumscriptus; formed about the hair follicles, lichen pilaris, pityriasis pilaris, lichen scrofulosus, and the lichen of phthisis. The most common mistake, that of confounding lichen and scabies, is at once avoided by observing the multiform aspect of the latter and the uniform character of the former. Those eruptions in which vesicles and pustules occur are eminently char- acterized by the occurrence of discharge; and this at once divides diseases into two great classes: in the one class, where secretion or discharge occurs, crusts form; in the other, crusts are entirely absent. Ulcerative diseases are easily recognized. The character of the secretion affords most reliable information. If there be serosity, without crusts, it is intertrigo ; if thin, few, flimsy, light-colored crusts form, and the discharge stiffen linen, it is eczema : if the crusts be a little thicker and in little circular patches, herpes or vesicular scabies. Sero-purulent, with slight yellow crusts, eczema im- petiginodes; or if stuck on and flattened, impetigo contagiosa; purulent, forming thick crusts of a yellow color, becoming more or less dark, ec- thyma, furunculus, purulent scabies, impetigo sycosiforme, impetigo scabida, sycosis ; and if cockle-shaped, rupia, of course. Sanious, rupia and ecthy- ma cachecticum. Fatty, acne sebacea, seborrhcea, sebaceous ichthyosis (legs). Hemorrhagic, haemidrosis, etc. We must distinguish scales from crusts: scales are altered epithelial cells. Redness with scales, lasting on to chronicity, is seen in tinea circinata, ery- thema circinatum, and herpes iris. Scales, as a primary formation, if par- tial, in lepra ; if general, ichthyosis. Tubercida.—There are four diseases somewhat alike, in which " tubercula" occur : their characters are as follows :— Cancer {epithelioma) tubercules.—Solitary, flat, hard, and tender. Scabs slight. When ulceration sets in the glands enlarge. There is much infil- tration around the ulcer, which is papillated, dirty-grayish, ichorous, or THE PROGNOSIS. 29 semi-scabbed, with hard, everted, and undermined edges. Epithelial ele- ments may be seen by the microscope. Portent ulcer begins as a small, pale, pretty soft tubercle, of very slow growth, almost painless, giving rise to an ulcer, without glandular enlarge- ment, presenting a clear surface, not papillary, without ichor, but with hard, sinuous, non-everted, and non-undermined edges. lupus has at its base an erythema that looks like searing; then upon this arise dullish-red, softish, round, gelatinous-looking tubercles, forming patches of various extent. Thin adherent crusts form. There is no pain. The course is indolent. The edges of the patches are inflammatory, rounded, and raised, but not everted. There is always a tendency to repair, and cicatrices form, accompanied by distinct loss of substance. Syp>hilis.—Tubercles commence as papules; they become hard, large, and flattish, but not so flat as those of lupus; they are dull-red at first, then coppery, and disposed in circles, or serpiginous, covered by thick dark scales. There is an ulcerating and a non-ulcerating form, the ulceration being often serpiginous and misnamed " lupus." Syphilitic tubercles often occur about the face. The ulceration is dirty, ashy gray, sloughy, and ichorous, the edges sharply cut and everted, surrounded by tubercles of a copper tint. With regard to parasitic diseases, no serious difficulty ought to arise if a microscope is at hand. Nevertheless, favus and impetigo are confounded with lepra, eczema, and tinea tonsurans, notwithstanding the cupped-crust favi of the former and the dry nibbled patches of the latter, in which the epithelial cells and hairs are freely invaded by the fungus, when this is easily detected. Chloasma, with its itching and desquamation, is very frequently indeed mistaken for syphilitic maculae. Sycosis is often non- parasitic ; in this case, the damaged split-up hairs will be absent, whilst the disease travels up into the whiskers. I hope that this section is so arranged as to constitute a general diagnos- tic chart. II. THE PROGNOSIS. Skin diseases are rarely fatal. When they occur as secondary manifesta- tions implanted upon already existing disease, especially those of long-stand- ing and in debilitated subjects, they are to be regarded according to their extent and nature as indications for grave anxiety. However, pemphigus neonatorum, ecthyma cachecticum, rupia, pemphigus foliaceus, are most likely to be followed by fatal results. Malignant diseases, of course, have a fatal issue. The sudden retrocession of cutaneous eruption is generally considered a most prolific cause of serious consequences; there can be no question that the latter frequently follow the former, but the modus operandi of the supposed cause is uncertain. Hereditary tendencies, especially when exhibited in a congenital manner, render the cure exceedingly difficult; in some cases, for example ichthyosis, 30 THERAPEUTICS. impossible. The older the patient is before hereditary predisposition shows itself, the more likely is he to get well. The presence of the scrofulous or syphilitic habit, mal-hygiene of all kinds, frequent recurrence, coexistent disorder of the mucous surfaces, such as ophthalmia, otitis, muco-enteritis, local degenerations of tissue (as in acne rosacea), the fact of a disease having become very chronic, symmetrical arrangement of the eruption, intemperate habits, dyspepsia, uterine disorders (such as leucorrhcea), denti- tion, old age, or very young age, all conduce to protract and render the cure difficult. As a general rule, a prognosis is required, not as regards fatality or danger, but the difficulty of cure, and particularly the likelihood of recur- rence. Lepra, psoriasis, ichthyosis, erysipelas, eczema, urticaria, and lichen, are the most likely to recur. All parasitic diseases are curable, and this depends upon the facility with which the parasite can be attacked and destroyed. In case of loss of hair, a cure is said to be impossible if the hair has been lost pretty suddenly; and generally, if there happens no subsequent attempt at reformation, the scalp at the same time being white, shining, tense, lowered in sensibility, and apparently with atrophied and indistinct follicles. In all cases of skin disease the earlier the patient comes under treatment the more likely is he to get rid of the cutaneous eruption; in other words, the most important point as regards speedy cure is early treatment, before the disease has had time to become localized. III. THERAPEUTICS. Bearing in mind what has been said, and especially having regard to the classification I have adopted, it is easy to see that the same principles of treatment which are applicable to diseases of the body generally, must be adopted in reference to affections of the skin. The basis of most cutaneous eruptions is inflammation—that must be treated upon ordinary principles ; we must not forget that, in the early states of eruptive disease, local irrita- tion plays a very prominent part. One of our chief aims should be to check and prevent this, adopting as much as possible a soothing plan of treatment. This does not appear to be the generally received opinion; nay, the empiricism of modern time has an exactly opposite tendency, and it is decidedly true that many treat skin diseases by attempting to overwhelm by medicinal action the natural progress of the disease. In a therapeuticcd point of view, skin diseases divide themselves into two classes—those which are purely local, and those which are general. Among the local, practically speaking, are parasitical, papillary, naevoid, hypertrophies of normal structures, such as molluscum, keloid, horns; certain pigmentary changes; chilblains, burns, scalds, etc. Among the general are blood diseases of acute and specific character, which require mere conduction through their natural stages; others are due to various degrees of debility, demanding general tonic or alterative action, THERAPEUTICS. 31 or the employment of specific remedies. In all cases special attention must be directed to the influence of diathesis; the gouty, the scrofulous, the rheumatic, the sanguineous, the syphilitic, the dartrous, etc., call for their appropriate remedies irrespective of the kind of local eruption ; or, to put it in another way, the general treatment varies in the same disease accord- ing to the general aspect of the patient; all deviations from the standard of health must be rectified before or in conjunction with the employment of spjecial medicines. In a large number of cases, disorders of the general health which appear to have little connection with the mischief, are the exciting or determining causes. In reference to local treatment in the general diseases, the idea is to soothe the part at the outset, in the secretory stage, to use alkaline washes and slight astringents; in the quiescent or early chronic stage, mild stimulants, absorbents, and finally revulsives; taking care in all cases to remove crusts, scales, and such-like by poulticing, warm foments, or greasy applications. In the very young the health of the nurse requires attention, and it is often advisable to make the milk of the nurse the medium of medicinal action. The use of irritants is to be specially avoided in the young, whose skin is delicate. In all wet diseases (the secretory) the local remedies should be used in a liquid form; in the dry, in the form of ointment; the formation of thick crusts does not seem to be favorable to the use of ointments. The free action of the kidneys must be carefully enforced. It is one of the most important points in treatment. In chronic diseases, dyspepsia is often present. In the secretory aspects, purgatives do good. Antiphlogistic remedies are bloodletting, emollients—e.g., the tepid bath, mucilaginous and acidulated drinks, but especially the acetates of ammonia and potash. When we wish to preserve the eruption from being injured for fear of ulceration, as in zona, pemphigus, and rupia, we employ mucilaginous fluids —e.g., oatmeal gruel; or even absorbent powders—e.g., lycopodium. Local maceration, by glycerine especially, is useful in hard, dry, cracked states—e.g., psoriasis palmaris. Irritation, if general, is allayed by tepid sponging, gelatinous and alkaline baths. Baths are useful for purposes of cleanliness, also as antiphlogistics, as soothing agencies, and as a means of employing various medicines. The anti-scrofulous remedies are cod-liver oil, iodides of iron and potassium internally, and iodide ointments, iodine baths, and the like externally. The anti-herpetic, as they are called, are typified by sulphur. The nervine tonics are quinine, alkalies, aconite and strychnine, alkaline baths. The anti-syphilitic are bichloride of mercury and iodide of potassium internally, and mercurial ointments externally. The gouty remedies are colchicum and alkalies, etc. The sanguineous, antimonials, etc. The anti-squamous remedies are arsenic internally and tar externally. I fear to add further detail on account of repetition. CHAPTER VL THE ERUPTIONS OF ACUTE SPECIFIC DISEASES (ZYMOTIC)—WHICH ARE OF CON- TAGIOUS NATURE, OF DEFINITE COURSE AND DURATION, ACCOMPANIED BY FEVER, THE RESULT OF POISONING OF THE BLOOD BY SPECIAL VIRUSES-- ONE OF THE EFFECTS BEING THE DEVELOPMENT OF CERTAIN ERUPTIONS ON THE SKIN. These need not be dwelt upon at any length, at the same time it is neces- sary to give a short summary of the eruptions themselves, for diagnostic purposes. VARIOLA, OR SMALL-POX. The skin affection is characterized by the appearance of bright red hard acuminated points, distinct from each other at first, the size of hemp seeds, which, passing through the stages of vesicular and pustular inflammation, arrive at their maturity on the eighth day of eruption, when they scab into a dry brown mass, which becomes detached in from twelve to twenty days, leaving behind permanent cicatrices or "pits." Small-pox is often pre- ceded, as regards its local state, by more or less erythema, which subsides on the appearance of the vari. Small-pox is said to be discrete, when the pustules are scattered; coherent, when the eruption is plentiful, and the vari are " closely packed side by side but still distinct;" confluent, when they run together ; modified, if succeeding to a prior attack or inoculation. The disease is also primary or secondary, as regards the number of attacks. Variola sine variolis is the name given to the febrile attacks which are un- attended by eruption. The mucous surfaces are affected in like manner to the skin. Small-pox is, by universal consent, divided into five stages,— incubation, the length of time which elapses between exposure to the poison of the disease, and the development of the first effects, (5—20 days—Dr. Marson, of the Small-pox Hospital, says 12): invasion (2 days): eruption: suppuration: and desiccation. The "Period of Eruption^—Eruption makes its appearance on the third day after the first appearance of constitutional disturbance, and travels over the entire body within a day, when the febrile condition is greatly relieved. The spots show first on the face about the forehead, and thence extend to trunk and limbs. These spots are, in the very outset, small papules, red, hard, pointed, more or less closely packed or scattered, affording a good guide as to whether the disease will be confluent or not; if the skin be very red and erythematous, probably the case will assume the confluent form. On the second day of eruption—fourth of disease—the papules get trans- MODIFIED VARIOLA. 33 formed into vesicles ; but if these be punctured, nothing escapes; on the third day of eruption—fifth of disease—umbilication commences as a cen- tral depression, which becomes more marked every day, pari passu with suppuration; the pustules are " whitish and surrounded by an mflamed areola " (fourth day of eruption—sixth of disease) : if the contents of the pustule are now turned out, a little " disc " of dirty plastic matter, present- ing an umbilicated shape, and attached to the cutis beneath, will be noticed. In the confluent form these changes are not distinctly seen. It is not at all unusual to observe the confluent in one, the discrete form in another part of the same subject. The onset of Maturation is observed about the end of the fifth or beginning of the sixth day of eruption, eighth of disease. The contents of the umbilicated vesicle soften down into pus, the umbilica- tion diminishes with enlargement of the base of the pustule, and a yellow color replaces the white ; the contents are the same plastic disc and pus. Maturation, as it is called, is " complete on the eighth day of eruption," tenth of disease ; between the eighth and eleventh day, tenth or thirteenth of disease, secondary fever sets in, when the stage of Desiccation is reached. This is the period of recovery or resolution, when the local and general symptoms subside, the scabbing dries, and the discharge ceases, the crusts fall off in the next three or four days (fifteenth day of disease), exposing raw red surfaces, which desquamate, and by-and-by leave behind red-looking marks, which gradually fade and assume the well-known aspect of small- pox marks. When small-pox is produced by inoculation there are some differences. On the third day the puncture is inflamed, it is itchy, and sur- rounded by a little blush of redness, the spot too is slightly indurated; on the fourth or fifth day the central point acuminates, and a little coming vesicle is seen; on the sixth day there is an early state of pustule, and it is umbilicated; seventh day, a pustule (inflamed) is formed with an inflamed areola; ninth to tenth day, maturation takes place, umbilication goes; twelve to fifteen days, desiccation takes place; twenty to twenty-five days, the scab falls off. The disease is rarely confluent. MODIFIED VARIOLA. The effect of vaccination is to lessen the severity of variola, and the dis- ease occurring in vaccinated subjects is called modified small-pox. There are differences of opinion as to whether there is any relation be- tween it and varicella. The distinction of varicella (vesicular), modified small-pox (varioloid, as it has been termed), and variola is well marked in the extreme degrees of either disease, but they shade the one into the other by insensible stages. At times one meets with cases which may be called either variola or varioloid,—indeed it is not uncommon to observe the vesic- ular in conjunction with the umbilicated form; at other times the eruption is simply papular and scarcely reaches the vesicular stage, yet is traceable to the action of the small-pox poison. Varicella has been regarded as small- 3 34 VARICELLA. pox modified by vaccination, but there is good reason to look upon it as a distinct disease. In modified variola, as compared with true variola, the secondary fever is absent: the only stages present are those of primary fever and eruption. As a rule the pyrexial symptoms partake of the character of those of vari- ola, but are of less severity. The eruption may be papular ; it observes the same behavior as that of variola in the outset, only it is abortive at the papular stage, and in a few days the papulae subside ; there are a few vesic- ular and pustular spots generally about the face. At other times the vesicular stage is reached, and lasts five or six days, and, as in the papular variety, there are a few pustular spots on the face. In more marked in- stances, the modified variola is pustular, and the pustules may be globular (the varicella globularis of Willan, and swine pox of old authors) or um- bilicated, or the characters of these two varieties may be intermingled with conical vesicles. In other words, modified small-pox may abort in any of the stages which are passed through by ordinary variola. VARICELLA. This is a disease of children. After pyrexia of a few hours, or not more than twenty-four, the eruption of varicella appears, often on the back first of all, as distinct red papulae, which become vesicular in a few hours : the eruption is successive during three or four days. The same kind of changes in the eruption occur as in variola, but the disease is more superficial and the vesicle is unilocular, it is not umbilicated ; the contents are serous. On the first clay the vesicles are transparent, opalescent on the second and third day, on the fourth they shrink and desiccate, and on the sixth the scabs fall off. Sometimes the contents of the vesicles become puriform. The general symptoms are slight. It is diagnosed from the vesicular variety of modified variola by less se- verity in the antecedent pyrexia, the absence of the " shotty " feel of the erup- tion in its papular stage, the rapid formation of the vesicles, the absence of much inflammatory local hardness, the successive crops of eruption its com- mencement on parts other than the face, the absence of pitting the super- ficial character and the shortness of the course of the disease, and the absence of secondary fever. The disease is over in a week or so. INOCULATED VACCINA, OR VACCINATION. On the third day after vaccination there is seen a shVht red point if a puncture, or a red edge if a scratch, has been made ; the part is also eleva- ted. On the fourth day these signs have augmented; the papular stage is attained; there is local irritation; the edges of the wound are everted thickened, inflamed, hot, with a commencing blush of redness around. The disease may subside at this stage ; usually on the fifth day the epidermis is raised into a vesicle, which is decided on the sixth day, when it is of a whitish color, round or roundish, and with commencing umbilication. It attains TYPHUS RASH. 35 its full size on the eighth day (fifth of eruption), it is distended, flattened, whitish, and surrounded by a red areola, and more or less induration; the parts around now become irritated, tense, brawny ; the glands enlarge ; the blush of inflammation extends oftentimes to the shoulder, or down the arm itself. On the ninth day the umbihcation is lost, and the pox is getting pustular. If the vesicle is punctured, around the edge especially, a transpa- rent fluid exudes. On the eleventh day, the blush of inflammation begins to subside ; the contents are pustular, and the stage of desiccation commences. Up to this period the vaccine vesicle is chambered, so to speak, into sep- arate cells ; these now open the one into the other, and form one large pus- tule; the desiccation advances from the centre in the next few days (12th, 13th, 14th) towards the circumference ; the crust dries also, so that a dark, hard, dry, shrivelled scab remains; the redness has in great measure gone, but there is a lividity about the vesicle; the crust separates from the seven- teenth to the twenty-fifth day, leaving behind cicatrices, at first of dark color, which are permanent. Mr. Wilson, who is so excessively clear and definite in all his descriptions touching variola, recapitulates thus in regard to the stages of the disease. First two or three days, incubation • 4th, papular / 5th to 8th, vesicular (umbilication); Sth day, areola / 9th to 11th, pustular, umbilication lost, areola enlarged ; 15th to 17th, period of separation. TYPHUS RASH. This consists of two component parts:— 1. A subcutaneous mottling, of a more or less livid hue, and diffused gen- erally over the body. 2. Petechiae, small, about the size of pins' heads, scattered all over the body, and showing out from the mottling; at first these are slightly raised, and their color increases gradually in intensity; they do not fade by pres- sure, except slightly, in the very early stages. The eruption of typhus is not prolonged by successive crops. It makes its appearance between the fifth and eighth day of disease, and disappears a few days before convalescence. TYPHOID RASH Is characterized by the appearance between the eighth and twelfth day of disease of rose-colored, elevated, circular, softish spots, about a line or so in diameter, on the abdomen, back of hand, arms, chest, and back (if kept warm). They disappear by pressure, appear in successive crops, each spot lasting three or four days, and then gradually fading. There may be from half a dozen to a score at one and the same time present. Sudamina often coexist. RUBEOLA (MEASLES), OR MORBILLI. About the fourth day after taking ill with catarrhal symptoms the erup- tion appears, first on the face, especially the forehead, then on the chest 36 SCARLATINA. and limbs ; it reaches its height in the former situation in about two days, when it begins to fade. These changes are a little later on the other parts of the body. The eruption lasts altogether about four or five days, and leaves behind sometimes little, at other times a marked amount of desqua- mation, perhaps a good deal of mottling or red staining, especially if the cir- culation has been inactive. The rash has peculiar features ; it is of a dullish red color and forms little crescentic or semilunar patches of variable size, affect- ed by the pressure of the finger, and separated by natural skin. The color also may be livid if the blood state is bad. The crescentic form is supposed to be due to the peculiarity in the distribution of the cutaneous filaments of the nerves. The whole mucous surfaces are also affected, as may be seen in the palate, &c. Diagnosis.—The characteristic points are the crescentic form, with inter- vals of normal skin; dull red color of eruption, which appears on the third or fourth day; the presence of catarrh of the mucous surfaces, especially in the form of coryza. In scarlatina the color is bright red, and the rash is uniform, not cres- centic ; it appears also on the second day; the skin is ,very pungent and dry ; there is sore throat, the tongue is raw at the tip, or slightly furred, with red points peeping through to the surface: there is no coryza. In Roseola the patches are scattered, circular in form, not made up of crescentic portions, with intermediate healthy skin; the color is bright, and there is an entire absence of general symptoms, and coryza, &c. SCARLATINA. On the second day of illness the rash appears on the neck and face, and is made up of small red dots, which crowd together, forming patches of various sizes and extent; after a while the whole surface becomes of an uniform hue; on the third day, the eruption is seen on the body generally, the upper ex- tremities, and the mucous surfaces visible to the eye ; on the fourth day, the lower limbs are scarlet, the surface is hot, dry, and harsh; the eruption which may be called a general efflorescence of boiled lobster color, is most marked on the third to the fourth day, and it is generally more intense in color towards evening, especially in the loins and flexures of joints. On the trunk it is often " patchy." It fades on the fifth day—first on the face desquamation setting in about the eighth or ninth day. The diagnosis between scarlatina and rubeola is the only one that requires notice. In scarlatina the rash appears on the second day, in measles on the fourth after the first onset of symptoms. In scarlatina, the rash is bright red (boiled-lobster color) ; it is not crescentic, and it is uniform or not patchy, with intervals of normal integument. In rubeola, the rash is dull red, in little crescentic patches, with intermediate lines of healthy skin. The skin in scarlatina is very dry, harsh, and pungent. In measles this is not so marked, nor is the subsequent desquamation so distinct and characteristic. ERYSIPELAS. 37 In measles the changes in the mucous membranes are accompanied by secre- tion ; we have coryza, suffusion of conjunctiva;—in scarlatina, the mucous surfaces are red, dry, ulcerated; there is also sore throat of marked kind,— this is absent in rubeola. The aspect of the tongue is characteristic in scar- latina, and the pulse is very rapid and irritable. ERYSIPELAS. Erysipelas belongs to the domain of the general physician, and to skin pathology only to a slight extent, in so far as the evidences of the blood and tissue alteration produced by its special poison are shown to the naked eye. It is an acute diffused inflammation, ushered in by constitutional symp- toms, and exhibiting itself locally by the. presence of heat, tension, smarting or burning, over a surface disposed to vesicate; with a tendency to spread rapidly in extent, with more or less implication of the subcutaneous cellular tissue and the formation of abscess or gangrene of the latter. The constitu- tional symptoms are : a general feeling of illness ; depression; rigors especial- ly, with alternate heats, thirst, quick pulse, loss of appetite, sometimes wan- dering or delirium, nausea, with pain at the pit of the stomach ; and a white furred tongue, febrile urine, etc. It is usual to make two types of erysipelas. One in which the inflammatory action is sthenic, in which the general symp- toms are not grave, and in which the structures, though perhaps extensively, are not very deeply implicated; this is E. simplex. The other, in which the general state is grave, the structures are deeply (and extensively) affect- ed ; abscess, sloughing, and gangrene are frequent; the virus is of active quality and the blood state bad. This is E. phlegmonodes. The two divi- sional forms are merely degrees of one and the same state, chiefly influenced by two things—the quality of the virus and the state of the patient's health. A.—E. Simplex.—In this form of disease, the inflammatory action has its seat in the derma, and, perhaps, more or less of the cellular tissue be- neath. The general symptoms are those before described. The local symp- toms follow quickly or in two or three days, and commence as a burning or smarting sensation, followed by a feeling of tension; the surface then looks puffy, dry, and slightly glazed, shining; the edges of the patch look raised, the part is tender and hot. In two or three days, during which time the redness and swelling have increased, blebs may form, of various sizes and shapes ; these burst and dry into scabs; in five, six, or seven days convalescence sets in, the local changes abate in severity, and a yellow stain is left behind, with more or less peeling off of the cuticle. Several sub- varieties have been described, according to seat, aspect, and character of course. Thus we have,—(a) E. erraticum, E. metastaticum ; (b) E. miliare, E. phlyctenodes, cedematodes ; (c) E. faciei, E. capitis, etc., etc. Local Varieties.—The most usual situation is the face (of course I am speaking of idiopathic erysipelas); it generally shows itself at the side of the nose, often at its root, quickly spreading, with great swelling of the parts, favored by the large amount of lax cellular tissue—e. g., about the eyes, lips, 38 ERYSIPELAS. cheeks, and ears. The disease may extend to the mucous surfaces. The con- stitutional symptoms are often marked by depression, delirium, restlessness, headache, etc. Erysipelas of the scalp is usually traumatic ; it may be slight or very extensive, the whole scalp may be undermined, puffy, and infiltrated by pus generally, or in the form of local abscess, the cellular tissue of the scalp sloughs, and the bone gets denuded and exposed; and serious brain symptoms are often developed. Erysipelas of the breast is common in lying-in hospitals, especially in women who are out of health, from, it is said, over-distention of the milk-ducts: this is probably only a predisponent. The breast looks red ; it is tender, hot, and swollen; then feels brawny, pits on pressure, gives a good deal of pain, is accompanied by depression of the vital powers, and terminates mostly in abscess and sloughing of the cellular tissue ; the glands in the axillae often participate in the disease. Erysipelas of the vulva often attacks the vulvae of lying-in women, especially primiparae. In children, erysipelas, commen- cing at the umbilicus, is often seen; in hospitals particularly it leads to abscess and sloughing, and often death. When the scrotum is attacked, the swelling is sometimes enormous; this is produced by the rapid pouring out of serum into the interstices of the cellular tissue. Some call it " acute inflammatory oedema," or, when it runs on quickly to the formation of pus, " acute purulent oedema." Erysipelas of the lower limbs is a form which betokens a bad state of general health, and demands active stimulant and tonic treatment. Erysipelas has been observed to disappear from one and make its appear- ance suddenly in two or more places in succession, or to " wander " over a large extent of surface; in such instances it has been styled erraticum. The disease is not very deep, but very obstinate of cure ; and often seasonal, or periodic. The face is its selective seat. E. metastaticum speaks for itself. The mischief falls upon some internal organ, coincident with the disappearance of the external blush. It is probable, however, that the gravity of the symptoms in such a case is due to the extension of the erysipelas by direct continuity. E. miliare and E. phlyctenodes are degrees of one and the same aspect • in the former, the blebs are small, in the latter large. Generally speaking erysipelas presents bullae at the early period of its course ; they mostly give exit to a transparent fluid, and scabs form. In other instances, the disease is peculiar in its great amount of swelling, due rather to a difference in the seat of the mischief; for while the evidences of the implication of the skin are marked but slightly, the cellular tissue is noticed to be much more affected than in ordinary cases. The skin at the seat of disease pits easily on pressure (is cedematous), and preserves the impress made for a considerable time. This is the E. oedematodes of authors and is met with especially on the lower limbs of debilitated persons • it is also seen on the penis and scrotum. B.—E. Phlegmonodes is, so to speak, the inflammatory form. The CAUSES OF ERYSIPELAS. 30 general symptoms of invasion are severe, fever runs high, rigors are severe, delirium is not rare, typhoid symptoms often set in, and the patient is in con- siderable danger, or death may ensue. The characteristic of the local disease is the great rarity of the occuirence of resolution. The part attacked is painful, hot, tender, swollen, very red; in a day or two it becomes softish, rigors and throbbing pain announce the occurrence of suppuration, which may be very extensive; the cellular tissue, the fasciae, the intermuscular septa, all partake in the diseased action; the blush has gone, or nearly so, but the swelling has increased. The contained pus is mostly mixed with blood and portions of cellular tissue. In this variety, a change takes place for better or for worse about the fifth or sixth day. In some cases, where the virus is of bad quality, or the patient's health is markedly bad, the sloughing and destruction of the cellular tissue may be extensive and marked: this is the E. gangrenosum. The constitutional symptoms are markedly severe, the inflamed part becomes dark colored, blebs appear, filled with bloody fluid, the general aspect of the limb is ecchymotic, and it feels tense at first, then boggy, puffy, and at length gives way; dirty mat- ter exudes, the structures slough, the fasciae and cellular tissue mortify, and the patient sinks, or recovers with great difficulty, the local mischief taxing all the powers to their utmost for the process of repair. Causes.—Various causes have been assigned to erysipelas ; all we know is this, that it is due to a special poison, which attacks those whose resistant power is weakened either by mental or bodily ailment. It attacks women more than men in the proportion of about 7 to 4 ; though it is less fatal in the former, in women, too, the disease is mostly idiopathic. The death-rate of 260 cases, given by Mr. Bird, was 7#5 per cent. The average duration of cases is from ten to twelve days. It occurs mostly in spring and autumn; it is especially liable to occur in spirit-drinkers; those resident in hospitals; all cases of wound. There does not appear to be any connection between the occurrence of erysipelas and derangement of menstruation. It has its maxi- mum degree of frequency about the age of twenty, gradually decreasing till that of thirty-five (Aubree). Cold and moisture together are regarded as favoring its occurrence; and, on the whole, traumatic is more fatal than idio- pathic erysipelas. It appears that Blight's disease especially favors the oc- currence of erysipelas if any traumatic injury be received. Diagnosis.—Erysipelas can scarcely be confounded with any disease, with the exception of erythema; but the general symptoms, the tense, shining, smarting blush, and the implication of the cellular tissue, are not observed in erythema. The Prognosis.—The case is grave if the general symptoms indicate high fever, with subsequent prostration ; if the patient be old; if it occur on the lower limbs; if it be seated at the scalp; if there be diffuse abscess with depression; if the surface assume a livid aspect, and present phlyctenae ; if there be much vomiting and delirium; if it be phlegmonous variety, and phlebitis ensue, and if it be metastatic or erratic. 40 EQUINIA. Treatment.—In treating erysipelas, we must always look ahead, and cal- culate, to the best of our ability, the probable amount of depression that will be produced by the virus action and the formation of abscess, and the amount of demand that will be made by the reparative process. And we can often do this. If rigors are severe, if there be high fever, and if the local symptoms are equally marked, then not only will the present excita- tion produce a marked subsequent diminution of vital power, but abscess and destruction of tissue will probably be more or less extensive. Then if the patient be out of health, if he be surrounded by bad hygiene, and especially if he be of good or advanced age, we must husband all the power he possesses. The pyrexia is treated upon ordinary principles; only am- monia should enter into the composition of our saline mixtures. A brisk purge is required at the outset. Now should the disease be severe, we should be on the qui vive for the first symptom of failing power, and treat the disease as tending to produce acutely a typhoid condition. Common sense is our guide in regard to diet, wine, and medicine. Where the disease is less severe, sulphate of magnesia and quinine, or, what is better, tincture of steel, in large and frequently repeated doses, is the remedy I employ : TTi.xx—Til xxx— 3 i. every hour. Locally, we exclude cold, apply heat, and keep the part covered up. In the early stage, practise inunction of lard subsequently to painting the part with a solution of nitrate of silver in spirit of nitric ether; or if there be much pain, apply warm lead, belladonna, or poppy fomentations. In all cases early excision in suppuration, and for the relief of tension, is essential. EQUINIA, OR GLANDERS. Equinia, or, as it is usually called, Glanders, is a disease which originates in the horse, the mule, and the ass; and when it occurs in man it is com- municated to him from one or other of these animals, either by the contact of the "discharge" of the disease with wounds, or by pure absorption. In the former case glanders commences as an erysipelatous inflammation of the lymphatics and glands, following quickly upon the poisoning of the wound. In other cases there is a period of incubation of from three to fifteen days. However, the introduction of this poison into the human subject is followed by the development of acute febrile symptoms, rigors, articular pains delirium, marked prostration, with a tendency to gangrenous inflammation of the lymphatic vessels, the occurrence of a pustular and phlyctenular erup- tion, inflammation of the skin, ulceration and discharge from the nostrils with subcutaneous abscesses. The above is a rough outline of the disease Veterinarians describe two varieties of equinia, Glanders and Farcy. In the former the disease falls upon the nasal mucous membrane and the skin • in the latter the nose is unaffected, and the skin often escapes • the lympha- tics and glands are specially the seat of disease. Glanders may be acute or chronic. In the acute form there is inflammation of the lvmphatics, with abscesses specially about the face and over the joints. Pustules appear over DENGUE. 41 the cheek, the arms, and the thighs, and commence as red papules, with a distinct areola, isolated or semi-confluent; these are accompanied by bullae with dark areolae. At the same time there comes on what appears to be erysipelatous inflammation of the nose, eyes, and the contiguous parts ; and soon from the nose a thick, viscid, often foetid humor is discharged, and if the nasal mucous friembrane be examined, pustules and ulceration will be observed over its area. In the chronic disease the skin may be free from eruption, but the nasal symptoms are present. The general symptoms are the same as in the acute variety, only less marked. Farcy is either acute or chronic. In acute farcy all the general pyrexial symptoms of acute glanders are present, and occasionally some eruption oc- curs, but the nose escapes. The disease may therefore be regarded the same as acute glanders without the nasal affection. Inflammation of the lympha- tics and subcutaneous abscess are prominently marked. In chronic farcy the health deteriorates, and chronic indolent abscesses form about the fore- head, the calves, &c, giving rise to open ulcers. The disease lasts from a few months to three years. Acute glanders may be developed out of chronic farcy. Diagnosis.—The disease commences like rheumatism, but the occupation of the attacked, the commencement of the disease like erysipelas, the pros- tration, the absence of joint inflammation itself, the pustular eruption, and the ulceration and discharge from the nose are significant. In chronic glan- ders there may be no eruption, the disease then resembles ozama, but if farcy be present the diagnosis is certain. With regard to farcy, if eruption be present, no mistake can occur, but difficulties do arise in chronic farcy without eruption. We determine the nature of the case by exclusion. It may resemble syphilis. Prognosis.—Equinia is a dangerous disease, and in acute cases almost always fatal. Treatment.—I have no experience upon this point. It has never fallen to my lot to treat a case of glanders. We are told upon good authority that the combination of arsenic and strychnine acts apparently better than anything else. Hyposulphites, and perchloride of iron, have been recom- mended. The use of nitrate of silver to the eruption, and chloride of zinc solution, two grains to an ounce night and morning, to the nasal mucous membrane, or a weak carbolic acid lotion, is commended. DENGUE, OR DANDY FEVER. In East Indies, Calcutta, and West Indies, a disease called Dengue exists. About the third day the skin gets turgid, and an efflorescence, beginning at the palms of the hands, gradually spreads over the entire body; it is not unlike in some cases measles or scarlatina, of a blotchy aspect. The rash may be raised, and feel rough. There is often tingling, that may increase to most intolerable itching; in some cases distinct local swellings may be present. The rash begins to fade on the second and disappears on the third 42 FRAMBCESIA. day, being followed by some desquamation. One case is recorded in which an old man "peeled off" in scales, like pieces of parchment, leaving the skin behind quite red : in some cases subcutaneous abscesses form. Hence there is erythematous redness invading the whole body, beginning at the hands, accompanied by swelling, and followed by desquamation like scarlet fever. Dr. Furlonge described the disease as like measles, with papules and wheals, as a cross between rubeola and urticaria.* Dr. Mellis described it as a roseola or lichen simplex. Dr. Mouat as erythema papulatum, or pur- pura simplex, but disappearing on pressure, and in other cases as like rose- ola or lichen tropicus. RUBELLA, RUBEOLA NOTHA, BASTARD MEASLES, ANOMALOUS EXANTHEM. There is a form of eruption which resembles measles, but differs in seve- ral particulars, and about which much dispute exists. It was described by Dr. Babington under the term Rubeola notha; it is thought by others to be a Roseola. In some instances it seems to have a bright red punctated aspect, or is not unlike scarlatina. This is probably Hardy's erythema scarlatiniforme; Dr. Richardson has called it rosalia. It is common in Egypt, I know; it is reported as having occurred at Malta, India, &c. After more or less pyrexia, a dusky red papular rash appears. It is never crescentic, but is uniformly distributed. The redness, the hue of which may vary, is most intense during the first day, when the rash is seen on the face, arms, legs, body, in succession; there may be slight desquamation. There are no catarrhafsymptoms, though the fauces are reddened. The pa- tient very quickly recovers, there is no dropsy or renal disease following in its wake. It is not contagious, and it often occurs in those who have al- ready had measles. In one sense it is a satisfactory disease—it requires no treatment. It is difficult sometimes to say to which the eruption is most allied in aspect, rubeola or scarlatina, but in either and all cases there is an entire absence of the general features of these diseases. It is scarcely bright enough in color for a roseola, though it might very well be regarded as a roseola of dark color. I append a note on FRAMBCESIA. Framboesia, called also mycosis, pian, or yaws, occurs in America Guinea the West Indies. Opinions differ as to its nature, and I do not know where exactly to place it. It is said to be an exanthem. The disease com- mences with general debility, languor, and pains simulating rheumatism • then about various parts of the body, especially the face, axillae and genitals arms, and rarely the scalp : little red spots appear—generally more or less grouped—they have been described as resembling flea-bites, which quickly * " Ed. Med. and Surg. Journ.," p. 52 1830. FRAMBCESIA. 43 become papular : or rather at certain spots little reddish elevations appear, which in the course of a few days become quasi-pustular, give exit to a lit- tle ichor, and then become covered over by dry and adherent scales. The skin around is dry and harsh. The disease now makes progi'ess towards the formation of distinct tubercular elevations, and in two or three months the exact resemblance to a mulberry is produced: there is no pain, and suc- cessive crops of tubercles occur from time to time; so that the disease covers over a surface of variable extent. The little tubercular projections are united together at their base, and are free at the apex, and one of them becomes considerably more developed than the rest, so as to form a distinct projection like a nipple : this is called mama, or mother-yaw; it presently ulcerates, and then appears as a foul ulcer, giving exit to an offensive ichor. Various attempts at repair take place, as evidenced by the many cicatrices present. The disease may last for years: it is said to be inoculable by means of the ichorous discharge ; it often gets well, but may exhaust the patient. It occurs but once in a lifetime, attacks young people by prefer- ence, and seems to be produced by social and hygienic mal-conditions identi- cal with those of leprosy. It attacks black more than white people: it has no relation to syphilis. CHAPTER VII. ERYTHEMATOUS DISEASES. The diseases which rank under this head are exceeding simple and well defined. They are three : erythema, roseola, and urticaria. Willan placed these with the acute specific diseases, under the term exanthemata, but though pyrexial, and the result, as regards the eruption, of a disturbance of the normal state of blood, yet they do not run so definite a course; they do not depend upon so specific a cause in each case, and they are not contagious, hence they form a separate group. They are characterized mainly by the occurrence of active hyperaemia of the longitudinal plexus of the skin (erythema), and its immediate consequences—nothing more. In other diseases hyperaemia is present, but then it is the" insignificant element in the morbid processes ; the squamation, the exudation of serosity, the formation of crusts, the hyper- trophy of the papillae, the morbid cell-growth, all indicate peculiar altera- tions in the behavior of the tissues, which cannot be explained by the presence or as consequences of hyperaemia. In erythematous diseases the redness is rosy (roseola), or bright red (erythema and urticaria): in the latter " wheals" are present. The erythema is removable by pressure. Unlike the more common eruptive diseases of the skin, the erythemata exhibit the closest connection between local and constitutional phenomena. Febrile symptoms antecede and are relieved by the development of the ery- thema, showing that the local skin-changes are secondary, and only parts of a general disturbance, which is primary. These remarks apply generally to the three erythematous diseases, but there are one or two rednesses produced by local irritation which it is customary to include under the term erythema. In many of these cases there is a predisposition to hyperaemia in consequence of digestive disorder. Erythema of course occurs as part of many diseases. I refer now to those forms which constitute independent diseases. i. erythema. This disease is a superficial inflammation of the skin, occurring in slightly raised patches, diffused or circumscribed, of varying size, rarely exceeding however, three or four inches, and generally much less. The redness dis- appears at once by the pressure of the finger, but returns instantly on its removal; it is accompanied by slight swelling, simulating papulation or slight tuberculation from exudation : heat: and itching : and ends in furfu- raceous desquamation with slight staining. The general symptoms are slight: i. e. mild fever, headache, quick pulse; they may be nil. The varieties of this erythema eruption may be divided into two groups : ERYTHEMA. 45 A, local or idiopathic; and B, symptomatic. In the former the disease is merely hyperaemia, without much, if any, appreciable effusion into the cutis and cellular tissue ; in the other there is more or less escape of serosity from the vessels, and hence prominence of eruption. Hence the two groups have been designated respectively after Hebra, erythema hypercemicum and ery- thema exsudativum. Group I.—Idiopathic, local, or hyperaemic : includes erythema simplex, E. intertrigo, E. laive. Erythema simplex is produced by the irritation of external agencies, friction, stings, heat, the contact of acrid fluids, plasters, medicinal inunctions, and stimulating applications of all kinds. There is redness, diminished or dissipated by pressure, returning on the removal of the finger, with no sensible swelling, but a sense of heat, and variation in color according to the activity of the general circulation. When produced by external injury, it is said to be traumatic. The slightest forms of burns would rank under this term. Chilblains, or pernio, is another form of ery- thema caused by cold. Erythema intertrigo, or simply intertrigo, is the name given to the redness which is produced by the friction of two folds of delicate skin, especially in fat persons and children : this is seen in the groin, axilla, neck ; sometimes the irritation set up causes the exudation of a fluid, partly perspiration, whose acridity increases the local mischief, and presently an offensive raw surface is produced, giving out a muciform or puriform fluid (the erythema purifluens of Devergie). The same disease is seen about the prepuce and the vulva. Intertrigo is particularly seen in lymphatic subjects. It simulates eczema ; but the origin is evidently from the friction of two surfaces ; the secretion is not that of eczema—it is thin, muciform, stains but does not stiffen linen. Hardy correctly describes the disease pro- duced by the inunction of mercurial ointment, as a vesiculo-pustular ery- thema ; in which, upon red patches, little vesicles (or puriform vesicles) appear, quickly rupture, desiccate, leaving behind an erythema, whose sur- face desquamates: the disease subsides in a week or ten days. It differs from eczema in its acute course, and the character of its secretion, which is clear, not viscid, and does not stiffen linen, as in eczema. E. Iceve, is the name given to a blush of erythema, of greater or less extent, which is seen over cedematous parts, especially on the front of the legs in dropsy. The skin may slough and become gangrenous at the seat of the blush. The redness which precedes the formation of bed sores, receives the name of erythema paratrimma. It is caused by the pressure of constant lying when the system has lost much of its tone, as in fevers and other low- ering diseases. Hoblyn, in his dictionary, says paratrimma is a " species of erythema or cutaneous inflammation, produced by friction in riding or walking." There are certain local forms of passive erythema produced by mechanical obstruction to the passage of the blood through the veins, by tumors, ligatures, gravitation, inaction of the heart, varicose veins, and the like. In these cases the color of the redness is bluish, or dark; the erythema is 46 ERYTHEMA. removed by pressure, but tardily returns, and the part is often sensibly cold and swollen. Group II., or Symptomatic—Under this head rank those hyperemias which are the consequence of a more or less general pyrexial state. In all of them there is malaise, headache, and quick pulse, pains about the joints, and disordered bowels, a day or two before the eruption appears, which as- sumes different forms, and Hebra has included all these under the one term erythema multiforme. In England we specify E. papulatum, tuberculatum, nodosum, fugax, marginatum, and circinatum. The first three of these are stages, the one of the other, and during their course the redness assumes a bluish tint, and fades away insensibly into the surrounding skin. In E. papulatum, small red spots, varying in size from a pin's head to a split pea, appear; at first they are not raised, but presently become papular, of more vivid color, pale on pressure, and die away in a few days with slight desquamation. These spots may be aggregated or separated, and are seen especially on the back of the hand, the arm, neck, and breast. The disease lasts about three weeks, and seems to be associated with rheumatic symp- toms. It occurs mainly in young peopled E. tubercidatum is the same disease, in which the erythema becomes somewhat tuberculated. It is seen in servants who make a change of residence from country to town. E. nodosum is a more marked stage of the last' noticed; the spots are larger— as large as a nut or walnut, even attaining a diameter of two or three inches, the long diameter being in a majority of cases parallel to that of the limb, oval; they are generally seated on the anterior aspect of the leg, rarely on the arm, or above the knee. The swelling is raised, slightly hard, painful, and evidently accompanied by tumefaction of the cellular tissue; the red- ness, at first vivid, but not so defined or limited as in E. papulatum, pre- sently becomes purplish at the circumference and paler in the central part, dying away like an ecchymosis. The patch also softens and often simulates fluctuation, but it is said never suppurates. Chorea and rheumatism are associates. It is uncommon after the age of twenty, and appears to be connected in some way with adolescence. It is generally accompanied by pyrexia and rheumatic pains. Dr. Durkee, under the head of E. tubercula- tum et cedematosum, has described a disease consisting of little tubercular elevations, vesicating at their apices, then flattening, the skin meanwhile showing a " shrivelled or collapsed condition of cuticle." The E. excentri- cum of Biett is lupus erythematodes. The swellings in these varieties of erythema are due to effusion of simple serosity into the corium and cellular tissue of the skin. E. fugax is simply patchy-redness, which quickly disappears, and is capricious in its character. This variety of erythema is noticed in persons of irritable habit, in those who are suffering from any digestive or assimilative derangement (especially in females)—e. g., from dyspepsia, muco-enteritis, uterine, hepatic, or renal dis- ease of sub-acute character. The erythematous patch is red, but tender fading, and desquamating, and accompanied by more or less pyrexia. ERYTHEMA GANGRENOSUM. 47 Should the blush be circular with an unaffected centre, it is called E. cir- cinatum; and if it have a well-defined circumference, E. marginatum. I should imagine that these two latter were often the erythematous stages of parasitic disease, tinea circinata, and especially in hot seasons, of chloasma. Hardy describes an erythema scarlatiniforme that has been referred to under the head of rubella or anomalous exanthem. Acute diseases, especially at the time of convalescence, often exhibit a slight access of febrile disturbance, and after a little itching and local heat, red patches appear about the limbs, thighs, the buttocks, the neck, and face. They vary in size from that of a pea to that of the palm of the hand. They are vivid red, last a few days, and then fade with desquamation. This is frequently an accompaniment of thrush. Hyoscyamus, belladonna, and copaiba give rise to erythemata, noticed under the head of medicinal rashes, and lastly, after surgical operations red rashes occur: these are generally roseolous ; they may be erysipelatous or indicative of pyaemia. Erythema Gangrainosum.—In persons who are reduced by debilitating disease, patches of dull erythema may occur here and there, and instead of the reparative process being properly carried on, the part may slough and become gangrenous. This one readily understands. In many cases patches of purpura are the starting-points of the gangrene. Mr. Wilson records a case in which calcareous solidification of the arteries was found after death. The affection has been named erythema gangraenosum. In Guy's Hospital there are models of it. Dr. Morley Rooke, in 1864, describ- ed a case in which he believed it occurred. But I think it is different in aspect from true gangrenous erythema ; the case is worth mentioning. The patient was a lady, unmarried, good-looking, and hysterical, of general good health, with vivacious manners, and aged thirty-nine. After an attack of feverishness and hysteria, she began to betray very capricious tastes and tempers towards everybody with whom she had to associate. On the fourth day a small red patch appeared below the left mamma, in the sulcus be- tween it and the ribs, l1 inch by 1 inch in size. The patch was not elevat- ed, but there was some pricking sensation in it. Eor two or three days things remained in statu quo, then suddenly a good deal of redness over- spread a large part of the mamma, and in the course of the following day, a white patch the size of a shilling, flat, smooth, painless, was observed in the centre of the blush, and in the next twenty-six hours this had enlarged to the size of half an orange, the cuticle having become loosened at one part, and the skin beneath as white as, and about the color and appearance of, a smooth layer of firm wax or tallow (being insensible and dead). No bulloe nor vesication occurred. Patches next appeared in symmetrical order over different parts of the body for four months : after a time irritation of the kidneys and bladder set in, &c. Now this form of disease was wholly dif- ferent from true gangrene of the skin. There was, in the first place, an en- tire absence of any general enfeebling condition sufficient to account in any degree for the occurrence locally of gangrene—nay, the patient was 48 ACRODYNIA. stout, well nourished, and of good health. The erythema, at its first occur- rence, was an active one; it was of good color; the reparative process was active. The coexistence of gangrene due to a general lowering of vitality, and of activity in the local circulation with rapid repair, involve a manifest contradiction the one of the other. On this ground alone I deny that the affection was produced naturally. Then, on the other hand, suppression, not merely retention, of urine appeared in three weeks, together with cysti- tis, severe vomiting, &c.—symptoms at once referable to the absorption of cantharides, and its action upon the urinary organs : hence the bloody urine. In addition, the patches of disease sometimes only reddened, and did not slough. Then the rapid destruction of tissue, the general symptoms bearing no sort of relation to (wholly unaccounting for) such kind of destruction; the evident attempt to conceal the early erythematous stage of disease; the healthy healing of the sore ; the non-assumption by the bed-sore of the characters of ulcers elsewhere (supposing the blood to be under the influ- ence of a special poison); the period of repose assumed by the disease, its long course, the moist aspect of the slough (being quite different from that produced by blood-poisoning, and exactly that produced by local applica- tions) and the marked hysteria of the patient; all point to an artificially- produced disease, and so I feel sure it was. When erythema is followed by gangrene, there must be a sufficient lowering of vitality to account for local death, which is immediately induced by purpuras, by embolism, or by ob- structed arteries (calcareous or otherwise). ACRODYNIA. [Under this name is described an epidemic form of erythema which oc- curred in Paris in 1828-9. The disease was only the manifestation of some general blood state. The general symptoms were pains, malaise, anorexia, febrile movement, vomiting, diarrhoea, swelling of the face, and injection of the eyes, with the development locally, especially about the hands and feet (the palmar and plantar aspects), of vivid red patches of erythema, ex- tending sometimes to the arms and legs; the color presently changed to a very dark ecchymotic hue, and extended, more or less generally, over the body, neck, and face. The epidermis peeled off in flakes ; furuncles, papules, pustules, and bullae sometimes forming ; a discharge took place and dried into thick crusts; a good deal of pain and swelling accompanied these changes, with a certain degree of numbness of the limbs. The symptoms varied somewhat in different cases. Generally the disease became chronic lasting several weeks or months; and frequently recurred. It appeared to be fa- vored by a bad state of the general health, and Chomel thought it was caused by eating diseased grain. In pellagra a similar dark erythema is brought out by the action of the sun. I have seen also, on several occa- sions, a species of erythema which is not described in books that I am aware of. It occurs especially about the back and sides of the hands and fingers in those out of health. The skin becomes red, in little circular ERYTHEMA. 49 spots, from which the epidermis peels off by a centrifugal death, as it were leaving behind a red dry surface, marked by circular ridges of what appear to be normal papillae. The places are many ; the disease is chronic, and re- quires no treatment. It looks simply like the death of the epidermis, be- neath which is seen the reddened derma marked by circular ridges of prom- inent papillae. It is not erythema circinatum ; it is more like a superficial acrodynia.] Prognosis of erythema. Erythema when it becomes chronic is a source of great discomfort; in the more marked forms the disease lasts two or three weeks. In E. laeve and E. paratrimma, the prognosis is that of the general malady present. Diagnosis.—Erythema is known by its superficial character- the redness disappearing by pressure; by the peculiar change in the color of the cir- cumference of the patch from bright red to purple, the absence of marked itching, heat or tension, or burning, its general circumscription, little ten- dency to spread, patchiness, but slight elevation. Erysipelas differs in the shiny, hot, burning, tense, blushy swelling, the rigors at the onset, the ten- dency to spread, and the implication of the cellular tissue, the deep (non- rosy) hue. Urticaria is known from erythema by the peculiar stinging sensation; the presence of wheals, which go and come in a wondrously capricious and sudden manner; by the irritability of the skin, easily de- tected with the nail or slight friction. Poseola is something like E. papu- latum, but the general symptoms are especially pyrexial in the former, rheumatic rather iu the latter; the eruption of roseola is rosy or pink and of a defined character, often punctate : erythema is generally a partial, not a general affection like roseola; the latter often assumes the aspect of measles (false measles). E. marginatum and circinatum are said to be dis- tinguished (especially the latter) from herpes circinatus by the presence of vesicles in the latter, in which the erythema is very transient, and furfu- raceous desquamation subsequent to actual or abortive formation of vesicles, very distinct, but the diagnosis can only be settled by the microscope.' E. laeve and E. fugax speak for themselves, the former being associated with dropsy. E. papulatum may resemble lichen urticatus; but in the latter the papules entirely put into the background the slight- erythema; the papules are large and often pruriginous; the skin is irritable, with a sense of heat and stinging; and a tendency to the formation of wheals is apparent. The skin generally is dry and harsh. E. papulatum assumes a bluish tint after a few days; it is seen on the back of the hands, arms, and neck especially,— not on the body so much as lichen urticatus, and it is not truly papular ah oriqine. E. tuberculatum and E. nodosum can scarcely be mistaken; the oval, tense, red, subsequently softish feel, pale centre, and livid circumfer- ence, are absolutely distinctive of the latter. Erythema is, of course, a dry disease, and, except in the form of intertrigo, does not resemble ecze- ma ; but the latter is essentially a vesicular disease, and its secretion is viscid, stiffens linen, dries into distinct yellow crusts. Intertrigo is ofc- 4 50 ROSEOLA. served to be produced by the friction of folds of skin in fat subjects, and possesses no crusts, and only thin muciform discharge. Treatment.—In the local erythemata we must first remove all irritants, pay especial attention to cleanliness, and merely apply soothing agencies— e. g., to prevent dryness or friction, &c, zinc ointment, or glycerine and rose-water: liniment, aquae calcis; fine starch, or lycopodium powders; avoid poultices, and give aperients internally. In intertrigo we adopt the same plan of treatment in mild cases. Sometimes it becomes a troublesome disease, with sour acrid discharge inducing even excoriation ; this generally depends upon some internal derangement, whose type is muco-enteritis. In these cases, alteratives with chlorate of potash, in the first instance in- ternally, are of service, particular attention being paid to diet; such food as corn-flour, maizena, and the like, must be forbidden, and proper nutritive substitutes (Hard's food) employed in conjunction with a suitable quantity of milk. Then locally, zinc ointment, starch powder, bismuth lotion, weak zinc lotions, the calamine lotion, given in the formulary, and lastly, if chronic, weak solution of nitrate of silver may be used; syrup of iodide of iron and cod-liver oil are also called for. In the erythemata dependent upon general causes we have to remember the effect of ingesta ; that a gouty or rheumatic habit, disordered menstrual function, dentition, delicacy of skin, or lymphatic temperament, are present in greater or less degree. We are careful to give an unstimulating diet, to forbid spirits, wine, aud beer, to clear out the bowels, and in the early stage to adopt a saline regime, and tepid sponging, with emollient baths. Tonics are generally demanded; if there be any distinct rheumatic symptoms, we must increase the renal secretions, get the liver to act by aperients, and then give colchicum (in. acute cases) and iodide or bromide of potassium with bark. In E. nodosum, aloes and iron in combination are very useful in the fat, bloated, full-colored, but flabby and stunted lymphatic subjects that are often affected. Locally, the use of an alkaline lotion is all that is needed. In all cases, if there appear to be an overloaded yet anaemiated state of system, we may combine (saline) aperients with preparations of iron • and any neuralgic tendency is met with quinine. Bed-sores are best treated by attempting to " harden" the skin in the early state by spirit applications, removing pressure as much as possible • in latter stages by pads, cushions, and water-beds ; and usinw charcoal poul- tices or soap plaster spread on soft leather to the sores. For chilblains equal parts of turpentine and tincture of aconite or belladonna and soap liniment, together with tonic treatment, iron, quinine, and cod-liver oil is the best treatment. II. ROSEOLA. It is important to know this disease, not so much because it gives rise to any anxiety or trouble, as that it is likely to be confounded with measles and IDIOPATHIC GROUP. 51 scarlet fever. The disease is characterized by its being non-contagious, more or less febrile, and giving rise to the development of a rash, not much raised above the level of the surrounding part, and of rose color. The eruption is patchy, and its color deepens somewhat as the disease advances. It is accompanied by slight itching and sensation of heat. It is not pre- ceded by any marked signs or symptoms of catarrh, but only slight redness of the mucous surfaces of the palate and fauces. Roseola is divisible into two groups : Idiopathic—R. infantilis, aestiva, autumnalis, annulata, punctata. Symptomatic—R. variolosa, vaccinia, miliaris, rheumatica, arthrica, cholerica, febris continuae. We see, there- fore, that roseola is wont to occur as an accidental phenomenon in the course of acute diseases, where it is called symptomatic ; in other cases, it is the sole and primary disease. Idiopathic Group>.—Poseola infantilis is seen in infants, and resembles measles ; it runs an irregular course as regards precursory symptoms (which vary in degree), and in the extent, degree, and seat of eruption. Now, it is pretty general but patchy, now, limited to the arm, or the neck, or trunk ; the rose-blushes often come and go for several days capriciously, and are accompanied by local heat and itching, which are often marked at night. The catarrhal symptoms of measles are absent. The patches are about half an inch or so in diameter. The redness generally lasts a dozen or more hours. P. ct'stira appears, as its name signifies, in the summer-time: after slight pyrexia and much local itching, the rose-rash appears on the face, neck, arms, travelling thence over the bod}r; the mucous surfaces are affected, and the disease may put on the aspect of scarlet fever; the rash is unattended by desquamation on disappearance (about the third or fourth day), but leaves a darkish stain. Sometimes the rash is very uncertain and irregular in occurrence, and then the disease is prolonged in duration. It may be partial only, but always has the roseate hue. The very same erup- tion occurs in the autumn, generally in children, on the arms and legs, in the form of circular blushes, about half an inch in diameter, but of a dark hue. This is the P. autumnalis. When the disease assumes the form of rings (and this is generally observed about the buttocks, thighs, and abdomen), developed from little rose spots, and enclosing presently a healthy circle of skin, an inch or so in diameter, the variety R. annulata is present. The concomitant symptoms are the same as those of the R. aesfiva. Mr. Wilson describes a variety under the term R. punctata, in consequence of the punctated aspect of the rash. It appears to be pretty general, with slight fever and catarrhal symptoms. The ASymptomatic Group contains species which are merely rosy erythemata developed in the course of acute diseases, generally appearing about the arms, breast, and face, thence spreading over the body. P. vac- cinia coexists with the formation of the vaccine vesicle, and is accompanied by slight fever. It commences around and about the seat of the vaccina- tion. In cases of fevers, about the tenth day or so, and indeed whenever 52 ROSEOLA CHOLERICA. the weather is hot or perspiration free, a number of minute scattered vesicles are likely to be developed about the clavicles, chest, and neck; this is miliaria. It is often accompanied by a rosy blush, to which the name P. miliaria has been given. It is the P. febrilis of authors. Some further remarks in reference to miliaria will be found under the head of diseases of the perspiratory glands. So in acute rheumatism and gout, the rose rash has been termed P. rheumatica. Poseola cholerica (Rayer). The changes which the cutaneous circula- tion undergoes in cholera, predispose, as might naturally be expected, to the occurrence of eruption, especially during the stage of reaction, which varies very considerably in different instances. The eruption may be a roseola (Rayer,' Babington, and Romberg), and is then seen about the hands, arms, neck, breast, abdomen, and limbs; in other instances, the so- called exanthem of cholera is a "pustular redness," or miliaria, or herpes zoster, or E. tuberosum, or presents the aspect of urticaria. It is more frequent in males than females. After surgical operations a rash like scarlet fever very frequently occurs; its color varies somewhat; it is not contagious, and it wants the general symptoms, the throat complication, hot skin, quick pulse, and tongue of scarlet fever. It is due, no doubt, to some volatile poison free in the blood. It has no gravity. Little is known as to the cause of roseola. The varieties above-named have little right to the distinctive appellations. The causes, according to some, are legion—heat, cold, ingesta, irritation of delicate skin, gout, change of season, acidity, &c. The Prognosis offers no point of gravity or interest. The' Diagnosis.—Roseola is likely to be confounded with rubeola scarlatina, urticaria, erythema. In reference to it as contrasted with rubeola and erythema, Devergie makes some excellent remarks. He says the roseolous eruption always occupies a surface of the body more or less ex- tensive, commencing frequently about the breast or abdomen, or upper limbs ; and generally the surface is studded with many little confluent rose spots, between which the healthy skin is visible : the spots are largest about the breast, smallest on the limbs; oftentimes, the suiface is dotted over with rose spots. From rubeola especially it is known by the absence of catarrhal symptoms, coryza, &c. ; the want of relation between the febrile symptoms and the amount of eruption; the absence of epidemic influence • the irregular character of the eruption: it is not crescentic, not uniform not dark ; but irregular, rosy, and often commencing about the breast or arms instead of the face: by the circular shape, irregular course and frequent limitation to one locality. In erythema, the shapes of the patches, giving rise to E. papulatum, E. marginatum, and E. nodosum, are peculiar; the color is not rosy; the blush at the edge becomes purplish; the red blushes are less numerous more diffuse; the general symptoms are rheumatic, and less acute. ROSALIA. 53 In scarlatina, the aspect of the disease is graver; the fever is marked, the throat is bad, the tongue is peculiar; the skin harsh, dry ; the rash general, punctiform, boiled-lobster like. The progress is more uniform, and it can be traced to contagious or epidemic influence. In urticaria, the diagnosis is at once settled by the discovery or produc- tion of a wheal, and the peculiar stinging character of the local irritation, with the capricious character of the eruption. The Treatment consists in that which is merely tentative: so far as general measures are concerned, in giving salines, aperients, laxatives, Arc, and treating any special symptoms. Locally, in removing all causes of irritation—e. g., irritated and tender gums, by lancing; acidity of stomach, by magnesia, soda, or lime-water; intestinal irritation, by " alteratives," such as gray powder, rhubarb, and subsequent tonics, keeping up the warmth of the surface, and, if possible, bringing on perspiration. The surface should not be chilled. My general plan is to give salines with ammonia, a mild aperient, and then quinine. ROSALIA. Now, under this term has of late years been described a form of epidemic roseola, which sometimes assumes the aspect of measles, but mostly of scar- latina. Under the head of rubella, "anomalous exanthem," erythema scar- latiniforme, I have referred to this disease; and I think it as well to give here a general resume^ of the matter. Well then, in certain cases, after slight febrile symptoms, a rash develops pretty generally over the body; it sometimes looks like measles, but is too fully developed perhaps in the limbs, too little in the face, and there are no catarrhal symptoms present; at other times it is exactly like scarlet fever, save in regard to general pyrexia and throat symptoms. It does not give rise to desquamation or kidney disease. According to the aspect, therefore, of the rash and its color, has the disease received appellations that ally it to measles on the one hand and scarlet fever on the other; hence the terms rubella, rubeola notha, rosalia, anomalous exanthem, erythema scarlatiniforme. Its cause we do not know. The treatment is rest in bed for a day or so, warmth and light food. The most important point is to be aware of its existence, that we may not con- found it with true measles and scarlatina. III. URTICARIA, OR NETTLE-RASH. This is a febrile and non-contagious disease, in which are produced here and there on the skin reddened elevations similar to those that follow the sting of a nettle (urtica). The symptoms are general and local, therefore. When the disease is well marked there is more or less fever, quick pulse, dry skin, headache, malaise, mostly pain at the pit of the stomach, and often irritation of the mucous membrane of the intestinal tract, whilst on the skin appear what are termed wheals or pomphi: these are accompanied by tingling and burning; they suddenly come, and almost as suddenly go, with- 54 URTICARIA. out leaving any stain behind or desquamation. The eruption may attack a small part of the body, or the wheals may spring rip quickly in succession over a much larger area. Wheals may be thus described: at first a bright flush appears, the centre of this becomes slightly elevated, and pales, hence appears of lighter color; the tint may be rosy, but more generally it is whitish. These wheals vary in size and shape ; they may be linear, bandlike, irregular in outline, or oval; the white centre, which feels hard and raised, may be small, and the red halo large, or a large red patch may whiten at two or three points in its area. In all cases the accompanying sensation is a hot, tingling, burning one. Wheals are evoked readily by scratching. The skin generally is remarkably sensitive, and the application of any irri- tant is followed by the production of redness or even wheals ; so that it is possible by using the nail of the finger to write one's name or to draw figures on the skin, and these are marked out by red lines or wheals produced at the seat of the scratchings. Much discussion has arisen as to the nature of wheals. Some affirm that they are produced by spasm of the muscular fibres of the skin; others, by eftusion of serosity. It is most likely that both these conditions exist in wheals. Certain is it that there is slight effusion, and the approximation of two scratches in the artificial production of wheals, and their distancing on the application of chloroform or cold, seem to indicate that there is some muscular element in the case. It is prob- able that the vaso-motor nerves are irritated, the vascular channels are al- tered in consequence, effusion takes place, and, in addition, there is spasm of the muscular fibres of the derma. The occurrence of effusion is well seen when urticaria attacks the face, the breast, or the scrotum, for here much subcutaneous oedema is produced. This disease attacks all ages ; it is most frequent in spring and early summer, and it may be intermittent or periodic. Urticaria divides itself into acute and chronic.' Acute includes— Chronic includes— U. febrilis. U. evanida. U. ab ingestis. U. perstans. U. conferta. U. subcutanea. U. tuberosa. In the acute varieties there is more or less fever, well-marked symptoms of stomach derangement, such as nausea, white and dry tongue thirst quick pulse, headache, and general malaise. I have noticed in most cases the hue of the face to be bright, as though there was a faint rosy suffusion. The itchiness and stinging accompanying the eruption of wheals (which are scattered) are well marked, especially at night, and altogether the disease puts on an active aspect. The skin is irritable, and wheals arise easily from irritation. This, the typical form of the disease, is called JJ. febrilis. When the wheals are more closely packed together—coalescing (conferted) —the variety XT. conferta is present. These two varieties, which are really different phases of the same thing, last seven, eight, or ten days or more PATHOLOGY. 55 and in the conferted there is perhaps more swelling of the skin than hi the simple variety. Urticaria ab ingest is, as the name implies, follows the taking of special articles of food, and it may assume a very acute and severe form. It is sudden in its appearance, but quickly subsides. In the worst forms the patient seems poisoned, there is high fever, vomiting, headache, quick pulse, delirium, the mucous surfaces being hot, irritable, tingling, the conjunctivae implicated ; presently the face rapidly swells, so that the countenance is completely masked ; the ears, nose, eyes, and lips are swollen, hot, tingling; the mucous membrane of the larynx is evidently affected ; the swelling speedily subsides and travels to the body and trunk, and this very rapidly. It is accompanied by intolerable itching, and the formation of wheals is attended with alleviation of the general symptoms. Desqua- mation to a slight extent succeeds. The substances that generally act as excitants are shell-fish (especially mussels), pork, prawns, lobsters, oysters ; but eggs, fruit, rice, raspberries, strawberries, mushrooms, cucumbers, coffee, etc., and the generally harmless articles of diet, in certain subjects, induce it; and so may valerian, copaiba, etc. The chronic forms may result from the acute, or develop out of a state of tolerable health, and without apparent cause. There is little pyrexia pres- ent. When the crops of wheals are of pretty long continuance, the disease is called perstans. In other cases the wheals are small and very fugitive ; but the skin is irritable and the itching intense. This is U. evanida. The name factitious urticaria has been given to that form of the disease which is easily produced by mechanical irritation, and is not idiopathic. In persons broken in health, especially by intemperance, the urticated patches are raised, in consequence of the implication of the subcutaneous cellular tissue, in patches about the size of a nut or walnut; they show themselves on the limbs, and possess the especial feature of urticaria—viz., quick appearance and disappearance, or intermittence; it is called U. tuberosa. In some cases there is swelling and apparent oedema of the cellular tissue—now here, now there; but the wheals are more or less scarce and occasional. The redness, the heat, the tingling, and swelling exist, but it is only the accidental appearance of the wheal that dis- closes the true nature of this variety, called U. subcutanea (Willan) or cedematosa (Hardy). Even here capriciousness is marked ; the oedema goes . quickly. In some cases, in elderly people, who are apparently in good health, urti- caria may assume the characters of evanida, perstans, and tuberosa together. I have seen several of these cases; the only likely cause appeared to be dis- ordered digestion, with flatulence, pain after food, etc. In these cases the tongue was suddenly swollen so as to almost fill the mouth, the eye was closed, the face puffed out on one side, the scrotum and penis become enor- mously cedematous, and tuberose patches of urticaria showed themselves about the arms or the legs. Such a case was lately under my care. It seemed to me that bottled beer was the exciting cause. I could not 56 PATHOLOGY. prevail upon my patient to forego it. These chronic forms in some cases are truly periodic. Pathology—The following case, related by Dr. Heusinger, of Marburg, may well illustrate the pathology of urticaria. In a boy aged sixteen, " when lines were traced on the skin, the course of the lines, in the space of half a minute, reddened; and upon this reddened base there quickly rose up white ridges or wheals, so that in two or three minutes the lines of the writing stood up in strong relief, as exact in figure as if they were cut in marble by the most able sculptor. At the end of thirty or forty minutes the writing subsided and vanished completely, without leaving behind a trace of its presence. When the red lines appeared they were accompanied with an elevation of temperature sensible to the young man himself, and amounting to 1^ or 2-1 degrees of Centigrade, and when pricked with a fine needle, the wheals gave forth a minute drop of serum, as do the wheals of urticaria; but however much or frequently the experiment was repeated, the body felt no inconvenience. In explanation of the phenomenon, it is obvious that the stimulus applied to the nerves of sensation was reflected upon the skin in the form of redness, heat, and swelling." * In urticaria it is supposed that the wheals are due to the presence of fluid in a circumscribed space, this oedema being due to the escape of fluid from a " cluster of capillary loops springing from a common stem, and under the influence of a common nervous twig." Now, what is the sequence and nature here of the phenomena ? A mor- bidly sensitive skin; irritation applied: spasmus of the muscular fibres of the skin, and also of the capillaries, with subsequent dilatation. Hence hyperaemia, or redness, escape of serosity elevating the central part more than the outside of the lines, the whole constituting what is termed a "wheal." The tissues are passive, it is an altered state of circulation fol- lowing nerve disorders; the altered condition of the nerves of the skin is the basis of urticaria, and the disordered sensation, burning, tingling etc. preceding eruption, indicate as much. Granted this, it is easy to see that wheals may be evoked in many ways: (1) by local irritants, (2) by the cir- culation of acrid or effete products in the blood, which, coming to the sur- face, become oxidized and more active, and (3) by reflex irritation. Under the first head, or local excitants, rank the acarus, fleas, bu<*s, mosquitoes lice, flannel, the contact of numerous other irritants, such as "jelly-fish." Under the second head must be placed those changes in the blood induced by gout, rheumatism, or disordered digestion, the circulation of medicinal substances, such as valerian, copaiba; and under the third pulmonary- gastric, uterine, renal disorders, mental anxiety, and emotions of various kinds. In all these cases there is an influence that directly plays upon the disordered susceptibility of the cutaneous nervous plexus. Urticaria mostly * The case is recorded in Virchow's " Archiv fur Pathologische Anatomie und Physiologie und fur Klinische Medicin," June, 1867. PROGNOSIS. 57 arises, however, from stomach disorder, and the nature of the latter is such as to lead me to imagine that the solar plexus is oftentimes involved, the mucous surface being-morbidly sensible to even ordinary ingesta, fish, beer, etc. In very many cases the urticaria is not due so much to the circulation of any irritating substance or product, as to the reflection of impressions made on the stomach. We have ample proof that this is possible and likely, in the occurrence of flushing of the face after meals, and chronic erythema, consequent upon dyspepsial symptoms. It is important to add that in some instances we are enabled to discover distinct stomach or hepatic derangement. The type of the stomach derangement is pyrosis. In many cases the seat of the reflected disorder is not the stomach, but the lowest part of the oesophagus. In chronic cases I am not sure that irritation at the neck of the bladder is not sometimes an excitant of urticaria, and in females U. tuberosa follows uterine disturbance, according to Fouquet. If this general view of urticaria be taken it will be likely to lead to the adoption of a successful treatment. It may be worth while to mention that in the Brazils, the fruit of the Paullinia sorbilis (Sapindaceae), an ally of coffee, when mixed and taken as it constantly is with water, as a drink, produces urticaria. The drink is called guanara. Asthma has on many occasions been seen in association with urticaria. Dumontpallier has reported a case of intermittent urticaria, in which the attacks appeared each night for six weeks. The parents were both asthmatic, the grandfather asthmatic, the grandmother had angina pectoris and rheumatism, the brothers were rheumatic, and four of the children suffered from intermittent diarrhoea, alternating more or less with actual urticaria. Prognosis.—Urticaria has no gravity about it. Acute attacks {ab in- gestis) are of short duration. Chronic urticaria is abominably troublesome. The intermittent form is very obstinate. All depends upon our ascertaining the cause of irritation (direct or indirect) present. Diagnosis.—Urticaria ought not to be mistaken for any other disease. Its sudden and capricious character, the tingling sensation, the presence of wheals, gastric disturbance, and irritability of skin, are absolutely diag- nostic. I have seen it mistaken for scarlatinal rash ; but the error was soon detected by irritating the skin and the appearance of wheals. The evanes- cent character of the wheals distinguishes urticaria from the erythemata; and in the instance of lichen urticatus, there are pruriginous papules and few wheals, the eruption is of smaller size, feels hard and more persistent; the disease is really a compound of lichen and urticaria. It is the peculiarly capricious character which distinguishes urticaria. U. tuberosa wants the regular and persistent course, the lividity, the soft feel, the oval shape of erythema nodosum. Treatment.—Thoroughly unsatisfactory is the treatment of urticaria laid* down in books. " Correct any digestive disorder, improve the general health, and use remedies to allay itching, is its sum and substance." We have to deal with a sensitive skin; first of all it is our duty to prevent that 58 PELLAGRA. being in any way directly irritated ; flannels should be removed, the utmost cleanliness should be observed, no sudden change of temperature should be permitted to play upon it, either by way of exercise, draughts, or the like. Then we seek to soothe it, by emollient and alkaline baths, anointing it if possible with oil. AVe should seek to relieve the skin, to give it rest by throwing more work on the kidneys, and by the exhibition of saline aperi- ents. Then we must prevent the circulation of effete products, urea, uric acid, and control all kinds of disorder which may be reflected on to the skin, and lastly, tone up and lull by anodynes the nerve paresis. These are the princijdes of treatment. I find urticaria one of the most difficult and unsatis- factory of all diseases to cure. The acute are more satisfactory to treat than the chronic cases. The following'is a resume of what appears best to be done :— U. febrilis.—In simple cases, saline aperients, milk diet, no stimulants, alkalies largely diluted, alkaline baths, half a pound of carbonate of soda in an ordinary hip bath twice a day, lotions of bichloride of mercury, and rose- water, or cyanide of potassium. Amongst the Formulae other local reme- dies will be found. If the patient be gouty, colchicum should be given with salines ; when fever runs high, I have usually given acetate of potash, tincture of digitalis, with even potassio-tartrate of antimony. I should expect much from the tincture of veratrum viride. U. ab ingestis.—An emetic (zinc or ipecacuanha), a saline purge, and subsequently a mixture of carbonate of ammonia, prussic acid, and infusion of cascarilla. The treatment of chronic urticaria is most tiresome and diffi- cult. One has to analyze carefully every function of the patient, and it requires no little patience to arrive at a distinct conviction that what we are doing is a reasonable plan of treatment. If there be mental disturb- ance, change of scene does good. Pyrosis, atonic dyspesia, deficiency of bile, inaction of the liver, non-excretion of urea, uterine disorder, must be treated upon general principles. Generally speaking, it is possible to dis- cover some one thing which taken internally evokes the urtication : it may be beer: it often is, or condiments of some kind. Where it appears that the functions of the body generally are properly performed, bromide of am- monium, or if the disease be periodic, quinine is useful; aconite is another remedy ; arsenic is much vaunted; I do not know that it has done much good in my hands. PELLAGRA, OR ITALIAN LEPROSY. This disease is common in Lombardy, about Yenetia, Piedmont South of France, in some parts- of Spain, and Corfu. It attacks the poorer popu- lation to the extent of four or five per cent, in the districts where it is most prevalent. Pellagra is a general disorder of the system ; the external manifestations are only a part of graver changes in the system at lar^e. The symptoms arrange themseves into three groups :—1. Si-cther may follow an eczema); in the one case we have E. verrucosum, in the other E. spar- gosiforme; in another case the tissues may harden, in another ulceration may follow; now in all these instances the history of the case is our euide in determining the mixed nature of the disease. Then, lastly, eczema may complicate and occur together with other dis- eases : with lichen, scabies, even lepra vulgaris ; and in such instances we have necessarily a blending together of the characters of the separate dis- ECZEMA. 75 eases. To remember the possible co-existence of diseases is one of the first necessities to a safe diagnosis. The Treatment.—Eczema I hold to be of the nature of a catarrhal inflam- mation. This implies debility. It is highly unsatisfactory to consult books about the treatment of eczema. One gets very little from them. I shall not follow the bad example hitherto set of giving a general resume of the action of remedies ; but I will try and depict what we want in practice. Bemedies are local and general, of course. Some of the slighter forms of eczema produced by irritants, the action of the sun, friction, and injury, readily get well by the removal of the cause, and the use of topical seda- tives and astringents. But in the vast majority of cases Ave require to give internal remedies to correct vicious nutrition, or some influence that debili- tates, and so cripples, the restorative power of the system directly, and the reparative action of the tissues indirectly. Acute general eczema does not give us much trouble: salines and aperients to counteract the pyrexia, and vegetable bitters presently, with ammonia, or the mineral acids, with the use of zinc ointment or lotion, do all that is required. It may chance, how- ever, that the patient is a strumous or gouty subject, or suffers from nervous depression, or has been overworked: the indications here for appropriate treatment are obvious enough: cod-liver oil, colchicum with alkalies and amm/mia, rest, and mix vomica or quinine, or iron (if anaemic), soon aid and consolidate Nature's cure. But in the more ordinary forms of eczema it is the physician's duty to search carefully for flaws in the health of the patient, especially in regard to his assimilative functions/ The treatment of eczema can never be a stereotyped one. In the infant, cod-liver oil and steel wine are called for by the pale, pasty, lymphatic aspect of the little patient; and how rarely do they fail in effecting a rapid cure, provided the food be attended to and properly prescribed. The one great fault is pov- erty of the nurse's milk; and whilst we lay stress on medicine, we must not forget the prime importance of influencing the child through the natural means. Mothers, if need be, must take tonics, more animal food, fresh air, proper rest and quiet, and keep free from anxiety as far as possible. If the child is being " brought up by hand," " corn-flour " and other purely starchy compounds, I think, should be avoided. Fine-baked flour, and milk, with "wheat phosphates," is perhaps the best compound. I only speak as I have experienced. And going on to a later age, the same remarks apply in regard to remedies. The patient must be treated according to his or her dia- thesis and special nutritive wants and failings, and not the name of the disease. Then the sanguineous must take aperient tonics. I know none better than a mixture composed of sulphate of magnesia, sulphate of iron, dilute sulphuric acid, tincture of orange-peel, and some carminative. Of course the dose is to be regulated according to the aperient action of the medicine. But in adults we may discover a dyspeptic state, gouty tendencies, and loaded urine ; in these instances, cutting off beer and spirits, colchicum, 76 ECZEMA. purgatives, and then tonics—i.e., vegetable bitters and alkalies—are indi- cated. In eczema rubrum, aperients and tonics combined act best, In a very large number of cases, in persons of middle age, especially in hospital practice, one sees at once that bad living, hard work, and anxiety have prostrated the eczematous patient; under these circumstances good food and quinine cure. In the better ranks of life, dyspepsia (pyrotic, atonic, or irritable) are at the bottom of the mischief; luxury has entailed torpor of the secreting and assimilating functions: bismuth, soda, pepsin, mineral acids, or strychnine, as the case may be, are now available, and do good ser- vice, in ladies who have uterine mischief, iron and the like are called for. In all the chronic cases in which scaliness is the main feature, arsenic is serviceable. I am not disposed to extol the virtues of arsenic to so large an extent as is the fashion. It is a valuable remedy in eczema, but by no means a panacea. I find in the scaly cases, in which the health is seriously impaired, it does good ; but I know it also does harm when pushed beyond reasonable limits, and I regard it as positively unjustifiable to give courses of the drug for two years or more. In chronic eczema, with marked infil- tration and induration of the skin, a mild course of bichloride of mercury with bark is of infinite service ; and I fully agree with Dr. Frazer on this point. . My maxim is, treat the patient as well as the disease. So varied are the deviations from health, that it is impossible to give more than an indication of the line of procedure in eczema, taken as a whole. I would refer lastly to the value of purgatives and diuretics. In eczema, especially, purgatives are of use; they may act, and do, as derivatives from the skin, where discharge is free, and in all the more serious and inflammatory forms they should be given in conjunction with tonics. In the same way diuretics are useful over and above any general alkaline action they may have. Local Treatment.—If there be one thing more necessary to impress upon the minds of students, it is this; that the skin of an eczematous subject is a very sensitive and irritable one, therefore the main plan of treatment, as far as local measures are concerned, is to soothe and to allay irritation. In a large number of instances, local remedies suffice for the cure of eczema. The routine is to use either zinc or some mercurial, or other irritatino- oint- ments, and I believe that in a good proportion of cases the disease is made worse by the use of irritants. In acute general eczema the hyperaemic cutis is, as I have said, very sensitive, and the disease being inflammatory, we must rest,protect, and soothe; this is most important in the exudative and less so in the scaly stage. And other guides are the sensations experienced by the patient—the feeling of burning should make us very cautious in the use even of stimulant remedies. Water-dressing is useful at the outset but the best plan if there is much swelling is to lightly bandage with a lotion containing a fair quantity of liquor plumbi ( 3 ij ad § vj) or a lotion made of calamine powder 3 j, oxide of zinc, 3j, glycerine 3jss, water to | vj, this being used very freely so as to keep the surface moist, and ex- clude the air if possible. If the itching or sensation of burning is bad ECZEMA. t I poppy fomentations, cyanide of potassium ointment (gr. iij vel gr. v ad | j), chloroform, wine of opium, and belladonna lotions, are useful. A very convenient application is an ointment containing an ounce of elder-flower ointment, rubbed up with 3jss of liq. plumbi and 3 j of vinum opii. In the second or exudative stage it is the custom to employ ointments, but I generally, indeed always, avoid them ; in proportion as the heat or itching, the redness or swelling disappear, do I employ astringents, but whenever there are signs of irritation 1 use soothing and emollient remedies exter- nally—borax, carbonate of soda, and lead lotions are as good as any, and these in connection with aperient tonics generally, control the discharge, and I follow this plan even where the eczema is pustular. It is almost unneces- sary to add that the diseased parts should be most gently handled at all times. Soap should not be used, and no friction with the clothes allowed. When the third or scaly stage is reached, I believe it is often still highly necessary to avoid the use of any applications which act as irritants; I mean that induce continual smarting, serous exudation, or increase the red- ness and the induration of the diseased patch. There is a good deal of lo- cal (tissue) debility left behind in eczema, and irritability is one of the chief characteristics of the skin of an eczematous subject. Astringents are generally called for in simple forms of eczema—such as we see in the scalp. I prefer, in connection with tonics, the use at the outset of, borax 3ij, acetate of lead gr. ij, and glycerine 3 j, to § j of lard; a stronger ointment is 3 ij of ung. hyd. nitratis, 3 ij glycerine, and adeps | ij. In some cases the ammonio-chloride of mercury ointment acts very efficiently. Where thickening and induration finally remain, these may be regarded as secondary and ordinary results of congestion, and should be treated accordingly by revulsives. I often use a strong solution of nitrate of silver (3ij), in nitric ether ( I j), ointments made of the pyroligneous oil of juniper ( 3 j vel 3 iij ad r j adipis), or should that not suffice, iodide of mercury ointment (gr. v-xv to §j). I cannot say that "English skins" bear satisfactorily the " tar treatment" of Hebra; by adopting it I have often disgusted my patient, and am not disposed to push it in future. The above line of procedure holds good hi the case of children; but here in ad- dition an absorbent powder is serviceable. It may be made of oxide of zinc and calamine powder and starch in equal parts. I prefer a lead or calamine lotion with exclusion of air, and at night a layer of elder-flower ointment, to anything else as simple applications in eczema infantile. The calamine powder I speak of is not that of the shops. None should be used save that which has been repeatedly washed, and very assiduously rolled or ground to an impalpable powder, otherwise it acts as an (gritty) irritant. When eczema is general, other local measures are called for, and foremost amongst them stand alkaline and gelatinous baths, separately or con- jointly, if there is very much " soreness." Carbonate of soda four ounces, and three pounds of clarified size is that I most usually order in the early stages ; in other cases; where the irritation is great, a " size" bath may lb POISON-VINE EJKUPTIOX. even be advisable. Where there is free " discharge," and the patient is much distressed by the heat and irritation of the surface, we may make a thinnish paste with common whitening, and paint the surface freely over from head to foot, if necessary night and morning, taking care to keep the body as cool as possible in regard to the bed coverings, whilst seeking by aperients and diuretics to relieve the discharge, and " determine " it else- where. In the pustular forms, a strong borax lotion is my favorite, in conjunction with a weak citrine ointment. I repeat that in the disease which Willan called eczema, the plan is to soothe as much as possible. Authors have spoken very highly of certain plans which are based upon a different mode of action, but I suspect that this arises from the fact that lichenous, psoriatic, and pruriginous diseases have been regarded as eczema. It seems to me that one main argument in favor of the isolation of the " catarrhal " form of inflammation of the skin, under the term eczema, used in a limited sense, is to be found in the success of an emollient system of treatment, which is of little use in other diseases supposed to be stages of an eczema, in a much wider sense. Lastly, there is one exception to the rule here laid down in regard to the use of stimulants, and it is the case of eczema sec- ondary to scabies. Here the scabies must be treated and cured at all haz- ards, and then the eczema will probably vanish, at all events by the use of the simplest remedies after the specific treatment for scabies has been fairly employed. Impetigo, see Bustular Diseases. For special remedies, see selected formulae, Nos. 32, 33, 34, 46, 48, 49, 50-2, 64-9, 86-7, 123-6, 129, 146, &c. POISON-VINE ERUPTION. " The common poison-vine (Phus toxicodendron), a species of sumach and one or two other plants more rarely, cause, by contact, in some persons an inflamed vesicular eruption of considerable severity. The hands and face are its most common localities; but it may come out on the lower limbs or about the anus and genitals. Its duration, when severe, may be from one to two weeks; but it is often quite limited and of shorter course. " In the treatment of this annoying but not dangerous attack I have had a good deal of experience in my own person as well as with others. I have found the most relief, and the greatest effect in shortening- the'course of the disease, by reducing the inflammation, from lead-water, early, freely and frequently applied, with a large camel's-hair pencil. It should not be put upon the opened vesicles, which it irritates; but around them, upon the reddened skin. In the practice of my brother, Dr. E. Hartshorne, a very successful remedy has recently been the fluid extract of serpentaria paint- ed directly upon the eruption. It seems to kill it at once."__Dr. Harts- horne, Essentials of the Principles and Practice of Medicine p. 354 Phila- delphia, 1868. CHAPTER IX. PLASTIC INFLAMMATION, OR LICHEN. Willan included under the term Papulae three diseases—lichen, strophulus, and prurigo. In all of them are found little solid elevations of the derma (papula;), generally about the same color as the skin, scattered or collected, feeling harsh and solid to the touch, and attended by itching. In the case of prurigo, these elevations are known to be the direct result in some cases of a disorder of the nervous element of the skin; they are often accompanied by symptoms of atrophy of the skin, and marked signs of nerve paresis. Hence this affection is most properly transferred to the class of neurotic diseases. In lichen and strophulus the papulation is supposed to result from active inflammatory action in which the blood and tissues are concerned (a fibrous or plastic inflammation), constituting the primary and main disease. The papulation of true lichen is accompanied by dryness, more or less rough- ness, and general thickening of the skin. There is never any " discharge ; " lichen is not a " discharging " disease, and in this respect differs altogether from eczema ; it is due to the effusion into the skin itself of plastic lymph. Strophulus is considered to be the lichen of children, but I shall have occasion to deny this, and to state that it is a mixed disease. However, at examinations candidates are required to say that strophulus is the lichen of infants and young children. lichen. This disease is essentially chronic and non-contagious, characterized by the appearance of little papules, about the size of millet-seeds, slightly red or of the same color as that of the skin, distinct from, though close to, each other, at other times closely grouped. The former distribution is often seen on the inner, the latter on the outer aspect of the limbs; the papules feel hard and cannot be removed by pressure ; if they are scratched, a little clear fluid may ooze out. The skin generally is dry and thickened ; there is con- siderable itching. Once formed, the papules undergo little change until their diappearance; but then scales form upon them, and they are dry, very fine, and grayish. The disease has a great tendency to recur, to chronicity, to be complicated by other forms of disease, and to spread from one region to another. It may be acute or chronic. Its seat may be limited, or absolutely general; it exhibits, however, a predilection for the back of the forearms and hands, the lateral parts of the neck, and the face. As before observed, some think lichen merely a stage of eczema (especially Hebra and Hardy). Lichen may be divided into («) simple or uncomplicated, and (b) compli- 80 LICHEN. cated or mixed. In the latter group the characters of other diseases—urti- caria, purpura, or eczema—are added to those of ordinary lichen. Simple or uncomplicated. Complicated or mixed. 1. Lichen simplex. 1. Lichen urticatus. 2. " circumscriptus. 2. " lividus. 3. " gyratus. 3. " eczematodes. 4 " agrius. 5. " pilaris. 6. " tropicus. Under the head of lichen, Hebra includes two forms of lichen, named respectively, lichen rubra and lichen scrofulosus, to which special reference will be made. Lichen simplex is often seen in the summer, sometimes recurring in the same person several times; the papules are red, smallish, and more or less pointed, lasting a week or so, and followed up by the development of others; they are usually seen on the back of the hand, the outer aspect of the fore- arm, the neck, and the thighs: there is a good deal of itching. This form may last for weeks and months. The disappearance of the papules gives rise to a little desquamation. The skin generally is dry, thickened. L. circum- scriptus is present when the papules are collected together into little round or roundish elevated patches ; the border is well defined and papular, the surface elevated, rough and dry to the feel; its area increases by circumfer- ential enlargement, and its centre presently clears somewhat; there are gen- erally several circles, and their most usual situation is the back of the fore- arm or the hip; at other times the back of the hand or calf may be affected. The patches after a while get more or less scaly, or inflamed and cracked, simulating eczema, or in consequence of the centre healing, assume a circul- ate form; but the history, absence of moisture, and the dry red base of derma, are distinctive. When several patches run together and form bands as it were, the disease is named lichen gyratus (Biett) : this is nothing more than the coalescence of several circles of lichen circumscriptus. Lichen agrius, or the inflamed form of lichen, differs from the above in the presence of secretion, and hence approaches eczema ; but it is, as its name implies an acute inflamed lichen. It commences with fever, more or less marked head- ache, pains in the limbs, stomach derangement, and the like • some of these may be absent. The local manifestation consists of clustered or closely- packed red papulae, accompanied by intense itching and burning causing the patient to scratch violently; this in its turn sets up additional irritation the torn and excoriated papulae are inflamed, and exude a thin fluid'- the whole patch thickens, fissures, and becomes covered over with thin scales not the yellow puriform scales of eczema. Lichen agrius may also arise by inflammation of the chronic stage of any of the other forms of lichen not primarily as an acute form. The acute state is about ten or fifteen days in duration, the chronic weeks or months: this variety of lichen is observed LICHEN. SI about the back, neck, legs, arms, and shoulders: it constitutes one aspect of grocei's', bricklayers', and bakers' itch. Vesicles and pustules may however form; and then we have an inflamed, raised, reddened, excoriated, discharg- ing, fissured patch, the seat of intense and often intolerable itching and burn- ing, made worse by stimulation of all kinds, especially the warmth of bed. This is no doubt a mixture of eczema and lichen, and is rightly termed eczema lichenodes or lichen eczematodes. The disease either subsides or increases by the development of fresh crops of papulae. In true lichen agrius, the papules form the prominent feature. True lichen agrius, then, is an inflamed lichen; but the co-existence of lichen and eczema in one and the same patch closely simulates it. Lichen Pilaris.—Much dispute has arisen in regard to this variety. Oc- casionally one sees, either alone or in conjunction with ordinary lichen, lit- tle elevations like papula1, which are however seated at the hair follicles; in fact, the hair pierces the centre of the papule. A distinct alteration is felt by the finger. There is no doubt but that hyperaemia of the follicular plexus is followed by fibrous deposit outside the follicle, forming a papule. There is no reason why in ordinary lichen this should not happen, in the same way that hyperaemia and enlargement of the sebaceous follicles is seen as an acci- dent and accompaniment of scabies and other diseases. Indeed any irrita- tion may induce this " lichen pilaris," and it is sometimes seen in chronic scabies. Generally the papulation involving the hair follicles is slight, but I have seen it take on a very exaggerated form in the leg, the effusion of lymph producing hard, large flat papules, nearly the size of split peas, per- forated in their centres by hairs. In the last case I had under my care, in consequence of the number and close packing of the papules, there was a patch over the whole inside of the leg from below the knee to about three inches above the ankle: on the other limb the disease was not so far ad- vanced ; each papule was covered by what appeared to be a largish adhe- rent scale. This was made up of epidermis cells. The patch was elevated sensibly, felt dense, and was dark-colored. \ have seen other cases of the kind. There was in one case severe, and in a second scarcely any, itchino-. It might well be called lichen planus, but differs, as we shall see, from lichen ruber of Hebra, which is not seated solely at the follicles. Lichen pilaris then is " fibrous inflammation" seated at the hair follicles, the effusion of plastic lymph taking place around the follicular walls, and producing, accord- ing to its degree, more or less well-marked and distinct papulation, each ele- vation being perforated by a hair. It must not be confounded with pity- riasis pilaris, which is merely a desquamation of cuticular cells into, and dis- tending, the hair follicles, preventing the formation of the hair, and produ- cing a blocking up of the follicles, the collected cells forming " a knot " in the upper part of each follicle, and constituting in scrofulous subjects what He- bra describes as lichen scrofulosus, a distinct form of disease which, accord- incrto Hebra, shows itself by the appearance of little elevations, about the-size of millet seeds, either pale, or yellowish, or brownish red, never vesicular; 82 lichen. always grouped, sometimes in circles or segments of circles. The parts which have been papular after a while appear to be covered with a number of little scales ; the patches itch slightly, but not being scratched, are not excoriated nor discolored by blood. These patches remain in the same state for a long time, and undergo no further changes than exfoliation and involution. The disease is limited to the trunk, the belly, the breast, and back, being rare on the extremities. The course is very slow ; generally speaking the groups are developed at the same time, reaching their height in a little while, and then remaming in statu quo. Oftentimes, in consequence of the absence of local symptoms, the disease exists unnoticed for some time. When at its acme, other symptoms are observed: between the groups, and at the same time, on parts free from lichen—that is, on the extremities and face, more or less numerous isolated bluish-red elevations are developed; these are about the size of lentils, and look very much like common acne; some are said to contain pus, then by-and-by they wither and disappear, leaving dark- ly pigmented orbiform, lentil-sized marks in some places, whilst in others fresh formations take place. The skin between the diseased patches is the seat of desquamation, the scales being pale and shining; thus the whole skin assumes a cachectic appearance. In 90 per cent, it is observed in markedly scrofulous subjects, with swelling of the submaxillary, cervical, and axillary glands, with caries and necrosis, or tabes mesenterica. In no case is there lung disease. Hebra has seen many cases, and all recovered. It is not phthisical pityriasis. As to pathology, each knot or papular elevation is seated at the orifice of a hair follicle, and is made up of epidermic scales and fatty matter, in the form of fatty nuclei within the cells. The disease is seen almost exclusively in males, between the ages of fifteen and twenty-five. The treatment is cod-liver oil internally and externally. This disease is not a lichen. There is no inflammatory effusion outside the follicle, but accu- mulation of epithelium and fat inside. It is a pityriasis pilaris, and differs in no way from that disease which will be described under pityriasis, save that it occurs in strumous subjects, and is in consequence all the more severe. The fatty matter given out by the sebaceous glands is more abundant, and the acne-like spots are readily accounted for by the blocking up of the hair follicles into which the sebaceous ducts open, and the resultant inflammation, favored by the diathesis : the cicatricial marks left after the disappearance of the acne spots being due to atrophy, which is one of the most usual events in struma. The cure by cod-liver oil is one of the strongest arguments in favor of this view. Lichen ruber is really, as far as I know, a true lichen, but I am not cer- tain that the disease occurs in this country, save to a slight degree. Ac- cording to Hebra it has three stages:—1. In which are papules, millet size and discrete, covered with fine scales, not clustered, not irritable, and therefore not scratched and excoriated; not general, but confined to one part, mainly the limbs, keeping their original size and not themselves en- larging. 2. In which a patch is formed by the springing up of new papules lichen. S3 in the intervals of the old ones, the patch being dull-red and covered with scales. 3. The whole skin gets red and papulated, and at length cachectic; it desquamates in flakes. The nails become brittle and thickened. There is not much itching. The whole skin thickens and cracks from the muscu- lar movements, and what is of importance as effecting the determination of the nature of the disease, this latter state affects especially the palms of the hands, soles of the feet, besides the fingers and toes. " On examining thin sections of the skin with the microscope, the chief morbid change which has been discovered is in the root-sheaths of the hairs. As is well known, the root-sheath, in its normal condition, is a cylindrical tube, surrounding that part of the hair which is embedded in the skin. In cases of lichen ruber it is changed into a funnel-shaped body pointed below, expanding towards the mouth of the sac, and looking as if it were made up of several hollow cones, loosely included in one another, and having the hair in the middle. Besides this, the cutaneous papillae have been found to be enlarged, and the vascular loops which they contain to be di- lated in this disease." When the disease becomes chronic, emaciation, and a state of marasmus set in, and these are followed by the patient's death. Lichen tropicus, or " prickly heat," is generally described as an eruption of numerous papillae of vivid-red color, about the size of a pin's head, with- out redness of the skin generally, often interspersed wTith vesicles and ac- companied by a peculiar tingling and pricking sensation, which may be almost intolerable, and is excited and intensified by heat, warm drinks, flannel, &c. The disease mainly occurs in hot climates, and attacks the parts covered by the clothes, the arms, legs, breast, thighs, flanks, and the upper part of the forehead. It sometimes occurs in this country. On one day, the 21st of July last, during the unprecedented hot weather which prevailed, no less than seven cases came under my notice in the skin de- partment at Charing Cross Hospital. Now the disease is mostly regarded as a lichen. I cannot subscribe to this opinion. No doubt acute lichen is produced by intensely hot weather very frequently, but as far as I have seen lichen tropicus, that disease in which " pricking," burning sensations are marked—and many cases came under my notice in Syria—the anatomi- cal seat of the disease is the perspiratory follicles; the great demand made upon the perspiratory glands deranges their circulation, so much so, that they are mostly unable to excrete sweat; the result is that the surface is not properly cooled by evaporation, the sweat products are retained, and consequently the nervous plexus of the skin is acutely disordered: hence the burning, pricking sensation. Here and there over the surface, a cer- tain amount of perspiration is produced ; this collects beneath the cutis and forms vesicles. It is not uncommon to find lichenous papules intermingled with those of prickly heat, and even enlarged sebaceous follicles; these are accidental, the result of the disorder of the circulation. I should-there- fore take lichen tropicus away from its present position, and place it amongst the disorders of the perspiratory glands. To recapitulate. Under 84 lichen. Group I., or uncomplicated lichen, I rank lichen simplex, circumscriptus, gyratus, agrius, pilaris, ruber, transferring lichen scrofulosus to pityriasis pilaris, and lichen tropicus to disorders of sudoriparous glands, and this leads me, before noticing the second group—viz., mixed or complicated lichen, to speak of the Pathology.—Now one of the broad distinctions between lichen and eczema is the entire absence of discharge in the former and its presence in the latter. Very many different opinions have been held as to their anatomical seats. It has been said that the little solid elevations of the skin which we call papulae are seated at the sebaceous glands; others affirm that they are due to hyper- aemic follicles, with subsequent effusion; others that they are enlarged papulae of the skin. Now in some cases, where chronic irritation exists, it is very common to see congestion of the sebaceous follicles, as in scabies; in others the follicles become inflamed and prominent. These conditions give rise to elevations that look like papulae, but they differ from the hard, pale, or slight-red papulae of true lichen, which is produced by an effusion of plastic lymph into the skin, especially its papillary layer ; and this effusion is not limited, but is general, so that in well-marked cases of lichen the whole integument is dry, harsh, discolored somewhat, tougher than usual to the feel, contrasting strongly with the thin, light, delicate skin of an eczematous subject. As far as microscopic examination has gone this has been shown to be true ; the vessels of the papillae may be dilated, the papillae themselves hypertrophied. Even in lichen the irritation set up induces turgescence of the sebaceous and other glands, especially in lymphatic subjects : but these phenomena are only accidental to true lichen. It will now be seen why I regard lichen scrofulosum and lichen tropicus as misnamed and misplaced. I am not prepared to say the relative degree in which the vascular and nervous papillae are involved in lichen. And now I speak of Group II. or mixed forms of lichen. There are three diseases here : L. urticatus L. lividus, and L. eczematodes. The latter has been referred to under the head of lichen agrius. Lichen urticatus is simply lichen complicated by urticaria, described espe- cially by Bateman, confined to children, and of special obstinacy. It is gener- ally described as resembling the bite of bugs, but more properly as consist- ing of papulae, which are larger than usual, surrounded by redness and intermingled with wheals here and there. In consequence of the scratching, the points of the papules are torn off and a little dark speck appears so that the papules are more or le»s pruriginous. In other instances the papules themselves are a compromise, as it were, between the two forms of eruption • there are smallish, white, fugacious elevations in conjunction with an irri- table itchy skin; and generally pruriginous papulae are present. The disease it is highly important to observe, may attack the feet. In other instances the papula is developed out of an urticated spot; so that in all instances we may trace the composite character of this variety of lichen. The warmth of the bed is particularly distressing in augmenting the itching. When the disease lasts lichen. 85 some time, the surface is thickened, dirty, so to speak, and dry. It is com- mon in the middle months of the year (summer and late spring), and scabies is often at the bottom of it, and its original excitant. Lichen lividus is lichen in conjunction with purpuric spots. It is seen in those of ill-health, in the intemperate and badly-fed, especially about the legs, where gravitation comes into play. The development of the papulae is accompanied by a little ha-morrhagic effusion, and this may take place at the exact seat of the formation of papulae, or elsewhere : hence we may have as separate existences, hard, livid, flattened papules; or ordinary papules with purpuric spots—a mixed, not a confused eruption. The characters of ordi- nary lichen may be seen elsewhere—on the arm, for instance. Prognosis is not grave. Lichen circumscriptus and lichen agrius are often very obstinate, so is so-called lichen pilaris and lichen occurring on .the face. As a rule, the simple forms get well, with proper treatment, in two or three weeks. Causation is supposed primarily to be due to the existence of a peculiar (dartrous) diathesis, but of which I know and can comprehend nothing. Lichen appears to be most apparent in the nervous temperament in summer- time. It attacks all ages, and is evoked by local and reflex irritation, by a deficiency of alkali in the system; irregularities—mental, physical, alimen- tative, etc.; hereditary tendency; certain occupations—e. g., cooks, bakers, grocers, bricklayers, etc. ; by hot climates. Similarly in this as in other diseases—a predisposition to disease shows itself by tangible evidence when- ever any determining cause unbalances the resistant power of the system. Diagnosis.—There are some difficulties here. The chief points to re- member in regard to lichen are the dry and thickened state of the skin, the presence of papules, which are always to be found, if the disease is in patches, at its extending edge, their hard feel to the touch, and their tin- gling or itchiness. Lichen simplex and scabies may be confounded! Lichen is uniform, scabies multiform. In scabies, besides papules there are vesicles, often pustules, and the papules are not so closely aggregated ; the eruption also is in the line of flexion, not, as in lichen, in that of extension—e. g. lichen is seen chiefly on the outer aspect of the arm; it may occur on the back of the hands and fingers, but it is not interdigital. Lichen never, ex- cept in its urticated variety, occurs in the feet; it is common on the face ; scabies is not. In scabies too we find the characteristic vesicle and sillon; then the disease is contagious and easily removed by sulphur treatment. It is also seen in the seats of pressure, rarely above the level of the mamma, and not associated with the peculiar dry, harsh, thickened state of skin as lichen. Lichen urticatus closely resembles scabies, but the eruption differs in the evanescent character of some of the spots (urticaria), in the absence of ve- sicles of pustules, etc.; in its presence, oftentimes, about the face, and its general absence from the feet; for it is very probable that when it attacks the feet, L. urticatus is complicated by scabies. In the chronic condition^ so lichen. the papular aspect of the rash, with the peculiar hard solid feel, and brown- ish aspect of the papulae, will at once be distinctive. Prurigo may simulate lichen, but prurigo is associated with an unhealthy, relaxed, muddy, dirty state of the skin,—flabby is the word ; the papules (which are pale) are fewer in number, and each is marked at its apex with a dark black speck (dried blood), effused as the result of scratching. The skin is not thickened and dry, as in lichen, nor is there any attempt at scaliness, as in lichen, nor aggregation of papules into patches or groups. Prurigo is essentially a disease of advanced age ; pediculi are mostly pres- ent, and there is often a peculiar urticated state of skin, seen very markedly on the back and chest, produced by an exaggeration of the spaces enclosed by the normal furrows. Prurigo is not common about the face; the sen- sation is one of formication, and is altogether out of proportion to the local disease, whilst pediculi may frequently be detected in the folds of the linen. Lichen agrius resembles eczema, but the latter is moist and discharging, occurs in delicate and thin, not in harsh dry skins; again, the history and edge of the patch in lichen point to the existence of papules; then the patch is much thicker and harsher than in eczema, and wants its thick yel- low crusts : the latter in lichen are thin, pretty few, and " flimsy." Chronic eczema never gives rise to such a thickened condition as lichen. Lichen circumscriptxis, with its papules, ought not to be confounded with the vesicular or furfuraceous herpes circinatus, in which a parasite is found; nor with lepra vulgaris, which is entirely devoid of discrete papulae, and presents peculiar white imbricated scales, and as its selective seats, the points of the elbows and knees. It is important to remember that scabies may be complicated with lichen, and the latter may be set up as the result of irritation of scabies. One sees this state of things very frequently in the hot season—the irritation of a few scabious spots bringing out a pretty general lichen. Treatment.—The early stages of lichen, when accompanied by febrile symptoms, may be treated upon general principles. Salines, aperients, tepid baths, to which may be added bran, gelatine, size, and the like are proper. In lichen agrius poulticing, rest, and lead lotion, or an ointment containing watery extract of opium, lead, and adeps. To allay itching at this stage, besides the baths, ointments of cyanide of potassium may be used in the proportion of three grains to an ounce of lard; oxide of zinc borax of each a drachm, camphor ten grains, and adeps one ounce; or bichloride of mercury or borax lotion. Then, when the disease has passed the acute stage, we must treat the patient according to his constitutional bias. In a goodly number of cases we shall note that he or she is over-worked worried not taking sufficient food and rest, is annoyed by dyspepsia, and is looking thin and anxious. In such cases a change from depressing and over-work the correction of acid or atonic dyspepsia, mild aperients, and a course of mineral acids and bitters, will speedily be effectual, the local treatment STROPHULUS. S7 consisting in the use of mild astringents — zinc and dilute nitric acid lotions. In other cases, where the urine is loaded, and the skin generally is dis- colored and harsh, alkalies are of service, and may be given with ammonia and bitters, together with alkaline baths and borax lotions. In other cases it is apparently impossible to say that anything beyond general debility exists ; under such circumstances arsenic is to be employed. In lichen cir- cumscriptus again, an alkaline course is beneficial, and if there be any ten- dency to rheumatism bromide of potassium may be given in addition ; and in lichen agrius gouty tendencies must be met by colchicum. In the former variety of lichen weak mercurial ointment, the citrine ointment diluted 4 or 6 times, or the ammonio-chloride (grs. v. to 3 j) or acetate of lead, iodine, iodide of sulphur, and sulphur ointment, according to the induration and chronicity of the patch, and in the latter variety maceration with glycerine, borax 3j to § j of adeps with glycerine, or ammonio-chloride of mercury ointments, and lastly, painting with a solution of nitrate of silver, or glyceral tannin, are of use. When the disease is very chronic, and there is much thickening of the skin in general, and in lichen pilaris, a course of bicyanide of hydrargyrum, in the same doses as the bichloride, with bark, is necessary to cause re- sorption of the plastic material poured out into the derma; and local stimu- lation to the skin with sulphur vapor baths may then be employed. But, indeed, no one plan can be laid down for lichen. Each patient must be treated according to his individual peculiarities—one man will need cod- liver oil, another steel, a third aperients, a fourth arsenic, a fifth colchicum, and so on; but the tendency should be in the early stage to use alkalies, and in the later stages arsenic. The too free and early use of stimulants to the skin should be avoided—emollients and alkaline baths being most fitting for recent disease. In all cases stimulants are to be dispensed with entirely if possible, and the food is to be unstimulating. A very good form of local application for itching is dilute hydrocyanic acid a drachm and a half, Brandish's solution of potash half a drachm or a drachm, and six ounces of rose-water. Lichen lividus requires the free use of acids and bark, with good food. In lichen urticatus the presence of scabies must be very closely looked after. I have generally succeeded in curing this obstinate form of lichen by ensuring perfect cleanliness in the way of linen, giving diuretics, with occasional doses of calomel, cod-liver oil, and baths containing sul- phuret of potassium. See Formulae, Nos. 32, 33, 39, 41, 48-52, 58, 60, 72, 106, 122, 124, 126, 132, 141, 146, &c. STROPHULUS. This disease, popularly known as the red gum, tooth-rash, white gum, or red gown, a " papular " rash observed in children, is looked upon usually as the lichen of infants. It is a disease of acutish aspect, characterized by the appearance, on the most exposed parts, the face especially, but also the S8 STROPHULUS. neck, arms, and limbs, of successive crops of little red, irregularly dispersed or slightly aggregated, acuminated papules, intermingled with more or less erythema. The papules vary in size from pins' heads to small millet seeds ; are attended with itching, sometimes slight moisture, and desquamation. There are several varieties, as follows, according to Willan:—S. intertinc- tus, confertus, albidus, candidus, volaticus ; and in addition, Hardy and Bazin have described a mixed form under the name of S. pruriginosus. S. intertinctus.—In this variety the papules are vivid red, and seen about cheeks, forearm, and back of hands ; they are especially characterized by the intermixture of red blushes (erythema), and are intertinctured, in fact. It occurs in young infants under three months generally, and lasts from two to four weeks. When the papules are numerous and closely packed—con- fluent—the name S. confertus is used. There is less erythema here; the papules are paler, the disease is of longer duration than the last, and a recurrence is likely. This variety occurs about the period of dentition, and in a chronic state is often limited to a few patches, which run through a slow course, and leave the skin harsh and dry. It is also most common on the arm. S. volaticus is a term applied to the disease when it consists of small ephe- meral patches, made up of a dozen or so of papules, the skin being somewhat hot and itchy. This variety is observed about the arms and cheeks. Patches spring up here and there for two or three weeks. S. albidus is a misnomer. The name is applied to small papular eleva- tions, perfectly white, which make their appearance about the face and neck, and are distentions of the little sebaceous glands of the skin. In S. candidus the papules are large and whitish; they are seen intermin- gled with those of S. confertus; appear about the shoulders, flanks, and arms of children about a year old, and disappear in seven or eight days. The above are all simple varieties. The mixed form of disease presents, it is said, the characters of strophulus and prurigo conjointly, and is named Strophulus pruriginosus.—This is a true lichen, in which the papules are pruriginous ; it is an obstinate form of disease, and a not very rare one. It occurs in young children from a twelvemonth or so to eight or nine years of age. Papules appear pretty generally over the body; they are harsh, dry, discrete, not confluent; some are surrounded by a red blush. These papules itch considerably, are scratched, and then the apices become discolored from the drying of a little exuded blood, as in prurigo, but it is often only a very minute dark speck. After awhile the papules are covered by scaliness, the skin looks dirty and discolored. Ecthymatous pustules may result from the continued scratching. The chief seats of the disease are the back and front of the chest, the arms, and the face. The disease looks like a dotting over a dry harsh surface by pale papules with dark apices (pruriginous). The disease is mostly chronic. It follows as a consequence of uncleanliness, bad living, the want of fresh air and proper ventilation in dwellings, and is fre- quently seen in hot weather. It is easy to conceive that the nutrition of STROPHULUS. S9 the skin is very much below par, and that the disease is in a great measure due to a disorder of the nervous element in the skin. The disease is very uniform in its aspect. It is thought that the prurigo mitis of Willan may be this disease, which is better named lichen pruriginosus than strophulus pruriginosus. Pathology and Cause.—It is often said strophulus and lichen are one and the same thing in essence, strophulus occurring in the delicate and vascular skin of infants. After adolescence the nutrition of the body has so far changed, and the skin has become firmer and less elastic, so to speak, and strophulus does not occur. It is also said in books that in children simple disorder of the stomach leads to blood changes, and this is readily reflected on the skin, producing strophulus—ex., acidity, bad milk, teething. I can- not subscribe to this. The strophulus of authors is a mixed disease, in some cases a real lichen, in others a different matter. I believe that where- as the anatomical seat of lichen is the papillary layer of the derma, in what is often termed strophulus it is the sweat-follicles. The recent hot season (summer of 1868) has supplied me with a good deal of material, and in cases which have all the appearance in children of strophulus, the papillary elevations have been seen with a powerful glass to be seated at the sweat- follicles, and on viewing them in a slanting direction the central dark aper- tures of the pores were seen by the students. When we remember that in cases of strophulus the children attacked are those who are kept in heated rooms, or are muffled up from the fresh air—that the disease occurs during change of season, and on exposed parts—it will be readily conceived that the view I take of it may be the correct one. I think, therefore, that the simple forms of strophulus should really be ranked under the head of dis- orders of the sweat glands. In contrasting the papule of a lichen and strophulus, there is every differ- ence found: that of lichen is not removable by the finger, and it is solid feeling (exudation) and pale; that of strophulus is vivid red (vascular), di- minishable by pressure, and softish to the feel. Diagnosis.—In strophulus the papules have an exanthematous aspect which is very significant. As a rule, they are not so dry and harsh as those of lichen, and the disease occurs peculiarly in infants ; it is not accompanied by a harsh state of skin, by crackings, or the formation of crusts; it is more intermitting in its aspect than lichen. S.—or as I would call it, lichen— pruriginosus is recognized by the presence of lichenous and pruriginous pa- pules together. In lichen, the papules are generally closely aggregated, and there is the muddy aspect of the skin; besides, the disease is seated on the outer aspect of the limb, and the pruriginous papules are wanting. S. pruri- ginosus puts on a very close resemblance when pustules are present, as the result of irritation, to scabies; but the history of scabies is not papular, but vesicular : it affects the legs and feet, whereas S. pruriginosus does not; it commences in children often about the buttocks ; presents the characteristic vesicle and cuniculus; does not attack the face, as in S. pruriginosus. Scabiet 90 STROPHULUS. is sometimes pruriginous; but then it is so chiefly about the abdomen. It is the early history which clears up the doubt, for the ecthymatous pustules are the result in both cases of irritation—in one the strophulus, in the other the scabies ; and hence must bear much resemblance. If these second- ary manifestations are absent, the diagnosis offers no difficulty. Treatment.—In simple strophulus, cleanliness must be observed; the child must not be too much wrapped up; the use of soap must be avoided; the child should have proper food; the state of health of the nurse should be seen to ; local irritation—e. g., that of teething, hot clothing (flannel), must be remedied ; any aphthous state must be cured; acidity should be corrected, and gentle aperients given ; tepid sponging, spirit or alkaline lo- tions may be used locally. A very useful one is, carbonate of soda 20 grains, rose-water 6 ounces, with 2 drachms of glycerine. Almond emulsion, lime-water, and mild sulphur ointment may be also used. In the prurigi- nous form of strophulus, we must place the patient under the most favorable hygiene ; give him good food, good air, plenty of washing; and internally, iron, cod-liver oil, and quinine, or chloride of potash. See formulae for lichen. CHAPTER X. SUPPURATIVE INFLAMMATION OR PUSTULAR DISEASES—IMPETIGO—CONTAGIOUS IMPETIGO—ECTHYMA--FURUNCULUS—ANTHRAX OR CARBUNCLE—MALIG- NANT PUSTULE--DELHI BOIL--ALEPPO EVIL--BISKRA BOUTON. In many very different diseases of the skin, pus is present, and if the term pustular were used in its very widest sense, a large number of diseases would have to be included within it; for instance, acne; parasitic diseases, such as favus and scabies; pemphigus; variola; farcy; varicella; and so on. But in these the presence of pus is, as it were, a superadded phenom- enon ; it is not a primary or even essential condition, and it is thrown into the shade by the prominence of other features. In those affections which may more strictly be called pustular, the suppuration is the leading and the primary condition, that which we have to recognize and to remedy. Now under the terms pustular diseases, thus defined, are usually comprised impetigo, ecthyma, and furuncular affections—the latter term including furunculus or boil, anthrax or carbuncle, and pustula maligna or .malignant pustule. If we compare the two diseases, impetigo and furuncidus, we note in the former that the disease is very superficial, does not involve the deep struc- tures, is rather sero-purulent than truly purulent, has no tendency to ulcer- ate, occurs in lymphatic subjects, and is accompanied by a slighter degree of inflammation and less amount of concomitant pain and heat. The ana- tomical seat is the rete mucosum and derma. In furunculus, the disease is deeper, there is more inflammatory action, there is more pain, more swelling, there is sloughing and ulceration, and subsequent cicatrization. In ecthyma there is cachexia, freer suppuration, but no " core," as in furunculus—that is to say, no portion of the skin-tissue sloughs. However, what are called boils may occur together with ecthyma, which stands midway between the two groups. Now in furuncular affections the seat of disease is said to be the sebaceous glands. This will be more particularly dwelt upon in speak- ing of furunculi. IMPETIGO. In describing eczema, it was stated that in some cases instead of the se- cretion remaining sero-plastic, it became charged with pus-cells, in fact sero-purulent or puriform. The variety in .which this occurred is called eczema impetiginodes (pustular eczema). Now this purulent chaiacter may be assumed from the first, and then we have what is called impetigo. Most authors agree in regarding impetigo as a pustular eczema—an eczema 92 IMPETIGO. occurring in a pyogenic habit of body. It may therefore rank with eczema, but I have placed it under the head of pustular diseases at present, in order that I may compare it with another form of disease which is like it, but of whose true position I am yet uncertain—I mean that form of disease which I have called impetigo contagiosa (contagious impetigo). But I will first describe what is generally known as Impetigo.—It is characterized by the presence of psydracious pustules, which are elevations of the cuticle, by small collections of pus: they run together; the increased production of pus, sometimes at different points, augments the area of the purulent patch often to a large size. The pus is soon discharged by rupture of the cuticular wall and then dries into thickish yellow crusts, accompanied by more or less oozing. The disease then is an infiltration of pus beneath and in the deep layers of the cuticle; there is of course hyperaemia of the cutis. Now when the patches are small and scattered, the disease is called impetigo sparsa (scattered); when it occurs in a large irregular patch, I. figurata. When the discharge is free, and there is a heaped-up and thick crusting from the drying and col- lection of the secretion, it is termed I. scabida, and occasionally the deep tissues are inflamed, and then we have I. erysipelatodes. I must say a few words upon each of these varieties. Impetigo figurata.—After more or less pyrexial disturbance, numerous pustules aggregate upon a reddish surface; they run .together, break in two or three days, and discharge a tenacious fluid, which at first is very much like a concrete honey " (hence the name, Melitagra) ; presently becoming dry, yellow, discolored. The disease is generally observed on the face. The circumference of the patch is red, and exhibits fresh pustules ; several patches may coalesce; the crops of pustules are successive; the surface beneath the scabs is red and superficially excoriated. It often become chronic, and may cover the entire face. When this is the case, the deep parts are secondarily inflamed and swollen. The size of the crusts depends upon the amount of secretion. When it is free, as in infants at the breast, the scabs maybe " sta- lactitic;" hence also the terms crusta lactea, porrigo larvalis. The neigh- boring glands are swollen. I. sparsa, as I understand it, is nothing more than the above, in small and distinct spots. It occurs often over a wide area—the head, the lower limbs, and the trunk. I. scabida is produced from either of the above varieties by the formation of thick large crusts. It is best seen on the limbs, as in a case some time ago under my care, where both legs were covered from knee to ankle with hard, dry, brownish, and thick crusts, covering over a red weeping surface beneath, like the "bark of a tree." In I. erysipelatodes, the onset and march of the disease is marked not only by general but much local irritation—e. g., heat, tension, redness, swelling Local varieties attack the ear, the nose, the scalp, and face. It is usual to specify particularly I. capitis. This has received a host of names: por- impetigo. 93 rigo larvalis, tinea granulata, melitagra, crusta lactea, &c. It may be I. sparsa or I. figurata. The pustules are perhaps not so distinctly clustered, they are whitish, attended by itching, the presence of pediculi and swollen glands. The discharge mats the hair together into a compound, sour-smell- ing mass, beneath which the surface is red and tender. The sparse variety is the rarer. Children of strumous tendencies are attacked. Two other forms are described by authors, I. sycosiforme and I. acniforme. The former is really I. labialis, in which there is a good deal of swelling and tension, and the discharge heaps up into honey-like crusts, often just beneath the septum nasi. The latter is a suppurative inflammation of the hair fol- licles of the beard, and is often confounded with parasitic sycosis. But this impetigo of the beard is often an acute affection. There are impetiginous spots about the face outside the beard; it affects quickly at the onset a large extent of surface; it is more superficial than the parasitic vari- etv, has more crusting, the hairs in the follicle are not loosened or ren- dered dry and brittle, and there is no fungus present. The disease may become chronic. Pathology.—True impetigo is a suppurative inflammation of the skin, the anatomical seat being about the derma and the cuticle, at the basement membrane. Pustules seated at the hair follicles may be, as before observed, not impetiginous. Causes.—Impetigo attacks both sexes and all ages, but mostly the young. I. sparsa affects elderly people perhaps most frequently; in a person predis- posed, any irritant will evoke the disease—e. g., local irritation, uncleanli- ness, solar heat, teething. It is most common among the lower orders; in those ill-clad, ill-fed, ill-housed ; in scrofulous and lymphatic, pale, and pasty subjects. Prognosis is always favorable. Diagnosis.—Impetigo is known by the psydracious pustules, the yellow secretion drying into honey-like and subsequent thickish, dirty, yellow crusts. Eczema impetiginodes is a mixed form of disease, in which the on- set is that of eczema by vesiculation, the discharge in the progress of the disease becoming like that of impetigo. Ecthyma is known from impetigo by its phlyzacious pustules ; the hard, inflamed, indurated base; the thick dirty discharge; the adherent crusts, and the history of the case. In sycosis there is swelling of the subcutane- ous cellular tissue, indurated pustules, little secretion, change in the hairs, the presence of a parasite, and, in later stages, " tubercles," and the disease is seated at the hair follicles. Treatment.—This consists mainly in the administration of remedies cal- culated to counteract the evil influence of the lymphatic or strumous tem- perament present—as cod-liver oil, iron, quinine, milk, good animal diet, together with, locally, the use of emollient and subsequently astringent remedies. In the early stages of disease, when there are acute general febrile symptoms, salines, purgatives internally, and emollient cataplasms, poppy 94 IMPETIGO CONTAGIOSA. decoction, warm lead lotion, zinc ointment externally, are useful. If there be any irritation from teething, the gums must be lanced. Before commencing the exhibition of tonics, the bowels should be care- fully attended to. Saline aperients in those of pretty good age are called for, especially in servants who have had very little exercise, and who " stuff " themselves with unwholesome articles of diet. Having, however, rectified any error of this kind, we at once employ tonics, generally cod-liver oil and steel. Where there is any amenorrhea, a course of iron is called for. With regard to local treatment. At the outset, and in direct proportion to the degree of irritation present, our remedies must be of an emollient nature. Poulticing, fomenting with decoction of poppy-heads, to remove the crusts and allay inflammation, is the first step. Weak lead or borax lotion may then be used, and subsequently an ointment made of a drachm of the nitrate of mercury, or three grains of the ammonio-chloride to an ounce of lard. If the scalp is affected, the hair must be cut from around the disease. Pediculi are to be destroyed by the white precipitate ointment, chloroform vapor, the pyrethrum roseum or stavesacre ointment. I prefer the former of these. In many cases alkaline lotions are of use—ex. gr., carbonate of soda (sixty grains to six ounces of water). In impetigo scabida other steps must be taken; the general health must be regarded from a gouty, a rheumatic, or a latent strumous point of view, and treated accordingly—the kidneys especially made to act well. The diet should be good and unstimulating. Then locally, the scabs are to be re- moved by repeated soaking in glycerine lotion, and by poulticing, and the denuded surfaces may be treated with lead lotion, tannin and glycerine at first, and then the white precipitate ointment, or one composed of pyrolig- neous oil of juniper two drachms, and sulphur ten or twelve grains, to an ounce and a half of lard. Finally, painting with nitrate of silver solution will heal the surface, and if the limb is affected, and the skin is much swol- len, careful banding must be resorted to. In impetigo of the beard hot fomentation, the exclusion of air as much as possible, a course of iron with acids and sulphate of magnesia, and locally alkaline washes, then glyceral tannin, sulphate of zinc lotion, and the nitric oxide of mercury ointment, generally suffice. IMPETIGO CONTAGIOSA, OR CONTAGIOUS IMPETIGO. I am anxious again to direct attention to the clinical features of a com- mon form of cutaneous disease, seen especially in dispensary and hos- pital practice, and universally classed by practitioners with eczema impeti- ginodes or impetigo simplex, but which is, as regards nature and treatment, a wholly distinct affection. Its cure is usually certain and easy by local means. It is classed under the term porrigo, as used by some writers, and is one of the many varieties of eruption which together constitute the com- posite " scald-head." I have hitherto called the disease contagious impeti- go ; for it is essentially inoculable (contagious). It is often ^wasi-epidemic; IMPETIGO CONTAGIOSA. 95 it differs in severity and hi features at different times, tends to run a defi- nite course, exhibits a uniformity of character as regards the eruptive condi- tion, and is vesico-pustular in type. Mr. Wilson has recently stated that the disease is a distinct and common one. I had the pleasure of showing Dr. McCall Anderson some cases a few weeks since, and he acquiesced in the special nature of the disease. Dr. Clifford Allbutt has informed me that he is now satisfied as to the existence of the affection as I have de- scribed it. Clinical history.—The disease is seen amongst children of the lower orders especially, probably in great measure because the opportunities for contagion are more numerous, but occurs also in those who have all the ad- vantages of social position and good hygiene. It is ushered in occasionally by smart, generally by slight, fever; or the child looks ill, pale, languid, and is said to have been " in a burning heat," or to have had " cold chills." There is clearly an affection of the system at large before the occurence of any eruption, which in the majority of cases appears first of all on the face, or top or back of the head, in the form of " little watery heads " (ve- sicles), that enlarge into flat bullae. Sometimes the hands are attacked at the outset, and look as if burnt here and there ; phlyctenae may also arise out of and around the remnants of vaccinia, or about cuts or bruises. The disease then "extends to other parts, the back of the neck, buttocks, feet, etc. The vesicles are always isolated. In five or six days the bulla may reach the size of a sixpence or shilling, unless ruptured, and then it is flat and depressed in the centre, the contents becoming turbid. The secretion consists of lymph-like fluid, granular cells, and subsequently pus-cells. Scabs commence to form a few days after the appearance of the disease. They are characteristic of the disease, varying in size from that of a split pea to a shilling; they are flat, straw-colored, dry, and granular-looking, and appear as if "stuck on" to the part; they present, as a rule, no in- flammatory areola around their circumferences, though this is the case in severer instances of the disease. If removed, little sores are observed be- neath, more or less filled in by gummy-like secretion, or a little pellet of aplastic lymph. The disease may be spread from spot to spot by direct in- oculation with this secretion in the act of scratching. The crop of vesicles is to some extent successive, though the majority of the places "come out" in the first week or so. In some instances the disease resembles vaccinia very closely. There is always a uniformity about it; it always commences by vesicles ; there are no papules present at the height of the disease. On the face the spots may be confluent, and then the disease resembles eczema impetiginodes; but the patches are made up of the elements described above. On the head the disease consists of circular, mostly isolated, flat- scabbed spots about the top and back of the head, the hair being matted by the crusts. There are usually no pediculi and no offensive smell. The mucous membranes of the eye and the nose are often implicated ; then inflammation is produced by the development of little ulcers, that take 96 IMPETIGO CONTAGIOSA. their origin in the development apparently of vesico-pustules, identical with those seen on the surface of the skin. The eye may look as though affected by slight purulent ophthalmia, but soon recovers itself. All the children in a house may be attacked at one time, or consecutively, by the disease, and in such a way as to impress upon friends and attendants the idea of its beinc contagious, and under these circumstances it may be regarded as scabies. It may complicate eczema, scabies, and other affections, and vice versa. Diagnostic features.—Its apparently epidemic character in many cases; its attacking children; the antecedent febrile condition; the origin from isolated vesicles, which tend to enlarge into blebs, and to become pustular, the bleb having a depressed centre, and it may be, a well-defined, slightly raised, rounded edge; the isolation of the spots, the uniform character of the eruption, and its general and scattered condition; its seat, and frequent commencement about the face or head; the circular, flat, granular, yellow crusts; its contagious nature and inoculability ; its frequently following in the wake of vaccination ; the implication of the mucous membrane of the eye ; the absence of pain, and especially troublesome itching at night. It may be confounded with eczema; but the history is altogether differ- ent, and the isolation, the small scabbed patch, the characters of the crusts, and the facility of cure, at once distinguish it. Impetigo' sparsa does not arise from a vesiculation, but is primarily pustular, made up of aggregated pustules; it is not phlyctenoid; it is not contagious nor inoculable; it does not run a definite course; it is not confined to the young; it is not so amenable to treatment. Pemphigus ; but here the blebs are more persistent, oval, and distended ; the contents are watery and acid; it is non-contagious; it does not occur especially on the face or the head ; it is less inflammatory, and wants the characteristic scabs. Ecthyma : This is primarily a pustular dis- ease, seen also in adults; there is more induration and swelling; a good deal of pain ; it is non-contagious ; the scabs are heaped up and dark. Pus- tidar scabies: This is the disease with which it is mostly confounded. It must be remembered that the two diseases may co-exist. Both in chil- dren attack the buttocks especially; both may exist about the hands and feet; but the distinctions are rarely very clear. In scabies there is no febrile condition; the eruption is multiform. If there be ecthymatous pustules, like impetigo contagiosa, they are covered by dark thick crusts ; there are plenty of characteristic vesicles, with cuniculi, and papules. If the impetigo contagiosa begins about the buttocks, it appears presently on the face or the head, or both. There is not the irritation of scabies so bad at night, nor the effects of scratchings about the body; the bullous origin of the disease is distinct, and the peculiar scabs are characteristic. The hands are not specially affected in scabies in the child, but even impetigo contagiosa may attach the hands and feet markedly ; still there is no mul- tiform eruption. Inoculation will settle the point in twenty-four hours if we cannot find an acarus. We must not be misled into the idea that scabies exist because several children hi the same house have a certain disease, and ECTHYMA. 97 have apparently caught it the one from the other—a rule adopted by very many. Lastly, the two diseases may occur together. When a correct diagnosis is made, the treatment is easy. The natural course of the disease is a short and definite one. The disease sometimes occurs in badly-hygiened subjects, and, therefore, tonics may be given. The secretion is a most active element (per inoculation self-practised by the patient) in transmitting the disease to different parts of the same subject or toothers; and this ensures perpetuation and chronicity. And, therefore, we should destroy the secretion, and then alter the behavior of the surface that yields it. Astringents and antiseptics avail; but the best is a little ammonio-chloride of mercury ointment—five grains to the ounce. The scabs should be removed, and the ointment applied to the secreting surface. The disease is supposed to be due to the contact of those attacked with non-specific unhealthy pus; but there are many reasons against this, which cannot be noticed here. It is a very definite disease, dependent upon a particular poison, easy to treat, but little known. Impetigo Bodens.—Under this term have evidently been included many different diseases. Hardy calls the affection scrofulide pustuleuse. It is said to occur about the sides and tip of the nose, first as small pustules on a red base, that break out into ulceration, and are replaced by a brownish scab, which covers over a dirty foul ulcer. But impetigo is a superficial pustulating and non-ulcerating affection; the word rodcns signifies an " eating out," and it is most probable that by I. rodens has been meant now a syphilitic, now a scrofulous ulceration. ECTHYMA. This disease is described as consisting of isolated phlyzacious pustules— viz., those which are " large, raised on a hard base, of a vivid red color, and succeeded by a thick, hard, dark-colored scab, beneath which there is ulcer- ation." The pustules are generally distinct, round, and isolated; they are mostly general; they may be partial, and leave cicatrices behind. The shoulders, buttocks, and limbs are the parts usually attacked. There are two chief forms—acute and chronic. The local symptoms are generally in direct ratio to the amount of general disturbance. A cute ecthyma commences with slight febrile disturbance, and occasionally sore throat; locally, a sense of heat and burning, followed by the appearance of reddish raised points, with hard indurated- bases, and distinct vivid areolae ; these points quickly pustulate, vary in size from that of a pea to that of a shilling, and are often accompanied by acute, sharp pain. In two or three days the pustules give exit to discharge, which dries into hard, adherent, dirty discolored scabs, covering over circular ulcerations : the crusts fall off in a week or so, leaving behind dark stains. The ecthymatous spots may be many or few ; in the former case a good deal of irritation is set up; the patient may be unable to sleep from pain, and the glands and lymphatic vessels may become inflamed, and small abscesses form. The disease is 7 98 ECTHYMA. generally protracted by successive crops of pustules, or it may relapse into a chronic state. The limbs, shoulders, and trunk are the seats of the disease. Chronic ecthyma occurs under three forms :— a. E. infantile, which is the disease as seen in ill-fed, half-starved chil- dren, fed by unhealthy mothers. The pustules vary in size —- some are small, some large; the crusts are dark; the ulceration unhealthy, giving out a foetid and sanious pus. The disease affects the body generally, often commencing about the lower limbs; the scalp may become the seat of the disease; the child often wastes, becomes hectic, diarrhoea may set in, and death ensue about the fifth or 'sixth day. b. E. luridum, seen chiefly in old people and debilitated subjects: it is usually extensive; the pustules are large, slow in progress; they have a dull, livid look, a dark areola, are filled with sanguinolent curdy fluid; in a week or ten days they discharge their contents, which are dirty and foetid, and scab over or ulcerate. c. E. cachecticum is pretty much the same disease ; it is seen mostly on the lower extremities; there is not so much of the livid aspect; it is rather more active ; the subcutaneous cellular tissue is involved : the contents of the quasi-pustules are not so sanguinolent as in E. luridum, and there is not so much ulceration ; there is often a good deal of fever. In the last two varieties the eruption is really something between a bulla and a pustule. Ecthyma, it must be remembered, may result from any long-continued irritation in badly-nourished subjects. It is a frequent com- plication of scabies and prurigo. The three chronic varieties are but stages of one and the same disease ; so-called E. gangrenosum is rupia escharotica. Pathology.—Ecthyma is clearly pyogenic in character; the seat of dis- ease appears to be the uppermost layer of the derma, not unlikely about the glands of the skin; the depth of surface involved is less than in furun- culus, and there is no " core; " otherwise ecthyma would be well classed with boils, and described as differing therefrom in the fact of its more diffuse suppuration, and the aplastic character of its pus, explicable by the cachectic state of the patient. The tendency to ulceration and slouching, the lividity of the inflammatory areola, the disturbance of the general sys- tem, all point to a cachectic condition, which is readily explained by a reference to the so-called Causes of the disease. These are always such as lead to debility and an impoverished state of blood. They are in infants bad nursing, suckling by mothers much out of health, scabies, bad clothing, damp dwellings ; in adults and others, over-work, fatigue, convalescence from acute diseases, bad food, privations, various occupations that induce irritation of the skin—ex., bricklayers, excesses of all kinds, debauchery, uncleanliness, night-watching, overcrowding in public institutions, work- houses, jails, hospitals, and such-like. Prognosis is to be made according to the general condition of the patient. The ecthyma,j?er se, is of little guide, save when it is of the lurid variety in old people; then it is grave. ECTHYMA. 99 Diagnosis.—The distinct, large, isolated pustules, with an inflamed areola, a hard base, distributed over the body, are very distinctive of the disease. It may be confounded with Impetigo sparsa, but in this disease there are rather sero-pustules than pustules ; the discharge is viscid, yellowish, there are no dark scabs, no indurated, inflamed, and painful bases. Furunculus is deeper, it runs a slower course, and contains a central " slough " or " core," as it is called. It is more circumscribed, and there is little scab- bing. In AScabies ecthymatous spots are constantly seen, especially about the hands and feet, and in conjunction with other signs of scabies, being secondary in point of time thereto. Prurigo is complicated by ecthyma. The conical, dark, heaped-up, stratified crusts of rupia distinguish that dis- ease from E. cachecticum. Treatment.—We must recollect that ecthyma is a cachectic disease ; that it often occurs in those in whom the eliminating organs are sluggish, at the same time that effete material has been largely produced in the system. Firstly, if secondary to scabies or prurigo, we must treat the primary dis- order, then with the aid of tonics the ecthyma will soon disappear. Again, if it arise from the action of local irritants upon unhealthy skins, as from the contact of lime or sugar, we have only to remove these sources of evil, and use soothing remedies with astringents—alkaline lotions, or glyceral tannin, or biborate of soda or zinc ointments, and give internally iron, min- eral acids, or other suitable tonics, for the case to get well. But suppose there is no external cause of this kind, we must treat the impoverished state of blood which gives rise to the disease. I am of strong opinion that elimination first of all needs attention. In young subjects, saline aperients together with tonics are the best remedies. After a good colocynth purge, the exhibition of such a mixture as sulphate of magnesia, sulphate of iron, tincture of calumba, and cinnamon water, or if the appetite is bad, dilute nitro-hydrochloric acid with sulphate of magnesia, quinine, and infusion of roses, soon improves the whole tone of the system. But this end is still further secured if we take care that our patient eats wholesome food, that he gets his proper rest, and the proper amount of air in his sleeping-room ; especially that he is cleanly, and not over-worked. All these are material points in the treatment. If the patient be young and growing, he must be well dieted, have a sufficient amount of wine or sound beer, and take cod- Liver oil. Then locally, in these acute cases, emollients are alone admissi- ble—warm lead lotion and poppy-head fomentations. Presently we may substitute opiate and tannin ointment—extract of opium, ten to twenty grains, a scruple of tannin, with an ounce of simple ointment. I trust to the general and not the local remedies. Then there is still the chronic form of ecthyma to deal with. Even here I lay great stress on a sufficiency of aperients, and on the mineral acids, with bark, bitters of all kinds, quinine; if there be much nervous disturbance, pain, restlessness, and the like, opiates judiciously exhibited are of service; change of air will some- times work wonders. In the cachectic varieties^ free living, plenty of meat, 100 FURUNCULAR AFFECTIONS. wine, with bark and ammonia, must needs be given; and locally in chronic ecthyma the scabs should be removed, and attempts made to get clean and healing surfaces by the application of weak Condy's fluid, weak carbolic acid lotion, simple sulphur ointment, or weak nitrate of silver lotion, when it is necessary to stimulate. If there be much irritation, lead and opium lotion, or charcoal dressings, may be of service. A good application is an ointment made by rubbing together an ounce of lard, and half a drachm or so of Friar's balsam. No two cases are exactly alike, and the special knowledge of the physician is often needed to detect some flaw in the performance of the organic func- tions which mainly determines the occurrence of the disease. Other re- medies will be found in the formulary. FURUNCULAR AFFECTIONS. I have said that furuncular affections differ from impetigo and ecthyma, amongst other things, by being deeper, and by their pustules containing in their centre a dead piece of tissue which is called the " core," in fact a cen- tral " slough." This " core " is indeed the essential feature of a boil. Now we are told in books, and expected to say at examinations, that furunculus or boil, anthrax or carbuncle, and malignant pustule, are forms of one and the same disease. But malignant pustule is produced by a specific poison, and should be ranked elsewhere. The general character of furun- cular affections is in the occurrence of inflammation of a limited extent, affecting the tissues deeply, the central part dying and forming " the core." Some think this core is a true exudation, some a piece of " dead cellular tis- sue." When a boil is, so to speak, multiple, when there are several " cores," and the cellular tissue is much involved, and more or less sloughy, then we have a carbuncle. But, to put it in text-book language, " the characters of distinction between furunculus and anthrax relate to their prominence, depth, breadth, color, number of cores, and degree of pain." Furunculus is a solitary pustulation; it is more prominent, less deep, involves less of the tis- sues around, has a deep red areola which assumes a bluish tint after a while : the " core " is single, and the pain is less severe. Anthrax is less prominent; it is deeper, involves more tissue, is much darker in color, possesses many " cores" (dead tissue), and is accompanied by greater pain. First of FURUNCULUS, OR BOIL. The general symptoms are as follows in some cases :—Febrile disturbance, rigors, loss of appetite, headache, disordered bowels. Locally, a little red lump, the size of a split pea, makes its appearance : it is tender, painful and tense; this soon becomes indurated, the disease is felt to be pretty deep, a red blush surrounds the base of the swelling, and changes from brifht red to purple. In from three to six days, the apex of the boil becomes yellow from the formation of pus : the pain is now throbbing, the induration of the tissues at the base augments, and so does the amount of pus in the centre of FURUNCULAR AFFECTIONS. 101 the pustule. If left to itself, " the pustule" bursts, and presently " the core" eomes away, healthy granulations at once spring up, and repair is quickly completed. Sometimes the suppurative stage is scarcely reached, and then we have blind boils. Furunculus generally attacks the neck, but- tocks, arms, especially in young people, and there are successive crops of pustules, so that the disease often lasts a considerable time. The glands may be enlarged. The pain is severe in boils that occur in parts that are dense and cannot swell, as in the meatus of the ear and the pudendum, or those that are freely supplied with nerves, as the face. ANTHRAX, OR CARBUNCLE, Is a multiple furuncle ; it arises as a hot hard swelling, not so conical as that of the boil, more indurated, however, the cellular tissue around being much more extensively implicated ; the color is dusky, the sensation burning, dull, throbbing; in size the carbuncle varies, the swelling becomes " brawny," due to the meshes of the cellular tissue becoming filled with aplastic lymph. The next step is the formation of a quasi-abscess; the central part softens, feels boggy; the skin thins over the surface, and at several points openings occur, through which slowly issues more or less sanious pus ; and the little holes are seen to be plugged up by small white cores, which presently loosen and come away; the apertures are red and papillated, the edges indurated and everted, particularly when several openings coalesce, so as to form one or more large openings. Gangrene may set in ; the healing process is often indolent; the parts remain undermined, brawny, dusky, shreddy, and also sloughy. Carbuncles are generally solitary. The patient, if the attack be severe, gets into a very depressed state. The posterior aspect of elderly people is the selective seat of carbuncle. I shall refer to the cause together with that of boils. HORDEOLUM, OR STY, Is a small boil seated at the edge of the eyelids, and involving a Meibomian gland. It is not an active kind of boil, but progresses sluggishly, the pus- tular centre being small; it is painful, and some time lapses before all traces of its existence go. There may be one, two, or more, on one or both eyelids. Pathology and Cause of Furuncular Affections.—Now, under what con- ditions, first of all, do boils occur—(1) during seasonal changes in spring and summer; (2) from eating diseased meat (frozen) ; (3) when any special alteration is made in the ordinary habits and economy of the body, as in the training of prize-fighters; (4) from the influence of cadaveric poisons ; (5) from sudden change of diet; (6) after fatigue of long duration; (7) dur- ing convalescence from debilitating diseases; (8) as a consequence of the action of septic poisons, as in fevers, etc.; (9) in albuminuria; (10) in the diabetic habit; (11) during adolescence, and in the first stage of manhood. In most of these cases there are " debility " and an overloaded state of sys- 102 FURUNCULAR AFFECTIONS. tern—ex., the circulation of urea, of sugar, of septic poison, or of effete matter which is plentiful during convalescence. But with this state of things—i. e., evident general disorder of the system—the local inflammation is active, and the suppuration is " healthy," the pus laudable, the process of repair peculiarly vigorous and complete in its character. Now, it is this which gives the lie, as it were, to the doctrine that a boil is due to the occurrence of a spontaneous gangrene or death. It supposes that there are two actions going on side by side of diametrically opposite characters—a gangrenous and a vigorously reparative one. If the primary death result- ing in " the core" were due to a tendency to gangrene in the system, why should there be present in the same subject and in the same part a thoroughly satisfactory process of repair. What, indeed, is there in the clinical history of boils, or the condition of patients affected by them, to account for the spontaneous death of a piece of cellular tissue ? If " the core " be regarded as an exudation, we have no analogy to support such a proposition. It is clear that the only satisfactory explanation is that which recognizes that some disorder in the circulation of the part first takes place, that the tissues fail to be properly nourished, to perform their functions, and then die (slough), and that an attempt is made by suppuration to get rid of the moribund or useless tissue. M. Denuce, of Bordeaux, believes that the anatomical seat of the disease in furuncle is the sebaceous gland (as is the case in sty) ; this gland, in the performance of its emunctory act, is disordered by the effete matter with which the blood is charged; it is then congested and inflamed, then it suppurates, dies with the contiguous cellular tissue forming " the core," and healthy reparative action is at once set up after the dead tissue comes away. " The core " is a dead sebaceous gland, and more or less of its contiguous cellular tissue. It is easy to see how it is that friction and irritants of all kinds determine the seat and occurrence of boils in those who are predisposed to them. It is said in the case of a blind boil we have an inflamed sebaceous gland, which happens to recover itself before the stage of suppuration is reached or needed. Boils occur in parts where the glands are large, where the skin is tough, and liable to be injured—ex., the back of the neck, shoulders, and the outer side of the limbs. The boil varies in character and degree according to the depth of the cellular tissue around the gland involved, and the state of the blood; boils are large and severe in debility after convalescence, in diabetes, albu- minuria, and the like; small and painful in young and plethoric subjects. If boils are the result of an inflammatory state of the skin glands their occurrence in full-blooded and apparently healthy persons is explained by the overcharged state of the blood with the waste products of the body. In contrasting boils with simple acne, we notice that the latter is merely a choking up of the sebaceous duct by fatty secretion, with more or less secondary inflammation; there is not necessarily suppuration. In boils the whole gland itself is involved, not merely the excretory duct; the alteration of the blood current is primary—tshe gland is disordered and inflamed as a FURUNCULAR AFFECTIONS. 103 consequence. In acne rosacea we have a closer approach to a boil; there is not suppurative but plastic inflammation of the gland and the tissue outside. Let acne rosacea suppurate freely, and though the cause be different the result is mainly the same. The microscopic structure of " the core," it is said, bears out the opinion here expressed, to which I have long inclined. In carbuncles we have a similar action to that in boils, but a much severer degree of disease. Here a group of sebaceous glands is involved, and in consequence of the more cachectic state of the nutrition the reparative attempt is less perfect, the inflammation is of a lower type, and the cellular tissue to a much greater extent sloughs and dies. The nutrition is not only unequal to prevent the local disorder, but also incapable of putting repair in proper operation; and what is the blood state in carbuncle ?— a tendency to a diabetic condition. This has been exemplified of late by many observ- ers—Prout, Goolden, Landouzy, Wagner, De Calvi, Fonseca, Menestrel, Kiichenmeister, and others. Anthrax is very common in Pernambuco, and Fonseca finds it connected with diabetes, or a diabetic tendency. Sugar occurs in the pus of the carbuncle, and it is a curious fact—so it is stated—that when anthrax develops, the sugar is diminished or disappears from the urine. M. Verneuil not long since corroborated Wagner's observation relative to the occurrence of phlegmonous and gangrenous inflammation in diabetics, before the French Academy, in certain cases of gangrene of the lower limb occurring in connection with saccharine urine. Lastly, I said that ecthyma and furunculus, save in the absence of the " core," bore some resemblance. I cannot but think that some change in the blood current leads to superficial suppuration about the upper part or the ducts of the sebaceous glands in the topmost layer of the derma, in ecthyma, in which disease a pyogenic habit of body is present; at any rate, boils and ecthyma- tous pustules often occur together. Diagnosis of Polls and Carbuncles.—No error can possibly be made in respect of these two diseases; in the former, the hard, deeply seated indura- tion, the pain, the central suppuration, and the " core," are distinctive. The manifold openings, the boggy feel, the sloughing, the grumous discharge, and the implication of the cellular tissue in carbuncle, are very peculiar. Furunculi are sometimes epidemic. Treatment.—If the view I have given of the nature of boils be correct, then we may at once lay down a definite plan upon which to base our treat- ment. Boils are accidents common to many conditions, but produced in all these upon a similar plan—viz., a disordered blood condition, with nutritive debility and deficient elimination in subjects whose tone is lowered. First, of boils. There is always deficient elimination; it may be in a young and naturally vigorous youth who is rapidly growing, and is perhaps hard worked, and who does not get quite the right food he needs,—it is plentiful, but scarcely wholesome. If the disease assumes what may be fairly called a sthenic form, here saline aperients and a modified diet suffice; but where there is marked want of tone, in such a case sulphate of magnesia, infusion 104 FURUNCULAR AFFECTIONS. of roses, and quinine at first, and then cod-liver oil, would be the proper remedies internally. Again, in those who are breathing a vitiated atmos- phere—in the dissecting-room, for example—change of air, quinine, aperients, and rest, soon improve the general condition; or bark and chlorate of potash, with the mineral acids, are equally good medicines. In the case of individ- uals of mature age but good average nutrition, the emunctory functions may be disordered; here we must again eliminate and tone. If the urine be loaded, and the bowels irregular, the combination of acetate or bicarbonate of potash with ammonia, followed by calumba and an alkali, are advisable. If there be a gouty diathesis even colchicum or iodide of potassium are called for, with tonics. In the case of boils occurring during convalescence from febrile diseases, there is still the removal of waste products to attend to, and the necessity for tonics at the same time. These remarks mainly refer to young persons ; but boils trouble middle-aged and elderly folk. In some instances we have to deal with careworn and anxious men and women, who have a pretty hard struggle to maintain their position, and a good many mouths to fill at home, and who are yet originally healthy and sanguine subjects. The diet of these persons has been deficient; it requires to be not only more ample, but more varied, if possible. Here again aperient tonics seem to me to be indicated, and I believe that opiates (the watery extract) freely given, if there be much nervous excitability, will lull the patient, both as regards his pain and his depression. Then it is of prime moment that we are sure that our patient's gall-bladder is properly emptied. In some in- stances of over-worked middle-aged persons, the sallow complexion, the al- most actual icterus, the loaded urine, flatulent dyspepsia, and want of tone, point mainly to a congested and inactive liver as the source of mischief. Such a case demands podophyllin in repeated doses, the nitro-hydrochloric acid internally with nux vomica, and the careful regulation of the diet; the avoidance of saccharine matter, pastry, and malt liquors. In young women who are naturally of good constitution, and who get somewhat anaemiated, or have their menstrual functions disordered, boils are often seen about the armpits. In such cases aloetics and quinine with iron, moderate exercise in the open air, and plain food, are called for. In all cases fresh air, abstinence from work, if at all needed, and frequent ablution, should be prominent items in the treatment. With regard to local treat- ment, in the vast majority of cases boils always run on to suppuration, and the object to be attained is the removal as quickly as possible of the " core " or dead tissue, whilst we improve the general blood condition. In the slighter forms, which we know by experience will probably " subside," emollients may be applied, lead lotion, warm applications, poppy-head fomen- tations, or pressure by means of soap-plaster, by which means boils may be helped to abort; we may attempt by aperients and diuretics, if need be with tonics, to prevent their formation. In the more decided forms we encourage the suppuration, help the evulsion of the dead tissue, and favor the healing of the ulcer subsequently left. We must also allay pain. Now FURUNCULAR AFFECTIONS. 105 poulticing, the prevention of local irritation by proper protection, resting the affected part if this is possible, are the means generally employed, as every- body knows ; but though practitioners know this, they do not appreciate the contingent fact that, inasmuch as local irritation of all kinds determines the occurrence of boils, local remedies, such as poulticing and the like, should be confined as much as possible to the exact seat of local inflammation. Noth- ing is more common than the springing up of fresh around old boils from the neglect of this precaution. Now, when suppuration has set in, then we may hasten the preparation and exit of " the core" by the application around its indicated locality of potassa fusa or acid nitrate of mercury. We may, to sum up, attempt to moderate and limit the suppurative action at the outset, but we must, when pus has shown a tendency to form rapidly, at once encourage it. When the " core " has come away, any simple astringent dressing does—nitric acid lotion, with or without opium—the disease is over, and Nature quickly repairs the damage done. Then general and local treatments are directed to tone up the system and to prevent a repetition of mischief. In all cases of boils there are conditions which show that the health of the patient is naturally vigorous, that it is somewhat perhaps below par at the time of the occurrence of boils, but especially that effete products are in excess in the system. Denuce is of opinion that the cutaneous glands are disordered, that the gland function becoming perverted, the glands in- flame, suppurate, and finally slough. The treatment, therefore, consists in eliminating, toning up, and helping on the suppuration in the skin and the discharge of useless portions of tissue. I believe this is the best and most useful account I can give of the matter. Then with regard to the treat- ment of carbuncles, the same line of procedure holds good, only the consti- tutional condition is one of more serious importance; it is one produced by such an influence as a diabetic tendency. The local mischief is therefore severer and more extensive, the suppuration is less healthy, more tissue dies. It is thought several glands perish, forming so many " cores," but their sur- rounding cellular tissue is specially involved in the death or slough; the reparative circumscribing action is not so manifest, the healing is not so rapid or perfect, and serious results are more common. Uric acid is allowed to be more abundant in the blood. The indications are clear—the combating of gouty tendencies, and the stimulation of the liver and kidneys at first. The restriction of the diet to plain animal food, and large doses of quinine with opium—the latter if there be any decided diabetic tendency or much nervous prostration—the whole tempered with the aid of more or less stimulation, good nursing, and the freest support, as the case may need. Now we know that if the patient is tolerably strong and has no organic disease, the carbuncle itself will slough out, and reparative action quickly follow. The case gives us no anxiety, but we may materially aid the cure and moderate inflammatory action, by aperients, by diuretics, by opiates, or by tonics. In one case the patient's strength may fail at an early period, and here we give what would be inadmissible in another—port wine, plenty 106 PUSTULA MALIGNA. of strong beef-tea, and full doses of bark and ammonia; but yet we must not forget the diabetic tendency, or the importance of liver and kidney ac- tion. Then with regard to local measures. It is clear that the sooner the carbuncle is " ripe " and the dead tissue away the better; thereby the sooner the pain and its effects on the body generally are lessened, and the 'sooner Nature can commence repair. To this end we need to keep out the blood from the tumor, and to destroy artificially the part that will die ; taking measures, by internal medicines, to bring the blood back as quickly as pos- sible to a condition of healthy activity. And so, locally, we employ pressure by strips of soap-plaster; if this does not seem to succeed, we incise to relieve tension and pain. The incision may be subcutaneous or not, crucial or single. Surgeons are mostly in favor nowadays of pressure, and afterwards caustic applications, with poultices to hasten the softening up of the car- buncular swelling; pain being met by opium once or twice a day. When the process of repair is approached, stimulating applications are needed; the best perhaps is some Friar's balsam, a drachm, say, rubbed up with an ounce of lard, or a carbolic acid ointment. M. Soule, of Bordeaux, has suggested that Vienna paste be applied early, and an incision be made the next day: this prevents the presence of a wound that can absorb from without into the veins, whilst the dead tissues are the more readily removed ; after the incision, the wound is to be dressed with tincture of iodine more or less di- luted. In both boil and carbuncle a certain part has to die and come away. The sooner this occurs the better, and therefore I think that caustics are the best remedies, incisions being employed to relieve such tension as cannot be pre- vented by pressure. PUSTULA MALIGNA, OR MALIGNANT PUSTULE. Within the last few years very definite facts have been obtained in regard to malignant pustule. The disease is characterized by the occurrence of a boil-like inflammation, accompanied by gangrenous changes, and produced by the contact of a certain animal poison derived from beasts affected with the disease called charbon, or Sang-de-rate, which has prevailed from time immemorial on the Continent. General Description.—The disease varies in severity according to the amount of tissue involved, the degree of gangrene, and the occurrence of secondary pyaemic results. It attacks the exposed parts or those which come in contact with the hides or secretions of diseased animals; therefore the face, and neck, and hands, are the chief seats of the disease. It com- mences as a vesication on these parts, accompanied by induration, an in- flammatory blush of dusky hue, and filled with sero-sanguinolent fluid. At first there are itching, heat, and burning ; the central part now blackens and forms an eschar: in severe cases a large surface becomes rapidly gangre- nous. When this stage is reached, constitutional symptoms of a typhoid nature develop, and these correspond in severity to the local changes. They PUSTULA MALIGNA. 107 follow the local symptoms, and are produced by absorption of poison from the gangrenous part. If death occur it is from pyaemic conditions, induced from the fourth to the eighth day. But the gangrene may be arrested, then the subsequent progress of the case is that of anthrax. Malignant pustule is at first a local disease. Numerous bacteria have been found in the blood, but it is not certain what influence, if any, these possess in the causation of the disease, or whether they are accidental and secondary to the blood changes. The cause of malignant pustule is, as stated, the contact of an animal virus, derived from animals affected with " charbon." Dr. Bichaud, quoted by M. Baimbert (of Chateaudun), has observed the disease largely since 1830, and he now asserts that it occurs in those who touch the dead carcasses of " charbon" animals, are in constant contact with beasts, or are stung by flies that have feasted on the former. The disease is very common in the plains about the Alps from May to October, when the sheep in their pere- grinations die plentifully on the road. The disease may also be got by direct inoculation—as in butchers, herdsmen, drovers—from contact with hides or tainted hair of diseased beasts, and, it is said, by eating the flesh of the latter. In a recent number of the " American Journal of Medical Sciences," is a paper by Dr. A. H. Smith, on Malignant Pustule, as it appeared in the vicinity of Las Cruces, New Mexico, in 1865. During the summer of that year an epidemic resembling charbon, or the malignant pustule of surgical writers, occurred. It commenced as a papule of a livid or purple color— hence the Spanish designation " grano negro;" and at the earliest stage the tissues round about could be felt to be indurated to a considerable extent and depth, and distinctly creaked on being incised ; the section had the ap- pearance of dense fibrous texture, containing in the meshes dark pigment. The boundary was abrupt and well defined; little blood flowed from it, and the sensation of the part was less than that of the skin around. In from seven hours to two days the papule became like the vaccine pustule, only livid or black, and erysipelatous redness extended around it, spreading often- times with great rapidity. The pustule and the swelling around steadily in- creased, as the rule. In some cases the former was stationary, the latter very active; the cuticle was then raised by effusion and blebbed, and sloughing ensued; the pain was burning, but only in exceptional cases severe. The constitutional symptoms seemed to bear an exact ratio to the extent of the local mischief; the breath was offensive; tongue moist, coated; pulse quick and strong, becoming small and frequent; the skin relaxed, perspir- ing after a while ; no delirium. The only one whom Dr. S. saw die was comatose. Great difference existed in the extent of the disease: in some only a small spot was present, the size of a split pea, made up of a little redness, and in a day or two the patient was well. In favorable cases the disk of dead tissue in the centre sloughed, leaving a healthy granulating surface behind. Cause.—Dr. Smith says: " A careful inquiry enabled me to trace it to in- fection from diseased animals." A distemper prevailed at the time to a 108 DELHI BOIL. slight extent amongst cattle, and was described by the Mexican rancheros to Dr. Smith. " The fact that in every instance the pustule occurred in a part of the body not protected by clothing goes far to confirm the view of the disease, that it is not in any degree the local manifestation of a consti- tutional infection, but always the result of direct local inoculation." He gives the following instance:—" Two men were engaged in skinning an ani- mal which had died of the distemper. One of them had a pimple on the face which he had scratched with his nails until it bled. The other had received a scratch in the face from a thorn in passing through the chaparal. The day was extremely warm, and the men frequently wiped the perspira- tion from their faces with their hands, covered as they were with the fluid from the animal. In a few hours pustules were developed upon the abraded surfaces in both individuals. The disease proved fatal in one (which I did not see), and the other recovered with a considerable loss of tissue from the cheek." Dr. Smith says it is impossible to say if simply eating the diseased meat sufficed to give the disease, although many people declared they had not touched the meat. One case appeared after handling dry hides. In one case a woman was attacked. She had eaten, with the rest of the family, of a goat that got the distemper, but which was killed " for fear it should die." Several ate the flesh, but this woman alone was attacked, and she had prepared the goat for the table. The Treatment consists essentially in fully destroying at the earliest possi- ble moment the eschar or vesicating part by caustic (potassa fusa), subse- quently incising, applying charcoal poultices, with chlorinated soda washes, and giving internally a cathartic ; followed by free doses of tincture of steel, carbonate of ammonia, and brandy, with generous diet. DELHI BOIL, ALEPPO EVIL, AND BISKRA BOUTON. In this place some notice must be taken of these three diseases endemic in India, at Aleppo, and in Algeria, respectively, whose pathological position is at present uncertain. They are believed to be allied, in many particulars, to anthrax. These affections all bear a close resemblance, and it is generally thought that they are the same in nature. I must content myself with the descriptions of those who have written upon the subject, as I have little per- sonal experience of these diseases. Compared with anthrax they are very chronic ; they are at first papular, then suppurate, and finally ulcerate. Delhi Poil, called Arungzebe, after the monarch of that name, who suf- fered from it, is seen at Delhi, in Scinde, Moultan, Agra, Lahore, Muttra, and Aden. In 1857, at the first-named place, 400 to 700 per 1,000 of the troops suffered from it during their first year's residence there. It attacks new comers to the cities in which it prevails. It is not dangerous, but in- tractable. The disease begins by itching; then the patch looks reddish and warty in the centre, where it then scales, so as to resemble a patch of lepra vulgaris. According to some, a small pustule next appears in the middle; others say a thin ichor is discharged; at all events, the next stage is the for- BISKRA BOUTON. 109 mation of a brownish crust, which becomes elevated in the centre, whilst ulceration goes on beneath, and if the disease is irritated the crust rapidly increases. The ulcerated surface is raw, with flabby, irregular, fungoid granulations, that bleed freely. The Fig. 1. sore discharges a thin, darkish-colored fluid, the ulcer meanwhile enlarging at the circumference. The reparative pro- cess commences at the centre after two or three months, and more or less disfig- urement finally results. The most com- mon seats of the disease are the backs of the elbows, forearms, back of hands and fingers, ankles, legs, face, thighs, and near the scalp. *The general health is good, it is said. As to the cause, the na- tives think that the disease is due to drinking water impregnated with organ- ic and saline impurities; it certainly affects those who live well and in good situations. It is more frequent after rains, it is said. It rarely attacks unexposed parts; it is inoculable ; some think it malarial. Mr. Godwin, Assistant-Surgeon, Boyal Artillery, has seen much of the disease, and his experience will be found in the Lancet for the present year. Dr. Fraser has also written on the disease in the A rmy Medi- cal Beports, 1860. I am enabled to give the two following sketches of the disease from photographs of Deputy-Inspector-General Dr. Murray, of the Indian Service, which were given in the Lancet a little while since. Piskra bouton, or Piskra Putton.—The following account of what appears to be the same disease as Delhi boil, is given by Deputy-Inspector Dr. Payn- ter in the Army Medical Beports for 1867, at p. 438, and it will be noticed that he refers to its similarity to an anthrax. " We find, in the southern part of the province of Constantine, about 160 miles south of the sea-coast, at a military station with a considerable civil population of European colonists as well as natives, an endemic disease, so common that it is called the ' Biskra Button,' from the cir- cumstance of its prevalence at and around Biskra, the first station in the desert. It is, however, not peculiar to this part of Algeria, for it is also found at Tougort, Ouargla, and Tlemcen, and is probably to be met with in all parts of the desert. It is also seen in parts of the neighboring kingdom of Morocco. This singular disease attacks its victims during the months of September, October, and November, at the end of the great 110 THE ALEPPO EVIL. heats of summer. Consequently, I had not an opportunity of seeing it in its first stage; but, from the description given of it, it appears to commence with an itching sensation, long before any appearance is appreciable on the skin. After a time, a small tubercle is perceived about the size of a very small pea, located, very superficially, in the layers of the skin and subcuta- neous tissue; remaining stationary for some days, or even weeks, and caus- ing little inconvenience; at length it enlarges, the epidermis scales off; and shortly, a small ulcer appears, which discharges a sero-purulent fluid. Seen by myself during the month of February, in its chronic stage, it presents precisely what I may describe as a small superficial anthrax. Differing in diameter from one to two or three inches, these patches present the appear- ance I have alluded to; and when pressed, a thick purulent secretion oozes out through several openings. There were a few cases in the military hos- pital at Biskra at the period of my visit; and with the exception of being in- convenient, disagreeable, and unsightly, did not appear to give any particu- lar pain, or cause any constitutional derangement. This eruption appears, most frequently, on the legs, fore-arms, dorsum of feet or backs of hands; on the nose, cheeks, and ears: varying from one or two spots to a dozen, or even more. The affection lasts from four to eight months as a general rule ; oftentimes, for a year, a year and a half, and occasionally for a longer period. Whatever the period may be, the appearance, when cured, or cicatrizing of itself, as it does if left without treatment, is that of the cicatrix after a burn. The disease attacks natives, Europeans, all sexes and all ages: and, occa- sionally, relapses are met with (i. e., one attack not rendering the person free from a second invasion). Of the cause of this affection little is known. Bad water, heat, dirt, etc., have all been named; however, these are very prevalent in other regions where nothing like this singular disease is seen. It has been met with in the horse in some of those regions where the human race is liable to its attacks; but not, I believe, in the dog. It is said not to be contagious. The cause of the affection not having been settled, its treat- ment is of course not very defined. Thorough change of air possibly short- ens the time required for its cure, and is probably the best remedy. This disease partakes of most of the characters of the Aleppo button." The most successful treatment is to blister the ulcers in the early stage, and ap- ply iodine subsequently. l he Aleppo evil, or button, is no doubt the same thing as the last-described disease. It is endemic about the Tigris and Euphrates, at Aleppo, Bagdad, and Bussorah ; it is met with at all ages, and attacks both natives and stran- gers, the latter after a short residence. It is like the Delhi boil, confined to the cities, and occurs once in a lifetime. It begins as a papule, which pus- tulates in two or three months, and scabs over whilst ulceration goes on beneath the crust to the extent of from a quarter to two or three inches, having all the characters of that in Delhi boil. After a year or so the ulcers heal, leaving an indelible cicatrix. At Aleppo the disease is ascribed to bad water. Where there is one tumor it is said to be the male, that which is FURUNCULAR AFFECTIONS. Ill surrounded by several smaller ones is called the female. The disease is pain- less ; it never kills, and is indolent in its course. Now, all of the last three described diseases, it will be observed, bear close" resemblance the one to the other. They really seem to have some of the characters of disease directly produced by external influences, as the bites of insects. But there is no evidence that they are so produced. The treatment is the same in all cases—viz., that stated under Biskra Bouton. Cochin China Ulcer.—In the Dublin Medical Press, May 21, 1862 (from Gaz. des Hop.), it is stated that M. Bochard, Chirurgien-en-chef of the French navy, describes an endemic form of disease which attacked some of the French in China. The debility consequent upon the mal-action of the climate predisposes to it. It is prevalent especially in wet seasons, and appears to be uninfluenced by age, sex, or constitution. It is non-contagious. The disease consists of ulceration, which follows some lesion of the skin, often the most trivial, in those out of health. The lower limbs are chiefly attacked, and particularly the parts about the ankle and instep. M. Bochard has never seen it attack the plantar surface. Generally the ulcer is solitary, but the disease may attack both legs. The ulcer is usually two inches and more in diameter, and may extend more or less, or completely round the leg. Its shape is always angular. It does not usually penetrate more deeply than the skin and cellular tissue : it may, however, attack the muscles, and even bones, producing caries. The progress of the disease is rapid. First of all, some lesion occurs, then a red areola makes its appearance, quickly fol- lowed by ulceration, pain, and, by-and-by, insensibility. After a time the ulcer stops in its increase, gets clean, is covered by a pultaceous scab, that is subsequently thrown off and often re-formed, together with sanious discharge. Some cases demand amputation; in others, attempts at repair are made, and change of air cures the patient. Sometimes the disease becomes chronic. At Brest Hospital the "ulcers presented a depressed, uneven base, traversed by deep red longitudinal streaks, consisting of small anastomosing blood-ves- sels, having between them yellowish lines of pultaceous aspect." The edges were hard, irregular, the skin around wrinkled, and anaesthesia was noticed in the parts around the sore,—in one case complete anaesthesia of the dor- sum and plantar surface of foot, even to red-hot iron. No cure has yet been made out. CHAPTER XI. BULLOUS DISEASES—HERPES, PEMPHIGUS. Under this head are included the diseases which are especially characterized by the occurrence of bullae. Willan described a bulla or bleb as " a large portion of the cuticle detached from the skin by the interposition of a trans- parent watery fluid." In fact a bulla is a large vesicle. It will be seen that in the wide sense of the term several diseases are really bullous, such as ery- sipelas, herpes, pemphigus, rupia, eczema of the fingers, and impetigo con- tagiosa. But there are only two that really rank under the term Bullous— i. e., herpes and pemphigus. Erysipelas belongs to the distinct class of zymo- tic diseases; rupia is syphilitic, and grouped under that head ; the bulla produced by the coalescence of vesicles in eczema is accidental and secondary; and in impetigo contagiosa, the primary stage is a vesicle, the secretion is sero-purulent, and the general behavior and outward aspect are those of an impetigo. Besides, herpes and pemphigus are peculiar and alike in regard to the influence of the nervous system in their production. Therefore, true bullous diseases, or those which are probably of neurotic origin, and in which the bullae are primary, with transparent contents, are herpes and pemphigus. HERPES. This disease is characterized by the presence of vesicles larger than those of eczema, distinct from each other, mostly chambered and seated upon an inflamed base ; these large vesicles, or small bullae (bullulae), are generally tolerably few, they do not rupture, as the rule, but their contents, which are alkaline or neutral when clear, and slightly acid when turbid, after becoming opaque disappear by resorption, but now and then by rupture and desicca- tion into light brownish scabs. The bullulae last about seven or eight days. The disease is mostly accompanied by sensations of heat, tension, and burn- ing, which indeed are felt to a greater or less extent before the appearance of the eruption; occasionally severe neuralgic pains occur before, together with, or after, the eruptive stage. This is particularly the case in what is called Herpes zoster, or shingles. Writers generally divide herpes into two groups — the phlyctenoid, including the disease as it generally occurs about the body (herpes phlyctenodes) ; with certain local varieties—H. labialis, palpebralis, nasalis, auricularis, and herpes zoster; and the circinate, including herpes circinatus, and herpes irris. 1. Phlyctenoid group).—Herpes phlyctenodes occurs in any part of the body, and its description will apply to all the local varieties. It commences with a sense of local heat and inflammation, with some erythema; upon this HERPES. 113 arise round grouped vesicles, from ten to twenty, in patches the size of sixpence to a five-shilling piece, surrounded by a red areola : there are gene- rally several of these patches; they mostly occur about the face, arms, neck, and upper limbs. The contents of the vesicles, at first transparent, become milky, then quickly disappear; the vesicles shrivel, and scabs remain; the smarting heat and tension also subside; the disease lasts ten days or more; the vesicles get to their height in two or three days, and dry up on the sev- enth or eighth. When seated about the lips, the disease is named H labialis. The patch here is small, and generally the bullulae not over-developed. It commences as a " cold," with pyrexia, &c.; then the local heat, smarting, and tension are followed by a patch of herpes, with about six or eight vesicles. Herpes affects the mucous membrane of the pharynx and palate. It is common after catarrh—of which it is probably a definite part—typhoid, remittent, and intermittent fevers, cerebro-spinal meningitis, pneumonia. Herpes occurring under these circumstances, is said to be symptomatic, as contrasted with the more general idiopathic forms. II. praspmtialis is often syphilitic; in simple cases, the patch scales over in a week or so; the scabs fall off, leaving little ulcers the size of pins'-heads or more, which quickly heal, the prepuce being irritable and red. If syphilitic, there are successive crops; the prepuce gets hard, and indurated about the seat of the herpes; coition is sometimes painful. The mucous surface is more or less irritable, and the origin from bulluhe clear; the bullae give place to little ulcerations, which are close together, and quickly scab over; in other cases, the vesicles abort, desiccate, and scale over; the little crusts fall off, leaving little pits, which presently heal. H. zoster, zona, or shingles, possesses the characters of H. phlyctenodes, but derives its special name from the peculiar manner in which it tends to encircle one-half of the body like a girdle. It is really H. phlyctenodes, but as it has some peculiarities in regard to distribution, I may give a special description of it. It follows the course of one or more of the cutaneous nerves, generally stopping short at the median line before and behind, though it may cross this point, and in this matter the experi- ence of Hebra, Wilson, Startin, Hutchinson, and myself agrees. It gene- rally affects the trunk, but may attack the face, the shoulder, the belly, or upper part of the thigh; the right side more than the left. Of 178 cases collected by Barensprung, in 101 the herpes was on the right side. It is most common in the young ; of about equal frequency in the two sexes, and occurs particularly during change of weather. It seems on some rare occasions to be almost epidemic. It is an acute disease, of definite duration, lasting about fourteen to twenty days. The patient often ails a few days before the eruption appears, is feverish, out of sorts, complains of headache, shiv- ering, perhaps pain in the side, which may be very acute and of neuralgic aspect; presently patches of erythema appear, and present, on close exami- nation, a number of little white points, which quickly enlarge into bullulae, perhaps coalescing and forming distinct bullae; they are tense, and contain clear serosity; in four or five days the vesicles become partially emptied, 8 114 HERPES. flaccid, the contents becoming turbid and dark; at the same time the red blush fades, and the patch scabs over; the crusts disappear in ten days or so, leaving dark red stains. The changes are not completed at the same time over the whole area of the patch, but are later in taking place in one part than another—hence travel, as it were, over the surface; conse- quently, several aspects or stages may be noticed in the same subject. In some rare cases, the H. zoster may ulcerate, or even become gangrenous. Pain may be a very prominent symptom; it may be lancinating, smarting, or burning. The convalescence finds the patient weak and neuralgic. The scars are not lost for some time. The disease rarely occurs twice in a life- time. It is usual to make certain varieties of zona or shingles. Boughly stated, they are Z. capitis, faciei, nuchae, brachialis, pectoralis, abdominalis, and femoralis. It is as well to know that the eruption follows the course of distribution of certain nerves: the trigeminal in H. facialis, the labial branch in H. labialis, &c. &c. When the limbs are attacked, and they are now and then, the line of eruption corresponds to that of the long axis of the limb; the eruption does not encircle the limb. A want of knowledge in this respect I have known to mislead. If we compare the various forms of herpes phlyctenodes, we find that they are not different, save in seat and extent. The herpes of the nose, mouth, and ear are identical, save in the part attacked. In zoster, there is not one patch as a rule, but a line of eruption often made up, however, of several patches; the main feature be-' ing the unilateral distribution. In the second, or circinate group, authors place two diseases: H. circi- natus and H. iris. Under the term herpes circinatus two totally distinct things have been classed, the one parasitic, the other not. In ordinary herpes phlyctenodes the whole area of the portion of skin included by the outer edge of the diseased patch presents the herpetic aspect; there is no clear centre ; but in certain cases there may be a ring of bullulae inclosing a portion of unaffected skin; the ring itself in diameter varies from one- twelfth to a quarter of an inch, and is made up of a red base, upon which are distinct bullulae, or large vesicles, giving place to subsequent scabbing; the diameter of the whole patch varying from half an inch to two inches, or even more. This is a truly herpetic disease; it has a short and definite course, identical with that of ordinary herpes phlyctenodes. I have seen it on the neck, face, and forehead in non-syphiiitic, and again in syphilitic subjects, becoming chronic, and being cured by syphilitic remedies in the latter. The syphilitic form is symmetrical and chronic, and accompanied by special concomitant evidences of syphilitic infection ; the other, or parasitic form of herpes circinatus, which I have ventured to call tinea circinata, is the ordinary ringworm of the body. It commences as a red spot, which enlarges in circumference, the central part getting paler or gradually recov- ering its natural appearance. There are various degrees of this disease. There may be a circular erythematous patch, which is more or less 'scaly, HERPES. 115 but is not covered by anything like crusts—in fact, a desquamating ery- thema. In other cases, at the extending edge vesicles may be plainly visi- ble, and the centre may clear; in other cases the centre may be unaffected, and the extending disease appear as a red ring inclosing a pale centre, the edge of the ring presenting a papular or vesicular aspect. This of course approaches most closely to the true herpes circinatus. I have seen tinea circinata develop rapidly as a largish patch, with well-developed vesicles, and then look very much like herpes phylctenodes; but in all these cases the origin from a small red spot, the papulation or vesiculation of the extending edge, the clearing of the centre, the slight desquamation, should at once decide the nature of the disease. The microscope should be used if there is a suspicion of parasite, and in any circular eruption which has a fur- furaceous desquamation. The disease, too, lacks altogether the definiteness as to outset and duration, of true herpes. The cause is the growth and irrita- tion of a fungus, and it is easy to see that the aspect of the disease will vary with the luxuriance of the parasite and the condition of health of the attacked. I hope the name tinea circinata will be given tc this ringworm of the sur- face, and it will not in future be confounded with herpes, with which it has only a similarity in external appearance. With regard to herpes iris I have little to say, as I know little about it. Two or three cases have come under my care; they occurred on the back of the hand in elderly people. The disease consists of a herpetic circular patch made up of concentric rings, there being generally a distinct vesicle in the centre. It is an unimportant variety. I would remark that the division into phlyctenoid and circinate groups of herpes is to me unnecessary. The Pathology of Herpes.—There is little doubt but that we are on the road to explain satisfactorily the occurrence of herpes. That it is closely connected with a perversion of the nerves going to the affected part is certain. Two clinical facts have now been sufficiently demonstrated, especially in zoster; they are—1. The constant occurrence of neuralgic symptoms prior to the development of herpes. Some of the most intense cases of " pleuro- dynia " are connected with zoster, and the pain is speedily relieved by the outbreak of eruption. A very remarkable case will be found recorded in the Lancet for August 21th, 1867, in connection with a gouty diathesis, showing the connection in ordinary herpes between pain and eruption. 2. The second fact is, the exact correspondence as to site of herpetic eruption with portions of surface supplied by certain nerves, and the development of the eruption in the course of nerves. To take the last point specially, zoster of the chest will make its appearance frequently in the part supplied by the posterior cutaneous branches of the intercostal nerves, then in that furnished by the anterior, and so on. With regard to the other point, much evidence has been put on record. Perhaps the most striking case is that recorded by Mr. Paget, in which herpes affected the parts supplied by the infra-orbital, the anterior dental, and the anterior palatine branches of the superior maxillary nerve. After catching cold, the patient was attacked 116 HERPES. on the third day with herpes of the cheek, side of nose, the upper lip, the palate, and buccal membrane. The final results were in some respects re- markable, and in keeping with the explanation as to the implication of the nerve trunks. A bicuspid fell out on the sixth day, a second on the seventh, and later still the canine and two incisors, whilst the alveolus in part ne-. crosed. In the herpes ophthalmicus, so fully referred to by Mr. Hutchin- son, the same truth has been illustrated in a very remarkable way. All these facts clearly show that the nervous system determines the seat of the eruption. Then as to the exact causation. In "almost all cases we are en- abled to understand how it is that irritation is reflected along the nerve trunks, going to the exact locality of the herpetic eruption. When catarrh affects the sensitive mucous membrane of the air-passages, the occurrence of herpes of the lip or nose can readily be understood ; the play of cold air (chilling), or the direct application of cold to a heated surface, will account for the appearance of herpes phlyctenodes; herpes praepiitialis has come on after an emission; after connection regularly, so as to leave no doubt as to the co-relation ; and after other irritation of the urethral mucous membrane. The passage of a catheter has before now been followed by rigor and labial herpes. There is no great difficulty in admitting this latter occurrence. The only point upon which we require enlightenment is that which con- cerns the why and wherefore of the reflection to the nerves that go to the lip. Gerhardt observes that the group of diseases in which zoster of the face occurs is remarkable " by the frequency of an initial rigor or the occur- rence of an increase of temperature even to 32° Beaumur, on the first day." He thinks that the irritation must be caused by the following peculiarity of the fifth nerve: " The branches run through narrow bony canals along with small arteries: these arteries contract in the initial rigor, but then dilate, and their abnormal size creates a pressure on the branches of the trigeminus and the sympathetic. The occasional result is the occurrence of a vesicular eruption. When this has once occurred an accommodation takes place in virtue of which a second attack of febrile dilatation of the vessels does not irritate the vaso-motor fibres so as to cause an eruption." It is curious that in intermittent fever herpes only occurs once, and it is held generally between the second and third fit. Pudendal herpes follows vaginal irritation likewise. In the case of herpes zoster more information is needed: that the nerve trunks are disordered there is little doubt, and here, as in other cases, this is followed by hyper- aemia and vesiculation. There is no reason why a cold should not give rise to zoster. But zoster is said to occur only once in a lifetime, one shielding from a second attack, and cold, chilling of the surface and the like, are con- stantly happening. Hence a good deal more clinical observation is neces- sary absolutely to verify this opinion. But other forms of herpes occur re- peatedly in the same subject—herpes labialis and praepiitialis ; and this does not at all militate against the part assigned the nerves in the production of the disease, or prove that zoster is different in nature from the more com- HERPES. 117 mon forms. It is also easy to see that emotional disturbance, mental dis- tress, may also play an important part in the causation of herpes. But the typical mode of production is seen in labial herpes, where irritation of the mucous membrane of the air passages is reflected upon the nerves going to the lip, giving rise to hyperaemia and vesiculation. It should be mention- ed that herpes zoster has been observed to occur during the exhibition of arsenic. Lastly, in regard to the pathology of herpes as a whole, I may state that the disease presents in many of its features a family likeness to the exan- themata, as observed by Willan. It has a definite duration ; it is anteced- ed by general pyrexial symptoms, presents eruptive phenomena which are not successive, but which go through stages of maturation and decline, as in the eruptive fevers. The Diagnosis.—Herpes cannot well be confounded with any other disease. The red base, upon which a few large clustered distinct inultilocular vesicles (bullulae), which are larger than those of eczema, and smaller than pem- phigus, are seated, with the acute regular course, of definite and short dura- tion, its non-secretory aspect, and the frequent presence of neuralgic pheno- mena, and ordinarily of smarting, heat, and tension, are diagnostic. Erysi- pelas may resemble H. zoster; but it is not unilateral, the bullae are large, the redness is accompanied by swelling, the edge of the blush is well defin- ed, and rigors are present. Prognosis.—There is no anxiety whatever to be entertained save in the occurrence of zoster in persons of feeble constitution in advancing or ad- vanced life. In this case great debility, and ulceration in the site of the herpetic patch, may result, and the special care of the physician will be needed to sustain the powers of the patient. The Treatment.—Usually the only thing necessary in the treatment of herpes is to protect the eruption from being irritated by the clothes of the patient, and other external influences. This arises of course from the fact that herpes is a disease of definite duration, and that the eruption is, so to speak, its " explosion." The temporary nerve paresis, of acute production, therein spends itself, and no cause exists for the continuance of the disease ; and so we find that when once the eruption is " out" relief from pain, neu- ralgia, and the like, is obtained, and the healing process at once commences in the affected skin. We only need therefore to help the reparative process set agoing by Nature. I use generally a lotion of oxide of zinc and acetate of lead with glycerine locally, and cover the patch over with a layer of amadou, or two or three layers of lint, in the early stage; and subsequently, when desiccation has taken place, apply a cerate composed of elder-flower ointment an ounce, lead lotion a dr.ichm, and prepared calamine powder two scruples; but glycerine of tannin is equally good, and indeed may be used from the com- mencement. In zoster the eruption may be oiled over, and then dredged with flour freely, placing upon this a layer of cotton wool. The great thing US PEMPHIGUS. is to avoid too much meddling. In some cases neuralgic pains are very se- vere ; here poppy fomentations: equal parts of the linimentum belladonna? P. B.% and linimentum camphorae, or olive oil : chloroform: morphia dress- ing, or, if required, the hypodermic injection of aconite and morphia, are necessary. And under these circumstances internal remedies are to be used . —quinine especially in full and repeated doses, ammonia and bark, and aco- nite or opium, as the case may be. After herpes zoster I always advise a course of tonics—the mineral acids and quinine with slight aperients. In certain other cases there may be special indications for general treatment, either by reason of pyrexia, or the debility of old age, bark and port wine and plenty of nourishing food being here requisite. Should ulceration oc- cur in zoster, nitric acid and opium lotion, or a weak solution of caustic (grs. x.—xx.) in nitric ether ( § j.) .will be servicable. In herpes iris nothing special is called for. In those cases which I have seen there was nervous debility present, and the mineral acids with bitters, and some astringent application locally, acted satisfactorily. Of course when herpetic eruptions occur in the course of catarrh or fevers, the proper treatment is that which is fitting for the general disease. See formulae 66 A, 71, 32, 62. PEMPHIGUS. This disease is characterized as regards eruption by the appearance of lit- tle separate blebs usually grouped in threes or fours, seated upon slightly inflamed bases, which by enlargement they quickly cover. These blebs may attain a size varying between that of a pea and a hen's egg. They are dis- tended with fluid, which is at first very transparent, but soon becomes milky, and is quickly reabsorbed, or the blebs or bullae simply shrivel, the distend- ed globe becoming flaccid. Yery often the blebs burst in a few days, and then the contained fluid dries into crusts of lamellar aspect, beneath which is the slightest ulceration; the contents are sometimes sanguinolent; the bullae are generally successive ; they arise in the course of a few hours • their outline is generally round or oval; there may be one or many, and they may be confluent, but are usually discrete. Now and then a species of false membrane is contained in the bullae. The reaction of the fluid is gen- erally alkaline, but with turbidity comes acidity. The local symptoms are slight itching and smarting at the outset, and more or less soreness. The healing process in pemphigus is sometimes tardy, a thin ichor being secret- ed by the surface originally blebbed, and so a quasi-impetiginous crust is often produced. The disease attacks all parts of the body__rarely the head palms of the hands, or soles of the feet; sometimes, however, the mucous surfaces—ex., the intestines, vagina, &c. Now this general description applies to all varieties about which much unnecessary fuss has been made. The term pompholyx was originally used to denote the chronic and most indolent form of pemphigus, but the two terms are now used in the same general sense. Pemphigus is almost always chronic, but there is an acute form; and we PEMPHIGUS. 119 have therefore, in accordance with most authors, to make two groups, acute and chronic. Acute pemphigus is seen in children, and is synonymous with pemphigus neonatorum. Now the greatest doubt exists as to the nature of this affec- tion. According to Dr. Steffen, there are three forms—(1) pemphigus oc- curring in children apparently healthy and ending favorably ; (2) pemphi- gus in children who have been badly nourished, or who have fallen into a state of marasmus, and in whom it.is therefore the result of cachexia ; and (3) syphilitic pemphigus. Under the second head would therefore rank the pemphigus gangraenosus which occurs amongst the ill-fed Irish, and so named by Dr. Whitley Stokes. From all that I can gather, and basing my observations on such an epidemic as that which occurred in the General Lying-in Hospital in 1834-5, it seems clear to me that there is a non-syphi- litic and a syphilitic form. When it is epidemic and occurs amongst the children in a lying-in institution, it seems to me to result more from the operation of acute blood-poisoning, such as that of puerperal fever. Appar- ently healthy children are seized with severe constitutional symptoms, the skin is livid, the areola dark ; the contents of the bullae are foetid; the ulcera- tion is unhealthy, deep ; its surface is dark, blackish, and exudes an ichorous matter; the edges, are livid, shreddy, so that large circular, depressed, black, gangrenous ulcers, acutely produced, are present. The feet and hands may be affected, but also the limbs, the genital parts, the abdomen— even the mucous surfaces and head; death occurring about the tenth or twelfth day. In other cases, in bad fed and overcrowded children, the dis- ease may not be so severe, but presents much the same kind of changes. There is a purplish base to the bullae, sanguinolent contents, ichorous dis- charge, and a good deal of sloughing and gangrene; the disease being pro- pagated by successive crops for weeks, and the child often dying, worn out by irritative fever and exhaustion. Pemphigus (neonatorum) acutus is also syphilitic, and occurs as a conse- quence of the cachexia of that disease. It occurs, not as an epidemic, but in connection with other symptoms of congenital syphilis, and is well-marked about the hands and feet soon after birth ; it may give rise to deep ulcera- tion. Ordinary pemphigus has sometimes an acutish aspect, there may be head- ache and pyrexia; in a couple of days or so, little red points appear; and upon these little bullae form, which rapidly increase and fill: there may be an areola ; all depends upon the increase of the bulhe. The latter and the red blush increase together, but generally not pari passu, for the bulla over- takes the areola and hides it from view. In two or three days more the bullae burst, a raw surface is left; but this scabs over: at first the incrus- tation is yellow, then brownish. The bullae seen on the limbs and trunk are successive, and so prolong the disease for some weeks. When the disease occurs in a more chronic form, it has been called P. diutinus, the two together making up P. vulgaris. Sometimes there is but one bulla deve- 120 PEMPHIGUS. loped at a time; it is large, bursts in one or two days, crusts over, and disappears; then another develops. It is chiefly seen in old people who are debilitated. The bulla appears after a little tingling about the ankle or the wrist. Five or six bullae in all show themselves. This form is styled pemphigus solitarius. All these forms may occur in children and young persons, as well as adults. There are two more varieties. In one, pem- phigus foliaceus, the disease commences on the front part of the chest by a single bulla, and by the development of others around, spreads over the whole surface, the bullae being more or less imperfectly formed; the skin is red in many places', but there is not much infiltration; itching is not severe. After the bullae form, large yellowish squamae are produced, with more or less desquamation; the scales, which may be large, are the remains of imperfectly-formed bullae, and are free at their margins, and they are reproduced very rapidly. The bulla? are successive and confluent; oftentimes the skin exhales an offensive odor. The scales have been de- scribed as resembling French pastry, pieces of parchment, or papyrus, and vary in size from three-quarters of an inch to two inches. It is often a fatal form of disease, death being ushered in by irritation of the mucous surfaces and dropsy, in old people who are weak and out of health. Lastly, there is a form in which the characters of prurigo and pemphigus are intermingled, to which the term pemphigus pruriginosus is given. The bullae are small and not well formed, though numerous, and the pruri- ginous itching is most distressing. Microscopical examination has detected in the fluid of pemphigus what seem to be mucus and pus-corpuscles, but are thought to be newly-formed epidermal cells. Bamberger declares that there is a great deficiency of solids, especially albumen, in the blood, and of phosphoric acid in the urine. Cause.—Little is understood in regard to the exact causation of pemphi- gus. It is well known that general debility, intemperance, cold, gastroin- testinal disturbance, moral emotion, cachexia, and bad living, often seem to evoke the disease, but what we want to know is the immediate and proxi- mate cause. From all that has been written, it would seem that the nervous system is specially concerned in the matter ; and that it is the channel by which morbid influences that result in the eruption are conveyed. In many cases an appreciable disorder of it precedes the eruption. Dr. Bussell has remarked this. That there is some serious constitutional disturbance, is shown by the fact that those who have died of the disease have been found to have fatty livers, and amyloid changes in other organs. Compare the case of leprosy. We have serious deterioriation of the general health, in which the nervous system is implicated, and one of the very first evi- dences of the latter is the production of bullae about the skin prior to, or in connection with, the occurrence of anaesthesia, which we know is due to distinct disease in the nerve trunks. This seems to me to throw consider- able light by analogy on the veritable mode of production of the eruption of pemphigus. The deficiency of solids in the blood, and of phosphates in PEMPHIGUS. 121 the urine, indicates a condition of blood which must disorder the nervous system, and may fully account for the disease. Now in herpes, we have the effect as it were of a temporary or sudden, or non-persistent influence; in pemphigus, we have a persistent and slowly-evolved influence, reflected through the nervous system upon the surface, hence in the one case a dis- ease of short and definite duration, in the other a chronic malady. But some different explanation is needed in regard to acute pemphigus. In this instance, it is possible to conceive that the nervous system is par- ticularly involved, although the whole body is affected seriously by septic poison, absorbed from without. It must be remembered that bullae occur in erysipelas, and here the burning heat, the evidently great and sudden distention of the vessels of the affected part, and the consequent rapid effu- sion, show that the nervous control over the vessels is specially at fault. If the acute effusion were due to the fact that the blood was of such a quality that it would not pass through the capillaries, we should expect to have bullae in all acute specific diseases. What I wish to emphasize is the fact that the morbid influences that cause the cutaneous changes in pem- phigus seem to operate immediately, not through the blood, but the nervous tract; why the nervous system specially is another question, beyond our knowledge at present. Jirognosis.—The cure is not rapid, but slow ; recurrence of the disease is frequent. In old people, where the disease is general, and in children with much ulceration, the issue of the case is often unfavorable. The gene- ral condition of the patient is to be our guide, and in these cases a cautious opinion is always needed. Diagnosis.—Pemphigus can scarcely be confounded with anything else, the bullae are so appreciable a sign. In eczema of the hands, bullae may be produced secondarily by the confluence of vesicles, but their origin is clear- ly traceable, and co-existent eczema is to be found elsewhere. Pemphigus is rare on the hands and fingers, per se. General eczema and P. foliaceus should not be confounded ; in the latter the bullae are present, the scales %are larger and peculiar, the skin is not infiltrated. In ecthyma cachecticum the pustules contain bloody fluid; there are no true bullae ; the crusts are thick and dirty; the ulceration is deep ; the dis- ease is pustular. In rupia, the bullae are smaller and flatter, the contents sanious, the crusts thick, dark, prominent—cockle-shell like; the ulceration beneath deep. Pemphigus foliaceus resembles pityriasis rubra ; but in the latter there is no history of bullae; the scales are altogether smaller; there is no characteristic odor, no wasting of flesh. Sometimes in impetigo contagiosa the bullae become somewhat large, but they are never distended as in pemphigus, but flat; the contents soon be- come purulent, and flat yellow scabs form, which are characteristic. It is clearly pustular. Treatment.—In the acute forms the disease must be treated as a typhoid disease, an aperient to begin, then salines, with ammonia, unstimulating 122 PEMPHIGUS. nourishment—strong broth—and as soon as the pyrexia is at all subdued, tonics should at once be had recourse to; in children, chlorate of potash and quinine, with wine, will be necessary; in the syphilitic variety much the same line must be followed as regards the child, whilst the mother • should be well toned up and well fed. Slight mercurial inunction in chil- dren who are in sufficiently good condition to bear it, should be employed. Then as regards local measures, weak solutions of permanganate of potash and carbolic acid, with the use of absorbent powders; and presently, when the sores are cleaner, weak nitric acid lotion seems to be the best. An oint- ment of scrophularia nodosa is advised by Dr. Stokes, in the gangrenous variety. In the chronic forms, good diet, with quinine, the mineral acids and arsenic, are the remedies usually employed internally. In many of the cases of pemphigus that I have seen, there has been a deficiency of proper meat in the diet, and a good deal of worry, the two together inducing an anaemiated and exhausted condition. In these instances, plenty of good food, with the mineral acids and cod-liver oil, and a due attention to elimi- nation, has sufficed for the cure. We may generally find some cause of de- bility in our patients, and it is necessary that we treat that specially. I think, in many cases, that aperients combined with tonics are called for. If we feed up a half-starved individual, or give tonics to a debilitated subject, whose waste products have already overcharged the blood, without taking care that proper emunctory work is carried on, we may even increase the disease. I have seen this, and therefore I think it important to attend to the proper elimination of effete products from the system, through the bowels and the kidneys. In the more quiescent forms, arsenic seems to be as good remedy as any. I am not certain that phosphorus with quinine is not a good treatment (with a thirty-second part of a grain of the former). In old people, pemphigus may be regarded as the hint of a " break-up." In such cases, a nourishing diet, quietude, and bark and acid are the best re- medies. Locally, in these chronic forms, we may let out the fluid from the bullae, apply some inert powder, such as lycopodium; subsequently weak astringent lotions, such as alum, tannin, zinc, or even ointments of zinc; and if the sores do not heal, use a solution of nitrate of silver, gr. iij. vel iv. In the pruriginous variety, conium and aconite, or quinine, internally, with alkaline baths, or cyanide of potassium lotion, may be employed. A very good application, to cool and comfort the surface in all cases, is a mix- ture of common whitening, glycerine, and water, made into a thinnish paste, and spread over the surface by means of a brush. CHAPTER XII. ALPHOUS DISEASE (LEPRA VULGARIS). This disease is characterized by hyperaemia of the cutis, hypertrophy of the papillae of the skin and the epidermic cells, as shown by the free pro- duction of well-formed, whitish, epithelial scales, aggregated together, so as to form a more decided scaliness than in pityriasis. There is an entire ab- sence of any discharge, vesiculation, or pustulation throughout the whole course of the disease. It arises as a primary condition, and occurs in about seven per cent, of all cases. The eruption affects parts of the skin (by pre- ference) whose epithelium is thick, especially the elbows and knees. It may be partial or general. At the outset the disease is attended by more or less pruritus; the increase of the patches is by centrifugal growth, and there is oftentimes a slightly red margin: the surface beneath the scales is dull red and shining and papular ; the scales are shed, to be again replaced by others ; in chronic cases the derma itself becomes very distinctly infil- trated and thickened. The general health is often apparently good. The disease is non-contagious, runs a chronic course, and is very prone to recur- rence. The structure of the scales or squamae of lepra is peculiar; if the under- surface be carefully examined it will be seen to be pitted or marked by lit- tle hollows, and these correspond to the enlarged papillae of the skin; the adhesion of scales to the surface beneath is decided. The scales, placed under the microscope, are seen to be composed of epithelial cells only, matted together, well-formed, sometimes even enlarged ; many are flattened to- gether, so as to be almost fusiform, and this results from their rapid growth and close package. Lepra occurs as an hereditary disease. It attacks males more than fe- males, and is most common between the ages of fifteen and thirty. The sanguineous temperament is present in many cases. All classes of society are liable to it, and it is seen mostly in summer and winter. Psoriasis is the same disease as lepra, according to most writers, but Mr. Wilson applies the term to chronic scaly eczema. The varieties of lepra may be given in a very few words. It was the custom to apply the term psoriasis to the ordinary patches of the disease, and lepra to that variety in which the centre of the patch clears, and the disease takes the form of a ring. This distinction is not kept up now. Lepra begins by little minute spots of a whitish tint, made up of epi- dermic scales heaped together; this is Lepra punctata. It usually affects the body and limbs. When the spots are larger they look like drops of 124 ALPHOUS DISEASE. mortar, and the disease is then called Lepra guttata ; it is seen about the arms, breast, back, legs, and thighs. When the eruption occurs in patches about the size of a shilling or so, we have Lepra nummularis ; it is pro- duced sometimes by the coalescence of smaller spots. When the disease is in a still more developed condition it is termed Lepra diffusa. It often covers a large extent of surface, is always seen on the elbows and knees; the scales are well formed, the patches generally thickened, and often cracked. When the eruption takes the form of bands, it is styled Lepra gyrata. This is always due to the running together of circles; the scales are thin and speedily reproduced. This variety is seen mostly in the back. Now lepra may pass through all these stages in one and the same subject, or the features of one stage may be preserved in individual cases. Then we have general psoriasis or lepra, which may present the features of any one of the varieties described. Chronic, or Lepra inveterata, in which the patches are much thickened and cracked, the scales large, dry, and adherent: the patches may be hot and tender, and slight discharge occur. This is what Devergie called " psoriasis eczemateux." It presents the characters of lepra, and, in addition, the tendency to pour out a fluid secretion, which dries into scales of rather larger size than those of psoriasis ; the surface beneath is red, and slightly moist: it is seen about the forearms and legs. The itching and pain are more marked than in psoriasis. The disease is a mixture of lepra vulgaris and eczema. The nails may be opaque, brittle, worm- eaten. When the scales are very white, the term Lepra alphoides is some- times used. Occasionally the accumulation of scales takes place to an unusual extent: the scales are heaped up so as to form crusts, something like those of rupia. Dr. McCall Anderson has given this the name of psoriasis rupioides. On removing the crust, a circular red surface is ex- posed, but it does not " discharge." There is a tendency in this form of psoriasis apparently to the production of pus. I have seen ordinary lepra vulgaris assume the characters described as rupioid during convalescence from intercurrent measles, the debility consequent upon the latter favoring cell proliferation. I regard psoriasis rupioides as lepra modified by ca- chexia, in which there is a tendency to pus formation. There is no ulcerative stage, and therefore the word rupioides is apt to mislead. Itching is only occasionally troublesome in lepra, and then it generally occurs at the out- set. The elevation of the patches of lepra varies, generally it is about a line. It is customary to make certain local varieties. L. capitis.—The head is the commonest seat of the disease, next to the elbows and the knees : the whole scalp may be affected, or there may be only one or two small points of eruption; when extensive, the disease travels on to the forehead, forming a kind of fringe along it at the upper part. There is co-existent disease elsewhere. The hair on the scalp thins out frequently. L. palpebralis is seen at the outer angle of the eye ; it is usually a part of more extensive disease in other parts; there is itchin^ scaliness, and the eye becomes irritated. L. labialis occurs on the lower ALPHOUS DISEASE. 125 lip mostly, and is often confounded with eczema; the surface is scaly, fis- sured, puckered in towards the angle of the mouth, and reddish ; the scales are speedily reproduced. L. palmaris et plantaris are important local varieties. The skin in the affected parts is thick, and the aspect of the dis- ease differs somewhat from the usual type. It may be limited to the centre of the palm of the hand or sole of the foot, coming on gradually and run- ning a chronic course ; in other cases, conjoined to the typical disease on the knees or elbows. The patches are dry, harsh, thickened, discolored ; the scaliness is not very marked, but the superficial layers peel off from time to time. Presently the surface cracks and fissures, and healing is very tardy; occasionally the surface bleeds. The muscular movements of the hand are painful. In other cases the disease runs a more acute course ; the palm of the hand is quickly invaded over its entire surface, and the disease may travel along the palmar aspect of the fingers ; the skin is red, " hot," cracked and fissured; as in the other case, it is sometimes attended by itching. When the sole existing disease, it is probably always syphilitic. Lepra (or Psoriasis) unguium is mostly a complication of the inveterate form of lepra, but may exist alone. The nails (and several are usually affected) lose their polish, and soon become opaque, thickened, irregular, and brittle ; they are then fissured and discolored in lines (from dirt), their matrix becoming scaly. The disease (lepra) also affects the scrotum and prepuce; the parts are swollen, red, hard, tender, scaly, fissured more or less, and give exit to a thin secretion, which adds to the scaliness; there are pain and pruritus, and the local mischief may be the sole, or part only, of general disease. When lepra is in progress of cure, the scales lessen and the reddened ele- vated surface beneath comes more prominently into view, but this diminishes gradually till the eruption disappears, leaving oftentimes no trace of its former presence behind. It may leave, however, pigmentary stains, the result of the congestion. It is in the disappearance of patches of lepra that the centre rapidly clears, and the ringed form or lepra circinata, or the lepra of old authors, is produced. Pathology and Cause.—Hebra and some of the French writers have sought to ally lepra vulgaris to eczema and lichen, but this relation is utterly negatived by the pathology of the disease. If a portion of skin affected by lepra be examined microscopically it will be seen that the papillae of the skin are enlarged, the epidermic cells of the Malpighian layer being specially well developed. In addition, cell growths, resembling cuticular cells, are ob- served along the course of the vessels running near to and into the papillae, and these vessels are like the other structures, of larger size than natural— in fact, hypertrophied. This new cell-growth is most abundant in the upper layers of the corium, and about the apices of the papillae, and here cells are piled together into little heaps, and no doubt are pushed forward to form the ordinary scales. Neumann, who has lately investigated this subject, finds that the vascular twigs sent by the vessels of the corium to the papillae 126 ALPHOUS DISEASE. are peculiarly well-developed, spread over the entire area of the papillae, and even disposed in circles, so that the "cells" which are outside the vascular walls are arranged in horizontal lines, as well as parallel to the long axis of the papillae. As the vessels are so abundant, the whole stroma of the pa- pillae is filled with the cells which lie outside the vessels. Hence there is hyperaemia of the cutis, hypertrophy of the papillae as a whole, and an exces- sive formation of the cells which ordinarily go to form the epidermis, this cell proliferation commencing in the upper layer of the corium, and chiefly around the vessels of the papillae, and coming forward to the surface in the form of the white imbricated scales. Now these changes are primary in lepra; cell proliferation occurs to a varying extent, as the result of conges- tion in other diseases—but here they are different from those observed in lepra. The cell-growth may exhibit an amoebiform character. This view of the pathology of lepra at once disengages the disease from all relationship with eczema. Then with regard to the cause—the circumstances that bring about this hypertrophous growth of the papillae and cuticular cells—little is known. The disease occurs oftentimes in those who seem quite robust and healthy, and a certain amount of constitutional vigor seems to be necessary to its development; but I don't think they are sound in nutritive power. I agree with Dr. Anderson that there is very frequently some cause of debility present, " though this is quite incapable of calling forth the disease unless the predisposition exists." What that is is as yet a mystery. 'Over-lacta- tion, " overgrowth " in youths, mental worry, bad living, over-study, all pre- dispose to the occurrence of lepra. Prognosis.—The disease always is difficult of cure and has a tendency to recur. The most obstinate cases are those of lepra nummularis of the back and buttocks, as far as I have seen, in which there is much elevation and thickening and deep redness, and lepra of the hands and feet. Diagnosis.—Bed patches covered over with white more or less silvery scaliness as a primary formation, without any history of discharge, are the main diagnostic points. Lepra may be confounded in its local varieties with pityriasis, lichen circumscriptus, eczema, tinea circinata, erythematous lupus, and, when general, with-pemphigus foliaceus, pityriasis rubra, lichen ruber, and the squamous syphiloderm. Pityriasis is known by its thin, branny scales, which freely exfoliate, and do not therefore form imbricated layers, the absence of all thickening or marked hyperaemia of the cutis. The diseased patch is not elevated, it does not feel thick and harsh, the elbows and knees are not specially affected. Lichen' circumscriptus is an itchy disease; it is produced by the aggregation of papules. The scaliness is slight, and it does not attack the elbows and knees. The skin generally is thickened. Eczema always has a history of " discharge." Crusts, as dis- tinguished from scales, are present in the early stage, and therefore it is only in chronic eczema, when the epithelial formation is recovering itself that any error can arise. In this the scales are mixed with blastema ; they are loosely attached and thin, not silvery white; there is burning and itch- ALPHOUS DISEASE. 127 ing; the disease is not seated at the elbows and knees. In tinea circinata there is a kind of scaliness, but it is rather a " fraying " of the epidermis ; there is itching, a circular form, the centre is often pretty smooth whilst the outer edge is somewhat papular ; it is unsymmetrical, often vesiculating at the edge of the patch, and under the microscope the scales are seen to be composed of blastema and epithelial cells and fat, together with spores and often mycelium that has found its way among the mass; and lastly, the dis- ease is contagious and may exist in several members of a family. Erythe- matous lupus should not be confounded ; there is no true scaliness, but deposit in the skin, with a tendency to loss of substance and scarring, a gelatinous look and a deep red color. The disease is mostly limited to the face, and occurs in strumous subjects, which is not the case in lepra. Pem- phigus foliaceus is known from general psoriasis by the fact of its origin from bullae, the presence here and there of bullae, the absence of silvery im- bricated scales, and the presence of large flakes or lamellae, produced by the collapsed walls of the bullae, together with more or less secretion. Pity- riasis rubra has no thickening of the cutis, no papillary hypertrophy, but constant exfoliation of flakes, together with small scales. It is very general, attacking every part of the body; there is a peculiar yellow aspect about the disease well seen if the blood is pressed out of a portion of the affected skin, and the hyperaemia is more generally and more perfectly marked. Lichen ruber is a papular disease. The confusion of Squamous syphilo- derma is by no means unlikely. For the diagnosis see syphilitic diseases. Eczema may complicate lepra, then we have the characters of lepra plus those of eczema. This is the explanation of those cases of chronic disease which commence as lepra and presently exhibit more or less " discharge " and crusting. Treatment.—Lepra, as I have said, puzzles us by its occurrence in per- sons of apparent sound health, but there are exceptions to this rule. We find a woman becomes pregnant, gets some stomach derangement, out comes her old enemy, psoriasis; another is nursing, she lives badly, presently suf- fers from hyperlactation—the disease appears. A gentleman who has heavy headwork to do, is worried, anxious, and becomes affected. A servant gets very little fresh air and plenty of work to do—debility follows and psoriasis results. Another partakes too freely of wine or seasoned food, or is influ- enced by circumstances which give him a gouty or rheumatic habit, or occa- sion a temporary change from his ordinary quiet mode of life, and he, too, suffers. Now, in all these instances, the disorder of the general nutrition helps out the disease, a predisposition to which exists in those who are attacked. Anything, in fact, which tends to lower the general tone of the system (the resistant power), is likely to conduce to the occurrence of the disease. Some of the best results I have obtained have been, in over-worked women, from the use of cod-liver oil, with steel, or quinine, or a course of the mineral acids. We must treat the patient rather than the disease. Now 12S ALPHOUS DISEASE. it is the custom to regard arsenic as the only remedy for lepra. I cannot subscribe to this. Every case should be treated upon its merits. The specific treatment is rather local than general, and the idea which I have in regard to treatment, is to tone up the system generally, by removing causes and conditions of debility, and mal-assimilation, so as to enable Na- ture to bring back the mode of cell-growth in the skin, to its proper charac- ter. Hence in growing children I give iron, cod-liver oil, and plenty of meat. In lactating women quinine, the mineral acids, good diet, and porter; in gouty and intemperate subjects, alkalies, and colchicum, or the mineral acids, as the case may be; in over-worked men and women, change of scene and rest from fatigue if possible. A full animal diet is often important in connection with tonics. Dyspepsia should be carefully attended to. When- ever there is much hyperaemia of the cutis, or any febrile symptoms, I use diuretics, and the best I have found is the acetate of potash, in half-drachm doses three times a day, with or without arsenic. Then, supposing that the general state of the patient appears to be almost faultless, what is to be done? Give specifics? This is what we are recommended to do. The one specific is said to be arsenic. Where the scaliness is free it does most good. If there be much hyperaemia, I combine it with alkalies. Dr. McCall Ander- son recommends carbonate of ammonia in large doses. Tincture of can- tharides has not been of much service in my hands, nor have tar pills. Iron, cod-liver oil, mineral acids, and bitters, in the anaemiated, or ill-nour- ished, dyspepic, and strychnine and phosphorus, with large doses of dilute nitric acid, in subjects suffering from nervous debility, have proved most successful. In old standing cases, where there is much thickening of the patches, a mercurial course is advisable, followed by tonics. The local treatment is very important. Bearing in mind the morbid cell-growth, it is easy to conceive why tarry preparations act efficiently, and they are the remedies of general applicability and utility in lepra. When cases first come under treatment, or more properly in the early stages of lepra, and before tarry preparations are used, it is necessary, if there be inflammatory symptoms, that, they be subdued by water dressing, alkaline and emollient baths, aperients, and diuretics. It is an important point not to stimulate the skin to too great a degree by outward applications, so long as the disease is increasing. This is a rule of some moment, inasmuch as the stimulation by tar or otherwise, may only increase the hyperaemia and consequent spread of the disease, 1 am sure of this. When, therefore, the disease is actively increasing, the emollient, diuretic, and aperient treatment should be first used. In all cases the scales, when abundant, should be removed by maceration, so that the applications may reach the real seat of the disease. If the disease is slight and localized to a few spots only, we may at once begin with tarry applications, for the scales are thereby removed sufficiently well. An ointment composed of olive oil 3 j., pyroligneous oil of juniper 3 ij., and adeps I j., may be used night and morning. At the hospital I ALPHOUS DISEASE. 129 employ creasote six drops, mercurial ointment gr. xv., and adeps § ij. Where the disease is more extensive, or the scales thickly covering the patch, alkaline baths are to be employed (four ounces of carbonate of soda to each bath), the patient "soaking" for some twenty minutes or so, or individual patches may be softened up with water-dressing, or glycerine plasma, and this is especially necessary in hardened spots of lepra about the hands and feet. Independently of its softening action, the alkaline bathing seems to exert some curative power. When the scales have ceased to form freely, a solution of nitrate of silver in ether (3ij. to | j.) painted over the spots night and morning helps the cure. In chronic lepra, with thickening of the patches, or where there is much elevation of the disease—ex., the nummular variety, a more decided impression may be produced by rubbing in a solution with flannel, of equal parts of tar and spirits of wine, or equal parts of soft soap, tar, and methylated spirit. When there is a tendency to " discharge," the nitrate of mercury oint- ment 3 ij-, with glycerine 3 ij-, and camphor liniment § j., is useful. When cracking occurs, as in palmar and plantar lepra, a paste made of glycerine and borax is useful, or the cracks may he. touched with nitric acid. Some- times tlie cuticle is so hard that it is necessary to poultice freely in order to soften up the hardened cuticular lamellae. Sometimes it is preferable to apply lotions to lepra; in that case the. following may be useful: liquor carbonis detergens § ss.— § j., glycerine f ss., water § viij. In very chronic cases, where the disease is limited to certain patches, it is advisable to use blistering, or iodide of mercury ointment (gr. x.—xv. ad | j.) so as to set up a revulsive action. The ill success which attends the treatment of lepra is generally due not to a want of remedies, but the mode of their application, and an inattention to individual peculiarities of diathesis, and of derangement in the assimilative and secreting organs. For other remedies, see Formulae Nos. 31, 68, 69, 86, 87, 112, 113, 124 et seq., HO, 146-7-8-9. 9 CHAPTEB XIII. STRUMOUS DISEASES--SCROFULODERMA AND LUPUS. The strumous habit of body often modifies the more common diseases of the skin. For instance, in lepra, the crusting is more distinct, and there is a tendency to the intermingling of pus corpuscles with the epithelial scales. So in ordinary eczema, in strumous subjects, there is more than ordinary infiltration of the skin; the cellular tissue beneath, and the seba- ceous glands are implicated ; there are locally more swelling and excoria- tion. This is due to the strumous diathesis ; but strumous inflammation of the skin may exist as the sole disease, and it is considered to include scrofu- loderma and lupus. In the former the general signs of struma, and the im- plication of the lymphatic glands and of bones are marked; in the latter no marked evidence of struma exists, but it is regarded as a close ally of, if not a part of, struma. SCROFULODERMA Is characterized by the appearance of indolent, dull red tubercular forma- tions, that tend to suppurate, and are soon covered over with a darkish scab, from beneath which oozes an unhealthy pus. Ulceration to a greater or less degree takes place, and the healing is accompanied by distinct scar- ring. The whole disease is of the most chronic character; one can scarcely mistake this strumous ulceration for any other disease; it may spread and cover a large extent of surface, and in this case the ulcerated surface is half covered by darkish irregular crusts, whilst the ulcers discharge a thin dis- agreeable dark pus, and granulations are flabby and pallid, bleeding freely on being touched : the edge of the ulcers is livid, and various attempts at repair are made. The mucous surfaces of the nose or eye may be inflamed and slightly ulcerated ; onychia may be present; there are old scars of for- mer strumous disease, and the whole aspect of the patient is a sufficient tell-tale of the disease. The treatment is generally most successful, viz., the adoption of better diet, the use of cod-liver oil, iodide of iron—certainly not arsenic—and locally an astringent ointment of tannin, or acetate of lead. LUPUS Is characterized by the presence of patches of a dull red color, out of which arise tubercles, that are small, circumscribed, vascular to a certain extent and somewhat hardish: they tend to soften, sometimes to ulcerate, to crust over, and finally disappear, leaving behind in process of cure indelible cica- trices. There is a low type of cell tissue deposited in the skin in place of STRUMOUS DISEASES. 131 normal material. There are three forms of lupus. The one in which the deposit is slight and superficial, whilst there is no ulceration, Ivpms erythe- matodes ; the second, in which the deposit is greater, the tubercular forma- tions are distinct, and the surface is affected not in depth, but area, L. non- exedens. The third variety, L. exedens, is that in which ulceration occurs, and eats deeply into the tissues. Sometimes hypertrophy occurs together with cicatrization, then we have lupus hypertrophicus. These forms are degrees of one and the same thing. The general health is often apparently good, and the disease seems to be local: as Dr. Jones remarks, " the pecu- liar tissue change which ensues upon the inflammation is the essential thing." It has some unequivocal affinities with scrofulous caries of bone, scrofulous disease of the skin, and tuberculous ulceration of the lungs, as before stated, and for these reasons I have classed lupus with strumous affections. Erythematous lupus, which may be associated with other varieties, con- sists of roundish patches of a deep red color and shining aspect, without sensible elevation; indeed, the skin looks just as though it had wasted somewhat, or become dry and shrunken from being " seared," though it is reddened; the diseased process creeps over the healthy skin (erythema centrifugum of Biett), and the surface of the disease gets covered over with thin adherent scales, which on removal expose a dry yet raw-looking surface of gelatinous aspect, and this may bleed. Erythematous lupus has been de- scribed in its slightest form as an obstinate erythema, with slight loss of substance. The central part often thins without ulceration, or is covered over by whitish scales; the disease now spreads from its boundary-edge, and may then exhibit some slight tendency to form crusts. Its usual seat is the face, cheek, nose, or even scalp; general symptoms are absent, and so is local pain. It may ulcerate. This is noticed when the subjects attacked are scrofulous, which is not always the case, at least to the appreciation of the physician. The disease mostly attacks children, and especially those of the lower orders. There are then various degrees of this erythematous form. It may be represented only by an erythema of dull red color and great obstinacy, leaving behind a slight cicatrix. In other cases there is more induration or elevation of the patch, and the loss of substance is some- what greater; the skin is thin, smooth, red, and shining ; lastly, this form may be somewhat modified by slight crusting, the scales being large and the cicatrix deeper. It must not be forgotten that patches of this disease may occur on the scalp, and on the fingers, hands, and toes, resembling chilblains, but occurring throughout the summer, and accompanied by slight loss of substance, thus differing from chilblains. The sebaceous glands are sometimes found to be specially involved when the face is attacked, and pour out a somewhat more than ordinary amount of fatty matter. Lupus non-exedens has as its basis the form first described; but, in addi- tion, little nodular elevations, which are softish, round, of a dull red, or reddish yellow color, often quasi-gelatinous-looking, stud the part, and by 132 STRUMOUS DISEASES. their aggregation or even fusion form a patch of greater or less extent, gene- rally of circular or serpentine form: these tubercles are covered by little scales, presently quasi-scabs, and little vessels are seen to run over and through the tubercles: this is very characteristic. The disease is seen in the face, especially about the nose, the lips, and chin. The central part of the patch may clear and cicatrize : this is the result of an absorptive pro- cess without true ulceration. The outer part is tubercular : there may be a semicircle of flattened tubercles at the edge, the central portion of the af- fected skin being tense and puckered. If the scales be removed from any portion, the part beneath is red, dry, shining, or even raw; the upper layer next the cuticle presents an appearance which has been termed " cornified: " it is of transparent glue aspect. The papillary layer of the skin is mostly affected. The process of healing is always attended by more or less loss of substance and sensibility; the cicatrix is below the level of the adjacent surface; there may be some discharge of a thin nature. This form is not unusually associated with the erythematous variety, and may be coexistent with ulceration of the mucous surfaces near. The loss of substance is rather by interstitial absorption than ulceration, as before observed; in some in- stances there is a general hypertrophy of the skin, with cicatrization. This is Biett's lupus with hypertrophy. Lupus exedens.—Ulceration is marked in this species of lupus, which commences in the usual manner by the aggregation of tubercles : and then slight discharge, crusting, and subsequent ulceration set in. The tubercles in this variety are harder, and lack the transparency of those in L. non- exedens. The ulceration varies in depth, being in some cases comparatively superficial and extensive, or, on the other hand, deep and circumscribed. In the first case there is the usual attempt at repair, especially by scabbing ; but the ulceration is active and marked: hence, though the surface crusts over, and the loss of substance is decided: there is a thin ichor poured out by the diseased surface. In the second case the ulceration eats deeply into the tissues, the surface is " mammillated," red, quasi-gelatinous, ragged, covered by a whitish exudation, and the edges are thick and red. Cicatriza- tion may then, and generally does, take place to some extent. The nose, its mucous membrane, bones, and, indeed, the whole organ, may be rapidly lost. In the cicatrix white bands of condensed tissue are seen running in all direc- tions. The disease is very chronic, and is accompanied by some local heat and tenderness, with puffiness of the surrounding tissues, and often pain of a gnawing character. The peculiar destruction of tissue affects all the structures ; even the glands and hair-forming apparatus are destroyed. The disease may attack the vulva, and then occurs between the ages of 20 and 50. Etiology of Scrofuloderma and Lupus.—The former occurs, according to Mr. Wilson, in the better classes of society, in 21, and lupus in 77 in- stances out of 5,000 consecutive cases. STRUMOUS DISEASES. 133 Lupus is a rare disease after 35, and not common after 30 years of age. Devergie noticed that in 45 cases, 28 possessed the lymphatic and 12 a com- bined lymphatic and sanguineous temperament. In many of the cases it occurs in phthisical subjects. It is more common in the country than in town, and rather more in the female than the male sex ; 25 out of 47 cases were females (Devergie) ; 46 out of 74 (Hutchinson). It is most common between 15 and 25 ; 16 years was the average in Hutchinson's 74 cases. Its selective seat is the face; in 41 of 44 cases (Devergie) this was the case; the nose was affected in 16 cases; the nose and other parts of the face together, in 26 cases; the lips, 4 times, etc. Lupus also affects the hands, arms, legs, etc. It is a disease of the poor rather than the rich. Prognosis.—The erythematous and non-exedens forms are remediable, but require great attention and care. The other forms often lead to hideous deformity, and are intractable to a high degree. Diagnosis.—Lupus occurs in young people, runs an indolent course with- out pain, is seated mostly on the face, possesses softish vascular tubercles, slight scaly adherent crusts, and a gelatinous aspect; there is no true ulcer- ation, the edge is dull red, inflammatory; there are attempts at repair in the shape of cicatrices ; the glands are unaffected and the general health is not cachectic, though not good : the patient may be florid. The so-called serpi- ginous lupus is often syphilitic ulceration. In some cases of acne, the seba- ceous glands may atrophy, and depressed cicatrices are left; but the seat of the disease, and the absence of tubercles, suffice for the diagnosis. Cancer affects especially the lower lip; does not occur before thirty ; is painful; its ulcer possesses everted, undermined edges; its surface is fungoid"; there are no attempted cicatrices; the glands are diseased; there are no crusts over the ulcer, but an offensive discharge; the general health is bad. In syphilis there is the earthy hue and the general cachexia different from the clear skin of a lupus patient; the tubercles are larger, round, hard, and copper-colored; they have no great tendency to desquamate or to ulcerate, and are found on other parts of the body ; those of lupus are flatter, softer, and covered by thin scales. Syphilitic ulceration is foul, dirty, sloughy, and presents a copper-colored areola ; crusts are greenish; the edges are sharply cut and everted ; in lupus with ulceration, the edge is dull red, inflammatory, and non-everted; the surface is not foul. Syphilis has also a special history and special concomitants. Podent Ulcer.—Here the tubercule is large; the disease occurs in old age; there is no tendency to healing; the course is very chronic; there is pain. Pathology.—The essential feature of lupus is the presence in the sub- stance of the cutis of new granulation-tissue (as Yirchow calls it), very soft, and more or less vascular, made up of an intercellular substance, in which are imbedded round cells, with nuclei and nucleoli—a new form of connec- tive-tissue—a form of cell proliferation which may extend to any depth, re- placing and invading the healthy structures, decaying and being absorbed. 134 STRUMOUS DISEASES. Additional supplies of cell material are produced, and these go through the same changes as those which preceded. Some of the cells give rise to pus corpuscles when the disease is marked. The cells also undergo a fatty change. Treatment.—In the majority of cases the real treatment consists in the destruction of the lupoid tissue by caustics. But general remedies are needed and these must first be noticed. Lupus patients, especially the young, are often flabby, pale, anaemiated, and perhaps unable to get proper food. In a fair proportion they are phthisical, and this seems to indicate what turns out to be successful—the use of cod-liver oil and iron in full doses. But then there is first of all frequently a weak digestion present, and this needs to be remedied by mineral acids and bitters. If possible, change of air should be secured the patient, who should sleep in a lofty and well-ventilated room, and take a large quantity of animal food, with more or less milk. A moderate amount of stimulants is also beneficial. In adults general debility oftentimes allows a strumous or a phthisical ten- dency to have its way; and in these cases we find deficient assimilation exists. In such instances I have seen the best results from large doses of nitric acid, with bitters and nux vomica. If there be loss of flesh and pallor, the syrup of iodide of iron or the superphosphate with cod-liver oil, does good. In florid subjects, the mineral acids act best; but these, to do any real good, must be given largely. Where the disease assumes the non- exedent form, and the tubercles are well formed, the patient does not ex- hibit any debility, and has not been living on scanty diet, a short course,of bicyanidc of mercury (gr. ^ to tl for a dose) with bark is useful. Mr. Wilson speaks well of the iodide of ammonium in two or three-grain doses three times a day. In the ulcerating form, Donovan's solution will be found useful in connection with cod-liver oil. Constitutional remedies may be alone relied upon if the disease is not extending. Then as regards the local treatment. The erythematous variety of lupus wants ordinary stimulation, with such an ointment as the pyroligneous oil of juniper (two drachms to an ounce of adeps), or one part of carbolic acid to twelve of glycerine—-the former used every night, the latter once a day, if it will be borne, and then the use of dilute citrine ointment; or, if there be much heat, a paste made of calamine powder, oxide of zinc, and glycerine, and perhaps a little lead lotion. The application of collodion when the disease is disappearing helps on the cure very much. However, if these measures do not seem to be successful, the use of potassa fusa, with an equal quantity of water, first to a limited part of the edge, and gradually, at intervals of several days, to other parts, will, with general remedies, cure the disease. The acid nitrate of mercury is almost as useful. But I think that when the application of caustics is followed by much discomfort, heat, and swelling, then the stim- ulating plan is the best; and, indeed, if a patient comes to me with an irritated and painful patch of lupus, I soothe for some time, using simple lead or opiate lotions, or an oxide of zinc paste. In the non-exedent form STRUMOUS DISEASES. 135 the potassa fusa, acid nitrate of mercury, Dupuytren's arsenical powder, iodide of starch paste (painless), the solid nitrate of silver stick, the actual cautery and the galvano-caustic, may be employed to destroy the tubercles. I prefer the acid nitrate of mercury, biniodide of mercury and glycerine (gr. x. to xx. to 3 j-), or equal parts of potassa fusa and water. The repeti- tion of the caustic depends upon the quiescence of the diseased patch. The exclusion of the air by a layer of zinc ointment is advisable. In the exedent form the solid silver caustic is the best. It must be deliberately and freely applied, and chloroform should be given if necessary. The chloride of zinc is preferred by some. Others again commend nitric acid, mixed into a paste with sulphur, and laid on with a spatula. After caustic applications a poultice should be applied, and the surface dressed with a soothing ointment—elder-flower and liquid plumbi. In all cases where the disease has been arrested, and tends to heal, any mild stimulant or astringent application may be used, or such as glyceral tannin, or nitrate of silver dissolved in nitrous ether (gr. xx.—xxx. to § j.). It muht be remembered that local remedies act in efficiency in proportion to any improvement in the general health which we bring about by our in- ternal remedies. I think it important to avoid the use of local remedies when these produce persistent heat and swelling, for under such circum- stances the local applications only tend to the spread of the lupus, by inter- fering too much with the healthy action of the contiguous unaffected skin, and therefore the local reparative process. The disease can be made much worse by caustics. For other remedies, see Formulae 10, 12, 13, 16, 104, 124 etseq., 139, &c. CHAPTEB XIV. CANCEROUS AFFECTIONS. Under this head I have to describe Epithelial cancer and a disease allied to it called Bodent ulcer. epithelial cancer, or epithelioma. This disease affects the face, especially the lower lip, the scrotum (consti- tuting chimney-sweeper's cancer), the vulva, prepuce, the glands of the groin, and rarely the anus. The earliest sign is a little hard lump under the skin, say the lip; it is flatfish, hard, somewhat tender, and increases in size, so that the lip " pouts; " its surface may be somewhat pale or dusky, and soon becomes slightly moist; at other times it is covered by a dryish scab, or an attempt is made at " papulation;" it may be also fissured; the tissues around the swelling become more or less indurated, though they do not ex- hibit any evidence of change upon the surface ; ulceration now sets in in the shape of a little central excoriation or abrasion, and this runs on to distinct loss of substance until an ulcer is produced, which has an eaten-out appear- ance : it is roundish, and bounded by hard, indurated, sinuous edges, which in an advanced stage are everted and undermined, in consequence of the ex- tension of morbid action; the base of the ulcer is dirty or grayish, more or less papillated; it may be reddish and inclined to discharge a thin fluid, or be disposed to scab over. In cancer of the scrotum the development of the papillae is peculiarly marked. The disease in this situation commences as a small pimple or nodule, or warty excrescence, which remains in a quiescent state without undergoing much change for some little time; it then becomes irritable, red, tender, excoriated, and gives exit to a slight moisture, per- haps slightly scabbed over; the moisture increases, sometimes to such a degree that it is." a thin acrimonious ichor, which excoriates the surround- ing skin." Very often other nodules appear and coalesce with the primary ones; ulceration now sets in in reality, the edges of the ulcer become everted, and throw out a luxuriant growth with scirrhous hardness, which discharges a very foetid, irritating matter. The progress of the disease is accompanied by the development of the papillae, so that by and by, very early sometimes, the disease looks like a " fungous cauliflower excrescence;" and this sprout- ing ulceration after a while extends deeply into the tissue. On section, in an early stage, the mass of an epithelial cancer looks of a grayish aspect, tinged occasionally with yellow: at the circumference, the boundary of the disease is well defined ; there appears to be no stroma, or at least the stroma is formed by the tissues of the part; beneath the papil- EPITHELIAL CANCER. 137 lary layer the surface is uniform, gray, shining, and close-textured ; gene- rally, the mass yields a slightly milky juice, and sometimes a semi-fluid cheesy material may be scraped from off it. In speaking of a diseased gland removed from beneath the jaw, which Mr. Paget examined, Mr. Hutchin- son observes, " Its cut surface presented a nearly uniform grayish substance with a diffused tinge of ochre-yellow here and there, with no trace of granular or fibrous structure ; it was all compact, smooth, shining. It yielded on scraping a yellowish, putrid, gruel-like thick fluid." In the ulcers, the pa- pillary layer is made up especially of the cancerous cell elements, and the fibrous appearance above described is visible beneath. The microscopic features of epithelial cancer are briefly as follows, after Paget:—(a) Epithelial cancer-cells, which are nucleated, flattened, round, or ovalish, seldom regular, often angular in outline, and with processes: with granules clustering around the nucleus which exhibits occasionally nucleoli, but generally granules ; the cells range in size from ^-^ to -g-g-Vo" inch, the nucleus on an average is -ysW lnch in size; (b) nuclei about -g-^Vo inch, free or imbedded in a homogeneous blastema; (c) brood or mother-cells, con- taining a varying number of nuclei in different degrees of development; the brood-cell is said to present a concentric arrangement, this being brought about by the continuous enlargement of the nucleus until its outer wall comes into contact with that of the parent cell; r(d) what are called globes epidermiques or laminated epithelial capsules, said to be diagnostic: they vary in size from T-JT to ?L6 inch; they are produced by the aggregation of successive layers of epithelial scales, curled one around the other like a ball; hence they look like fibrous tissue having a concentric arrangement: they contain granular matter, and nuclei are tolerably visible. Some say they are derived from the brood-cells, others by the aggregation of cells. All these elements are to be found in the juice expressed from epithelial cancers. Etiolology of Epithelial Cancer.—In 90 per cent, the disease attacks men, and in about 90 per cent, of cases the lower lip ; the disease is not common till after thirty, and its most usual time of occurrence is about the age of sixty. Of 222 cases collected by Paget and Hutchinson, 207 were those of men, 25 women, and three of the latter are known to have been smokers. The average duration of life in epithelial cancer is somewhere about four years, when it attacks the cutaneous surface. It may originate in a sebaceous gland about the nose or cheek. The Diaqnosis.—Epithelial cancer is likely to be confounded, when seated in the face, with lupus, syphilitic ulceration, rodent ulcer, and unhealthy sores about the mouth. Its occurrence in late life, its seat on the lower lip, the papillary ulcer, with everted, hardened, undermined edges, and the implication of the glands, are guides which prevent our being misled, as a general rule, as regards the similarity to syphilis. In cancer, the " sore is attended by more induration than are syphilitic sores; it is usually single, while the latter 138 CANCEROUS AFFECTIONS. are mostly multiple ; it causes enlargement of the glands, which tertiary syphilitic affections rarely do." In syphilis the history of the disease, the absence of the peculiar edges of the cancerous sore, the early age oftentimes of the patient, signs of syphilis elsewhere, and the seat away from the lower lip, will generally guide correctly. Lupus is a disease of young life, and can scarcely be mistaken for cancer. Podent ulcer occurs between the ages of fifty and sixty, but has never yet been seen to attack the lower lip; it occurs somewhere about the upper part of the face, near the eye, it is slow in progress, has no tendency to affect the glands, possesses no everted and no undermined edges; its surface is not foul, papillary, but clean, and does not give exit to any ichor. It contains no true epithelial cancer elements, but is simply fibrous degeneration. The Treatment of epithelial cancer is summed up in one word—removal, and the employment of a thoroughly tonic plan of general treatment. See Formulae 12, 13, &c. RODENT ULCER. Bodent ulcer has been called cancerous ulcer of the face, cancroid ulcer, ulcus exedens, noli me tangere. It has been confounded with cancer and lupus; and has been pretty generally regarded of late as essentially a fibroid ulcer, but there are those who believe it to be cancer. Sir Benja- min Brodie, in reference to it, in his " Lectures on Pathology and Surgery," p. 333, says—" A man has a small tubercle upon the face covered by a smooth skin; he may call it a wart, but it is quite a different thing. On cutting into it, you find it consists of a brown solid substance, not very highly organized. A tumor of this kind may remain on the face unaltered for years, and then, when the patient gets old, it may begin to ulcerate. The ulcer spreads slowly but constantly, and if it be left alone it may destroy the whole of the cheek, the bones of the face, and ultimately the patient's life; but it may take some years to run this course. So far, these tumors in the face and these ulcers are to be considered malignant. Nevertheless, they are not like fungus haematodes or cancer, and for this reason, that the disease is entirely local. It does not affect the lymphatic glands, nor do similar tumors appear on other parts of the body." The disease usually attacks some part near the eyelids; it is of slow progress • there is little pain. The disease has been described as commencing a« a " pimple," " a blind boil," " a small hard pale tubercle," " a little long cut;" which tends to scab after a small central crack makes its appearance. There is in fact a small pimple followed by a minute ulcer. The disease extends gradually in all directions, but very slowly. When an ulcer forms the edge is indurated and raised, but not undermined and everted ; and there is no infiltration of the surrounding healthy structures. The surface of the ulcer is dry, clean, glossy, and does not give exit to any foul secretion; it is irregular in form, more or less oval however. Mr. Paget says it is not RODENT ULCER. 139 warty nor granulated, and there is no upgrowth as in cancer. If a section be made, it is firm, pale gray, and fibrous. Mr. Moore notices an important point in regard to the extension of dis- ease. In rodent ulcer it is equal in all directions ; in epithelioma the growth tends downwards, and in two ways, partly, we are told, by transfer of morbid material to the glands in the cervical region, and partly by its more rapid growth on the side nearest the central organs of the circulation—that is, the line of transit to the heart. This Mr. Moore illustrates by the results of operations where, in removing a tumor, he cut through the oedematous tissues on the distal side, and the apparently healthy structures on the proximal side; and the disease returned in the latter and not in the former spot (suffering from impeded circulation). This is of importance in relation to operations. The disease differs from the ordinary progress of cancer by its greater slowness, the little pain, little hemorrhage, the absence of any attempt at the formation of a fungoid growth, of fcetor, whilst the glands are not affected. The ulcer may cicatrize, but the ulceration again breaks out in the locality of fresh deposits. The advances of the deposit and ulceration are unequal, hence the eaten-out or rodent appearance. The ulceration advances in depth also, the cartilages resisting the most of all the tissues. The growth is al- ways in one mass, not in distinct centres. To Mr. Jonathan Hutchinson and Mr. Moore we are specially indebted for a complete summary of all that is known of the disease. The microscopic characters are as follows:—An excessive growth of the fibro-cellular structure, well defined, firm, and gray- ish, mingled with fatty tissue, free fat, epidermic structures, exudation-cells, some of which are flattened and curled together somewhat similar to the globes epidermiques of epithelial cancer. Mr. Paget states that no true can- cerous elements are present. Mr. Moore states that he has found elements like those of epithelial cancer present. There is one peculiar difference in the behavior of the deposit in scirrhus and rodent ulcer. That of the former possesses contractility by which the relation of the surrounding parts is altered. That of the latter does not, so that the yet undestroyed parts keep their position. This same writer re- marks that though there is no true implication of the lymphatic glands, they may occasionally acutely inflame or suppurate, but are never permanently indurated. Bodent ulcer then occurs on the face, has an indurated edge, a tendency to spread without respect to kind of tissue, is of slow progress, painless, is. not related to any cachexia, never causes enlargement of glands, and microsco- pically is seen to be " fibrous degeneration;" it is allied to cancer, being probably the least expressed form of the cancerous cachexia. It is most common between fifty and sixty, does not occur before thirty; generally has its seat about the eyelids of either sex equally, and never attacks the lower lip. Pathology.—I have mentioned several important points in the above de- 140 CANCEROUS AFFECTIONS. scription bearing upon the nature of the disease, especially as regards its alliance with cancer. Mr. Moore, to whom I refer so much, has written an admirable book lately on the subject, and he inclines to the belief that ro- dent ulcer is not a fibrous degeneration, but a form of epithelial cancer, be- lieving that as compared together, rodent ulcer is composed " of a more fee- bly vital material," and therefore " the occasions are rare in which it imi- tates the cancerous character, by passing on to a subordinate lymphatic gland." Indications are found, he holds, in its microscopic history of the presence of cancerous (epithelioma) elements. This is, however, not the experience of other observers up to the present time. The comparative fa- cility of extirpation is not regarded as an essential difference between rodent disease and cancer. The infiltration, too, of parts around the seat, or recog- nizable seat, of disease, is looked upon as a matter of degree ; and so is the usual exemption of glands, upon which those who deny the cancerous nature of rodent ulcer lay the greatest stress, for we are told that " to look upon the power of infecting glands as essential to cancer, would be to confound it with enchondroma or tubercle, which do the same, or even with skin tattoo- ed with gunpowder." Mr. Moore suggested an explanation for the non- infection of the glands in rodent disease—that it is to be found in the nature of the diseased material itself, which is incapable of growing when transplant- ed, and the attenuation of the natural textures ; so that their absorbent ac- tivity is lessened, or there remains little material ready to pass to the glands. " The rodent cancer is an exquisite instance of a local ailment, being almost uninterruptedly continuous in its growth, from the solitary pimple in which it originates, over an area of half the face. At the same time, how- ever, that it has every local quality of cancer, it is so meagre a growth that it has no superfluous material for circulation in the blood to distant parts, and very little for the lymphatics and the textures nearest to it." However, as I said before, most persons regard the disease as a fibrous degeneration. Diagnosis.—" An ulcer with hard sinuous edges, situated on some part of the upper two-thirds of the face, of several or perhaps many years' duration almost painless, and occurring in a middle-aged or elderly person of fair health and without enlarged glands. Such a sore is almost certain to be of the rodent type." (Hutchinson.) It may be confounded with lupus, epi- thelioma, syphilis. Now, lupus occurs before the age of thirty, never after middle life, and always tends to heal. "Lupus begins as a pink, low, tuberculous elevation of the skin • rodent cancer has a firm, uncolored nodule in it. In lupus there may be more than one tubercle, and the intervening skin may be healthy, or pink or scaly, or oedematous; the pimple of rodent cancer is solitary. The sur- face of lupus first scales or peels before it breaks; the rodent cancer exco- riates, and then scales or bleeds. Both ulcerate; the lupus at one or at several of its tubercles, the rodent cancer by the mere deepening of its central scabbed excoriation. Lupus may cicatrize and cease at any time • RODENT ULCER. 141 rodent cancer proceeds with at most but a temporary and partial healinc* near its edge. Wlien both are far advanced, the lupus has a superficial appearance, though it have destroyed the whole nose ; rodent is precipitous and excavated. Lupus possesses, rodent cancer is without any, contractility. The margin of lupus, though thickened, is low, and bevelled both outwards by oedema and inwards towards the shallow ulceration; that of rodent can- cer is firm, and is commonly, in both directions, abrupt. The ulceration of lupus is smooth, and may be multiple, being divided by scars ; that of rodent is single and rugged. In the vicinity of lupus there are separate, rather soft tubercles, and an area of pink scaly integument; around the rodent disease the skin is healthy; and if a separate nodule do exist, it is compact, firm, and in great part subcutaneous. Lupus is not invariably limited to the face, but may at the same time appear on the hands or elsewhere ; rodent cancer is eminently local and centrifugal." (Moore.) Cancer occurs generally about the lower lip, rodent ulcer never; in can- cer the glands are affected, the general health is bad, the ulcer is moist and gives out an ichor, is warty more or less, its edges are everted and under- mined, and the parts around are infiltrated by cancerous material, and it is of more rapid progress. Syphilitic ulceration is more acute, there is no indurated solid edge, there is pus formation, the ulcer occurs often at an early age, the origin is not from a " pimple," and the concomitants of syphilis exist elsewhere about the body. Treatment.—The treatment is simple and satisfactory. Experience teaches us that extirpation by the knife, safe in the earliest stages, is the only successful mode of treatment, and it is effectual. Mr. Moore has lately shown that even in advanced and extensive cases the free use of caustics after'as much of the disease as possible has been removed, is attended appa- rently with comple success. But I must refer to his work on rodent cancer for fuller surgical details. When once the diagnosis is made, the line of procedure is easy, and it is extirpation. General remedies are of no avail. CHAPTEB XV SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. The remarks under this head will apply mainly to the effects of syphilis upon the skin. The result of the introduction of the syphilitic poison into the system is to derange more or less the whole of the nutritive processes of the body; as a consequence, we have a pyrexial condition similar to that seen in every zymotic disease, only more deliberate and chronic, and which has been termed " syphilitic fever." In some cases the infection of the system is so insidious that this febrile state is not marked or scarcely at all recog- nizable. " The blood is charged with a poisonous principle, and all the organs and structures supplied with that blood suffer to a greater or less extent. The brain evinces its suffering by mental dejection; the nerves by a general feeling of prostration and debility .... there is often neuralgia (nocturnal) .... the pulse is quickened .... the tongue coated, white, broad, ,and indented by the teeth. The fauces are more or less congested, the tonsils and soft palate being frequently swollen; there is irritation of the larynx, producing a mucous cough and often nausea .... the conjunc- tiva is congested and muddy, and the whole skin remarkable for its yellow- ish and dirty appearance, looking as if saturated with impure and discolor- ed humors." (Wilson.) The muddiness of the complexion is very charac- teristic. Dr. Brodrick has called attention to what he believes a diagnostic sign of the existence of an acquired syphilitic taint—viz., sub-sternal tender- ness ; it was noticed by Bicord. Various diseased states of internal organs, of the special senses, and fibro-cellular structures also result from the poison of syphilis, especially in hereditary instances. Syphilodermata exhibit the same elementary lesions as ordinary eruptions; they are erythematous, pa- pulous, squamous more especially, but also bullous, tuberculous, vesicular, pustular, etc. But they possess certain modifications of features as to color, shape, etc., to be immediately noticed. Syphilitic taint giving rise to eruptions may be hereditary or acquired. Hereditary syphilis is practically synonymous with congenital or infantile syphilis. The child, however, may be tainted through the medium of the milk of a syphilitic nurse. Congenital syphilis may be derived {a) from the mother contaminated before or after conception; (b) from the father (the mother being healthy) ; (c) when the parents are both syphilized, in double degree. It is uncommon before the end of the second or beginning of the third week, rare after the sixth month; the usual period of occurrence is when the child is about three weeks or a month old. No one can mistake the tainted infant. The general aspect is more or less marasmic, shrivelled SYPHILITIC ERUPTIONS. 143 " old man " like. The skin is dirty, muddy, it has lost its elasticity, and hangs in loose folds; it is dry, often exfoliating, and erythematous about the buttocks. The cry of the child is harsh, cracked (characteristic), and "the snuffles;" the presence of mucous tubercles about the anus and the mouth ; the fissures at the angles of the mouth ; ulcerations of mucous sur- faces ; the high arched palate ; the inflammation of the thymus gland ; va- rious eruptions over the body, especially about the feet and hands (perhaps bullous) ; a subacute onychia possibly present; and a family history of syphilis—are diagnostic. With regard, however, to the eruption, it is generally in the form of a dull red erythema of the hands, feet, and peri-anal region, with more or less tu- bercular formations. Acquired Syphilis.—An adult may exhibit hereditary syphilis, pur et simple. Acquired syphilis is more common, and has three groups of symp- toms. Primary, which is simply chancre, with which I have here nothing to do ; secondary and tertiary symptoms, made up of eruptions, diseases of the bony parts, and ulcerations, which follow as the consequence of the introduction of poison into the system, mostly'by way of primary disease. The secon- dary forms of eruption are—roseola and maculae, lichen, psoriasis, tubercula, pustulae (ecthyma, acne), rupia, onychia, and alopecia; accompanying these, are enlargement of the cervical and inguinal glands, mucous tubercles, noc- turnal rheumatism, loss of hair, and anaemia, more or less marked. The tertiary are—erythema and psoriasis of the hands and feet, the ulcerating tubercular forms, mucous tubercles, and syphilitic ulcers. These latter are geuerally accompanied by cachexia, nodes, periostitis, laryngitis, and deeply seated mischief—ex., in internal organs. The syphilodermata have certain peculiarities :— 1. There is a history of syph Hi tic inoculation, which tells its tale by the nu- merous symptoms (due to the circulation of the poison), noticed at the open- ing of this chapter; and, in addition by the presence of cicatrices, indura- tions, scars, and stains about the penis and groin. 2. Their color.—It is described as copper-colored ; in reality " a reddish yellow brown" (Wilson). It* is dull red at first, and becomes coppery after a.while, and as the eruptions vanish a dull red or yellowish dirty stain re- mains for a varying length of time. In the early stages of disease the tint may be violet, but this soon becomes replaced bjT the coppery hue. It is well marked in the tubercular forms, and at the circumference of ulcers and. pustules. 3. Their form, which is peculiarly circular. This feature is not perhaps of much moment, per se, but in conjunction with other points is of some aid in a diagnostic sense. It may be destroyed or prevented by the confluence of other patches, but even then the typical forn can be recognized in the component parts of the patch of disease. During the progress of syph- ilis there is a tendency on the part of the eruptions to assume the aspect 144 SYPHILITIC ERUPTIONS. of several forms at different times—a papule becoming a pustule, and so on. Syphilitic scaly eruptions are composed usually of small circular spots. Scales or squamae are thin, oftentimes very fine, gray, and few in number; fewer and lighter than in non-syphilitic cases. Cruses are thick, greenish, or black, and firmly adherent. Vesicles are flattish and do not readily rupture. Ulceration is a common feature ; the ulcerated surface is ashy gray, covered with a pultaceous substance, and bounded by sharply cut edges. Cicatrices are whitish and reticulated, or dull and brownish, leaving in their place on disappearance a yellowish stain. Fissuring is marked in the squamous forms. The horse-shoe form of pustu- lation or ulcer is very characteristic. The serpiginous is suspicious. 4. The Absence of Pain or Itching.—With the exception of mucous tu- bercles and some forms (moist) of infantile syphilis, syphilodermata are said to be generally unaccompanied by heat or pruritus during their existence. I cannot subscribe to this. In syphilitic lichen, even erythema (roseola), the pruritus may be distressing. In the tubercular forms, just prior to ul- ceration, the process of softening renders the tubercles sometimes painful and tender. 5. Polymorphism.—This is very characteristic of syphilitic disease. Sev- eral different kinds of eruptions may co-exist, and this is a rule of general applicability. It is no unusual thing to see papules, pustules, and squamae coexistent in the same syphilitic subject, and, as before remarked, one form may assume the characters of another. I shall give the salient features of the various syphilitic eruptions. PIGMENTARY STAINS, OR MACULE SYPHILITICA, Are generally a remnant of other forms of syphilis, mostly of roseola. They generally commence by slight pyrexia, pain in the limbs, anorexia, headache, and malaise, followed by the development of little roseolous spots, which soon fade, take a dirty-brown aspect, and subsequently a rather lighter hue. These maculae are neither elevated, itchy, nor hot; they are circular, in size ranging between that of a fourpenny-piece and that of a florin, scat- tered over a pretty large area, usually isolated, but occasionally confluent, forming sometimes bands (annulose) ; they do not disappear on pressure, and their especial seats are the neck, the breast, the face, especially the fore- head, and the arms. In children the maculation is so complete that the whole surface has an earthy look. In acquired syphilis, in adults there is oftentimes a significant staining, particularly well seen about the forehead. Macula? syphiliticae are unattended by pruritus or desquamation and some- times occur in conjunction with other forms of eruption. It has been said vthat they constitute a primary form of disease, but it is the rule that they -commence as roseolous spots, though the red blush may be very ephemeral and escape detection. They can only be confounded with pityriasis, but in the latter there is desquamation, itching, elevation, and absence of the copperish PAPULAR SYPHILODERM. 145 hue, and a want of circular form. Chloasma is attended with itching; the color is fawn, without any shade of copper tint; the surface is elevated, rough, and desquamative, and the microscope detects parasitic elements; chloasma, too, is peculiar in its seat. Syphilis never produces such staining as chloasma. EXANTHEMATOUS SYPHILIDE, OR SYPHILITIC ROSEOLA. This is one of the earliest secondary symptoms, occurring generally be- tween the sixth and ninth week after the reception of the primary mischief. It is preceded by pyrexia of mild character, prostration, and very frequently more or less irritation of the mucous surfaces—e. g., redness of the fauces, sore throat, etc. The eruption commences as little round spots of a pale- red color, with very well-defined edges, which may appear very suddenly, often in the course of a single night, acquiring in a little while a perfectly pale-rose tint; the spots are unattended by itching, and observed usually most perfectly and abundantly on those parts which are well covered and kept warm by clothing, especially flannel; hence particularly on the trunk. The little patches may be slightly elevated, isolated, and round ; they fade, but do not disappear on pressure. Sometimes they are scattered pretty freely over the trunk, the upper part of the chest (especially the lateral parts), and on the back. When the rash fades, it always leaves behind a branny-like or more deeply colored stain; the epidermis desquamates in largish but thin scales. This latter condition becomes more decided in a few more days. What strikes one is this: that there is evidently a large scattered amount of erup- tion without apparent cause, without local irritation, and only the slightest febrile disturbance, the eruption leaving behind a dirty staining. The cop- pery hue is evolved out of a roseola, which is somewhat dusky on its first appearance. In ordinary roseola the tint is vivid, and quickly disappears. The stains left by syphilitic roseola, when the congestion has disappeared, constitute the so-called Maculoz Syphiliticce, before noticed. In syphilitic roseola there is usually not only redness of the fauces and tonsils, but ulce- ration. PAPULAR SYPHILODERM Assumes the form of lichen, and all authors agree in describing two forms, the acute and the chronic. The acute consists in the development of small, hard, pointed papules, which are packed closely together, each being attended at the outset with a red areola, affected by pressure. The papules are seated upon the face especially, and also the trunk (on both aspects), the neck, and less frequently the limbs; they become covered over with fine grayish scales, and occasion- ally become pustular or ulcerate. The eruption is scarcely successive, for it arrives at its full extent within a. couple of days or so. Slight febrile dis- turbance precedes the development of this state. When the acute stage is passed, the disease appears to be constituted by little dark points or papules 10 146 SYPHILITIC ERUPTIONS. seated upon a somewhat dull-red base ; in a few more days this dark hue is replaced by a well-marked copper color, and more or less desquamation. The disease lasts a month or so, leaves behind more or less staining, and little cicatrices or pits, which are very characteristic. This form of syphiloderma then commences with congestion and subsequent deposition in the form of papular elevations; the peculiar coppery tint is masked at the outset by the congestive redness, and only shows out markedly when the latter disappears. , The chronic form of lichen possesses a slower and more indolent course, simply. The papules are larger, numerous, flat and broad, copper-colored, without distinct areolae, local itching, pain, or heat; they are seated on the outer sides of the limbs, the forehead, the trunk, and even the scalp. The papules are successive in mode of appearance, and on their subsidence leave behind coppery stains. The papules often become pustular. The Diagnosis of syphilitic lichen is generally easily made. A prior his- tory of syphilitic inoculation; the seat of the eruption on the face especially, its general distribution, coppery hue, and tendency to become tubercular; the absence of pruritus and pain; the general cachexia of the patient, and the evidence of concomitants—e. g., mucous tubercles, roseola, nodes, sore throat, etc., suffice. VESICULAR SYPHILODERM Is very rare. The vesicles are grouped together, and possess a copper- colored base; the disease is indolent, and usually possesses a very well-de- fined ed<*e: there is an entire absence of the ordinary local symptoms of ve- sicular disease—viz., itching and heat; the vesicles too are often abortive, and may quickly dry up, thin scales take their place, but a dark stain remains. Slight pyrexia is not an unfrequent antecedent, and significant concomitants are generally present. Hardy describes three aspects: they are, eczematous syphilide, varioliform syphilide, and herpetiform syphilide. The vesicular syphiloderma, or syphilide, occurs mostly in the form of herpes, or a modification of the bullous form of disease, in which the vesicles are varicellous or depressed more or less in their centre (varioliform). When there is slight vesiculation over a largish area, we have the eczema- tous form; if much crusting or pustulation, it is called impetiginous ; in other cases there are largish distinct vesicles seated upon a dull-red base; the vesicles do not easily rupture, but desiccate, and are replaced by dark-colored scaly scabs. This is the herpetiform syphilide of books. In all cases a cop- per-colored stain is left behind. This herpetic syphilide is noticed on the face, limbs, trunk, and penis, often associated with other syphilodermata, and generally within six months or so after primary disease. In the varioli- form variety, the vesicles are about the size of lentil-seeds, disseminated and intermingled with little bullae, which are pointed, and now and then umbil- icated. They possess the characteristic areola, crust over in a short time, beneath which a copper stain exists. The herpetiform sypilide may occur in the form of a ring with a clear centre. BULLOUS SYPHILODERM. 147 The Diagnosis is based upon the absence of fever, the persistent state of the vesicles, the coppery tint, the brown or dark color of the crusts, the staining, the history of the patient, and concomitant conditions. BULLOUS SYPHILODERM. Under this head are ranked rupia and pemphigus. Dr. M'Call Anderson informs me that he has seen a second case of syphilitic pemphigus in the adult. Rupia is known by tbe* development of small flatfish bullae (surrounded by a faintish areola, perhaps by none at all), few in number, containing at the very outset transparent serosity, but very speedily a mixture of blood and pus, giving place by desiccation to thick scabs, beneath which is more or less unhealthy ulceration, yielding a nasty, dirty, foetid discharge. The crusts are diagnostic; they are dark, stratified in such a way as to be coni- cal, like an oyster-shell. There are three forms : P. simplex, P. escharotica, P. prominens. Erasmus Wilson considers the first and last to be syphilitic, and B. escha- rotica to be the same as pemphigus gangrenosum, or cachecticum. B. sim- plex is very like pemphigus ; the contents, however, are thick, bloody, offen- sive ; and the scab is dark, thicker in the middle somewhat, and therefore slightly conical: the scabs are often successive ; in process of cure, it leaves a red stain behind; it affects especially the legs, loins, and thighs, never the face or head. B. escharotica, or pemphigus cachecticum, has been described. The general symptoms are those of irritation and deficient nutrition, with more or less hectic. The disease commences by bullae, which fill with sanies, and break forth into unhealthy ulcers : it has no thick crusts, and hence is really pemphigus. It attacks the lower limbs, the trunk, the neck, and scrotum. B. prominens attacks the upper and lower limbs, and the trunk; the bullae are few but large ; the secretion is free and thick: therefore the crusts are large and particularly well-marked, conical, and prominent: hence the name. There is usually an areola around the bleb ; the scabs augment by accretion, and cover over deep ulcerations. The scabs are dirty and blackish; they are sometimes almost an inch in height in the middle or apex of the cone. • Etiology.—The cachexia of syphilis. Diagnosis.—In rupia the bullae are small and flat; their contents are bloody and thick, and the scabs are dark, thick, and conical. In pemphigus the bullae are larger and full; the contents are clear, not dark; ulceration is slight, and the scabs are thin. In ecthyma there are pustules; the areola is well marked, the base is indurated, the scabs are adherent; there are no conical crusts, and the ulceration is not so deep. There is little difference apparently between pemphigus and rupia, except in the degree of crusting that occurs ; rupia differing from pemphigus in the fact that the ulcerated base of the bullae gives out a peculiar secretion which dries into thick, dark-colored, and more or less conical crusts. 148 SYPHILITIC ERUPTIONS. Pemphigus in the very young may or may not be syphilitic. It may be epidemic, attacking robust healthy children, running the course of ordinary pemphigus, and wanting the concomitances of syphilis; in this aspect it is met with among the infants of lying-in hospitals, and appears to be much of the nature of, and produced by the same causes as, erysipelas. Non-syph- ilitic and non-epidemic pemphigus is not usually seen in children before the seventh or eighth month of age ; the contents of the bullae (which are dis- crete in this species) are serous, and there is little tendency to ulceration. Syphilitic Pemphigus is now regarded as a positive existence. It occurs in those children in whom we can trace an hereditary tendency to syphilis, in those who exhibit signs of constitutional tainting (earthy hue of skin, snuf- fles, wasting, mucous tubercles, lepra, etc.); about the hands and feet espe- cially ; the bullae are abundant, their contents puriform, and they possess a great tendency to ulcerate more or less deeply, the ulcers having a cop- per-colored areola, and a nasty, dirty, foul surface, with thinly cut edges. It is sometimes congenital, and is seen most frequently before the end of the first fortnight of existence. Sometimes the bullae may be not weD marked and scabbing may be extensive in degree, the disease exhibiting a close rela- tion to rupia; indeed herein we see the link as it were between rupia and pemphigus. The ulcerative tendency displayed by syphilitic pemphigus is no doubt dependent upon the cachectic state of nutrition brought about by the syphilitic poison. PUSTULAR SYPHILODERM. There are three forms : (a) pustulating lichen or pustulating tubercules ; (6) that in which the pustules are primary, small, and resembling acne, often called tubercular syphilis—the syphilide pustuleuse acniforme of Hardy • (c) in which the pustules are larger, and assume the aspect of ecthyma (phlyzacious). Bupia was described under the head of bullous syphilide • it is not truly pustular. 1. The first, or pustular lichen of Wilson, is seen about the forehead and face, and on the trunk; the pustules are successive, numerous, isolated and scattered; soon acquire a coppery hue, and are indolent. Sometimes they are flattened, at other times conical, the points or summits beinw purulent • a thick greenish crust forms beneath which is an ulcer, depressed in its cen- tre, and leaving behind a more or less marked cicatrix and copper-colored stain; this is often associated with other forms of syphiloderma and pre- ceded by febrile disturbance. It often remains in one condition for weeks being remarkably indolent, the crusts adhering very closely and persis- tently. 2. The second is the acniform variety. In this disease, the pustules are the size of small seeds, and the seat of disease is seen to be the sebaceous follicles. The pustules develop and change slowly; there is a coppery base, and dark or dull yellowish adherent crusts form, and there is pitting left behind after cure. Other forms of syphilis are mostly present. PUSTULAR SYPHILODERM. 149 Dr. Tanturri believes there are two forms—(a) the glandular; (b) the fol- licular. a. In glandular syphilitic acne, the parts attacked are the epithelium, the proper wall of the sebaceous gland, and the neighboring connective tis- sue. It is distinct from impetigo in the fact that the epithelial layer alone is involved in that disease, whilst yellow crusts form which contain a large amount of nucleated epithelium, like that which is normally present in glands, granular epithelial cells, pus-cells, and fatty matter. These elements are in small quantity in syphilitic acne, but the deeper parts are chiefly in- volved. Simple impetigo is catarrhal, syphilitic acne parenchymatous. The diagnostic characters of this glandular acne, according to Tanturri, are in the earliest stages the occurrence of spots on the trunk and limbs, the acuminated pustules, their hard base, central suppuration, and the tendency to desiccation. In the suppurative stage, the hard base, central depression, the hard dry adherent crust of small size. In the latest stage the marked indurations, with central suppuration and desquamation at the circumfe- rence ; and lastly, the superficial cicatrices, the presence of pigment and fine scales. With regard to chronic syphilitic acne, the parts affected are the face, neck, trunk, and limbs; the pustules have slightly projecting bases, they are slowly developed, and suppurate only at their centre. b. Follicular acne Dr. Tanturri believes to be catarrhal; the part affected is that lying just above the openings of the sebaceous glands, the epidermic portion—not the dermic—therefore it is not parenchymatous ; it may occur in syphilis, of which it is an early symptom; its progress is slow, and it is of long duration. It is marked by a large development of epidermic cells, and may leave behind a sort of ichthyosis, with desquamation. It appears on any part of the body save the face, and in all cases there are pustules with a projecting base, a rose-colored areola, a yellowish centre, traversed by a hair. 3. The third or ecthymatous form (ecthyma syphiliticum) is seen about the trunk, but especially the limbs, the lower more than the upper, and oc- casionally the head. The pustules are phlyzacious, scattered, with a coppery base, and indolent, flattened, scabbed over with dirty brown or blackish scabs, covering ulcers with indurated and dark edges, which on healing leave behind cicatrices and characteristic stains. It may commence as a quasi- vesicular (bullous) disease, each vesicle having a red base, quickly enlarging, pustulating, and breaking out into obstinate ulcers; the crusts are peculiarly thick, and very adherent. The relation of ecthyma, pemphigus, and rupia, of syphilitic origin, is very close indeed. The Diagnosis.—When lichen, or even tubercular syphilis, pustulates and assumes the aspect of ecthyma, no difficulty can arise in diagnosis. Syphi- litic ecthyma is distinguished from simple ecthyma by the special history of the case, the concomitance of other syphilitic lesions, the coppery hue, the thick black crusts, the foul ulcers, the depressed scar, and the absence of a livid areola; syphilitic from simple acne, by the ulceration at the apices of 150 SYPHILITIC ERUPTIONS. the pustules, and the cicatrices left on healing, the absence of pain, the in- dolent, non-inflammatory aspect, the antecedent and concomitant histories. SQUAMOUS SYPHILODERM Commences after puberty, as described by Biett: the presence of a little white rim around the base of each patch is peculiar; it does not attack the elbows and knees by special predilection. A special form, lepra syphilitica nigricans, has been described ; in it the color of the patch is black, especially in its middle, the form circular, the margin more raised than the centre, the squamae very fine and dry, the surface beneath shining, and there is a gen- eral earthiness of the surface; the disease sometimes has the appearance of darkish livid stains. In other instances, the squamous syphiloderma assumes the aspect of what is generally regarded as psoriasis, particularly the variety guttata. There is a disposition to a circular form; solitary isolated spots are seen, the size of a pea, a shilling, or less; these are generally covered by thin squamae, which are hard, adherent, and gray, and seated upon a copper- tinted basis, which is smooth and shining, not elevated, not papular, not red, as in simple alphos ; a white rim surrounds each patch, and this is formed by the loosening of the cuticle around the circumference. These spots are scattered over the arms, breast, face, and trunk generally ; and when the palms of the hands or soles of the feet are diseased, the skin is dirty, harsh, scaly, cracked, and fissured. On the palm of the hand is exhibited a red- dish spot, over which the cuticle becomes hardened and yellowish; the sur- face then cracks, and the diseased action tends to spread, producing a " red, inflamed, hot, cracked, exfoliating surface," and assumes, an annulate, serpi- ginous, or tubercular form. If the central part heals (lepra), it is called E. palmare annulatum: these palmar and plantar diseases are tertiary symp- toms. Hardy has described a syphilide cornee ; it is merely plantar or pal- mar psoriasis, in which the epidermis hardens very much, and the coppery areola is well marked. Devergie thinks that the psoriasis palmaris, when it affects the palm of the hand rapidly, and the palmar aspect of the fingers as well, with pretty free desquamation, is pityriasis rubra, and not psoriasis at all. Syphilitic lepra is often intermingled with the papular and tubercular varieties of eruption. Diagnosis.—There are seven leading features which, taken together, are positively diagnostic of syphilitic alphos. (1) Alphos limited to the palms of the hands and soles of the feet, is in the majority of cases syphilitic. (2) The disease does not attack the elbows and knees by predilection as in the simple forms. (3) It is generally displayed in little circular patches, which are isolated and not confluent. (4) The patches have a peculiar whitish line circumscribing them, due to the elevation and attachment of the cuticle. (5) The squamae are thin, small, gray, and repose upon a cop- pery base. (6) There are generally significant co-existences of specific in- fection. (7) Copper-colored maculae follow in the wake of the disease. TUBERCULAR SYPHILODERM. 151 TUBERCULAR SYPHILODERM Is decidedly a common form of secondary syphilis, the tubercles for prac- tical purposes being regarded as an exaggerated condition of papules: they vary a good deal in size (from that of a pea to that of a nut) and form, but are always indolent, and mostly occur about the face, especially the nose, forehead, and side of the head. They possess a coppery tint, and are flat and hard; when they ulcerate, which they do when large, they become covered over by thick and black adherent crusts. The tubercles may be aggregated and in groups. The patches increase by the centrifugal growth of tubercles, and in the disease as now described, the edge is generally bounded by distinct tubercular elevations; the surface is muddy and cachec- tic. When the central part clears, as it were, the disease closely resembles epra; and when the tubercles disappear, the derma often appears to be atrophied, so that cicatrices are left in connection with a considerable degree of maculation. The tubercles may at other times be disseminated. This may be regarded as papular syphilis in a marked degree; the tubercles, rather larger in size than that of peas, are not arranged in any particular order, but are seen scattered over the trunk, the back, and the face; they are very indolent, do not ulcerate, and are only covered by squamae to a very slight extent. Several tubercles may collect, so that a ring is formed, the enclosed central area being tolerably healthy. The difference in the grouping of the tubercles has given rise to the divi- sion of the disease into tubercula circumscripta, disseminata, annulata. In these no ulceration occurs, but in other instances the tubercles do ulcerate, and this form is called— Ulcerating tubercular syphilide.—The ulceration in one instance may be deep, in the other superficial; the first condition is the syphilide tubercu- leuse perforante (perforating or deeply ulcerating tubercular syphilide). In it the tubercles are large, few, livid red, with a copper-colored areola, having a tendency to ulcerate deeply, with accompanying pain and discomfort; the ashy-colored and foul ulcers, which may become confluent, crust over, the ulceration meanwhile eating more deeply, the crusts being repeatedly shed and reproduced. In this way the nose may be destroyed and lost, the dis- ease resembling lupus : it is most common about the face. Severe ulcera- tion is generally a symptom of tertiary syphilis, and accompanies marked cachexia, indurations of the periosteum, syphilitic caries, etc. When the ulceration is superficial it creeps along the surface, and then we get what is called the serpiginous syphilide. It differs from the perforating variety chiefly in the fact that the ulceration takes place in a superficial manner, creeping over the surface; the form varies somewhat—it may be in bands or circles; the surface of the ulcer becomes covered over with blackish crusts, which fall and are reproduced from time to time; the tubercles themselves are large, and, if the ulcers heal, distinct livid cicatrices remain behind; if the tubercles become confluent, the ulceration is more marked. 152 SYPHILITIC ERUPTIONS. Another condition is the fissured tubercle ; it is smallish, and is noticed to be the seat of a linear ulcer, or a fissure in its centre ; there is a good deal of pain; and a thinnish ichor is exuded; it is seen about the side of the nose, lip, scrotum, and anus. There are then two distinct aspects of tubercular syphilodermata,—the ulcerating and the non-ulcerating ; but even these are not absolutely sepa- rated the one from the other. The non-ulcerating may be subdivided into disseminated and aggregated. The tubercles mostly disappear by resorption. The ulcerating form may be likewise subdivided into perforating and serpi- ginous ; but even a mixed condition of these two may exist. A syphilitic lupus or lupiforin syphilis has been described. The characteristic of lupus is the attempt at repair, which is so far successful that it gives rise to pe- culiar indelible cicatrices, and when tubercular elevations are accompanied by a dull-red tint and succeeded by deep ulceration, with more or less scabbing, sanious discharge, and attempts at repair, ending in partial cicatrization, the disease is termed syphilitic lupus; but it is a bad one, as likely to confuse between lupus and syphilis. Diagnosis.—Syphilitic ulcers are likely to be mistaken for lupus; the former have sharply-cut edges, tubercles around which are hard, smooth, dryish, dense, shining, and copper-colored. They occur in people of middle age, are accompanied by concomitants of syphilis, and the ulcers are foul, dirty, ashy, exuding an ichor, and the tissues around are infiltrated and in- durated ; in the lupus ulcer the edges are not sharply cut, but thickened and rounded; there is no copper-color; the tubercles are soft, red, quasi- gelatinous; the parts around are painful and oedematous; it often occurs about the face alone in young people; there is an entire absence of syphilis, and the ulcers are clean and dry. Sometimes a syphilitic ulcer originates in subcutaneous indurations ; these are observed in very old-standing cases. They are called tumores gummati, or tubercula gummata ; they are hard and about the size of nuts or walnuts. Presently the surface over them becomes red and tender, and ulceration commences ; but it is very indolent, indeed it has no tendency to heal; gives exit to a little fluid, scabs somewhat, and is not painful. Just as we have growths and eruptions of the cutaneous, so have we similar affections of the mucous, surface: it is only needful to refer now to those changes which are observable to the eye, and which are seated especially at the junction of the skin and mucous membrane; hence particularly at the orifices of the natural outlets : but not only here, for any part of the surface which is habitually bathed in secretion, and acted upon by heat, is liable to the same kind of disease. This form of syphiloderma has been called vege- tative syphilis, and is noticed mostly in the female about the vulva; in the child about the mouth, buttocks, and arms; and the penis in the adult. There are two species—mucous tubercles and condylomata (warts). Mucous tubercles (see Elementary lesions) are circular flat elevations, of soft look and feel, and may be described curtly as warts formed out of mucous mem- TUBERCULAR SYPHILODERM. 153 brane; they become more or less irritated, the parts around being also in- flamed, at the same time that they give exit to a faint, pale, viscid secretion : they may ulcerate, or become pedunculated, when they are to all intents and purposes condylomata; they frequently spring up in the seat of an old sore, and always cause considerable local discomfort. Condylomata are simply pedunculated little warts, occasionally sessile, differing frGm mucous tubercles in the fact of being firmer and not giving rise to ulceration or secretion. Syphilitic Alopecia is pretty common; the hair may thin out, if the cachexia be marked ; or it may fall off in patchy form. The diagnosis is made by a process of exclusion, and the positive existence of latent or developed signs of syphilis. Syphilitic Onychia may attack the structure of the nail itself, or the matrix especially. In early infancy (under a year), subacute onychia attacks several fingers at one time in conjunction with iritis, otitis, snuffles, etc.; it ends in exfoliation of the nail, and is not unfrequently attended by a papular rash, etc., over the surface of the body. The local symptoms are pain, redness, swelling around the base of the nail, followed by suppuration and ulceration of the matrix, with loss of the nail. This state is sometimes a secondary symptom in the adult, but usually the matrix escapes ; there is no pain and no exfoliation, but the superficial layers of the nail become affected. As Mr. Hutchinson described it to the Pathological Society, it begins at the root, where a " semilunar furrow is seen extending across it; the outermost layer is destroyed over the entire lunula, and a ragged border overhanging that part is presented by the distal portion; by degrees, as the nail grows, the diseased margin is pushed further and further on. The nails appear dry and brittle in texture, as is shown by the fissured and broken condition of the free edge." Several nails are attacked at the same time and that symmetrically ; the progress is very indolent indeed. The so-called tertiary symptoms are psoriasis and erythema, palmaris and plantaris (erythematous, Wilson), mucous tubercles, ulcerating tubercles, tumores gummati, and the large syphilitic ulcers which occur in cachectic subjects who have long been impregnated by the virus. Erythema and Psoriasis of the Palm of the Hand or Sole of the Foot.—In cases where we can trace the history of syphilis and its cachexia, these two forms of disease are seen. A red spot appears about the centre of the palm of the hand, it remains dry and cracks, and assumes the form of psoriasis (lepra). It creeps farther and farther over the surface, sometimes in the form of rings, the central part clearing as regards the redness, but remain- ing dry and discolored. Often the affection assumes the aspect of a tubercu- lar eruption. An erythemato-squamous eruption, somewhat like lupus, but not so "vascular" and copper-colored, occurs in old syphilitic subjects about the forehead and other parts. The diagnosis from simple eczema palmare is sometimes difficult, but the exfoliation, earthy staining, tubercu- lar aspect, and especially the " ringed " character, if it be present, aid effec- tually in connection with other special concomitants. 154 SYPHILITIC ERUPTIONS. TREATMENT OF SYPHILODERMATA. This consists in the first place in subduing the feverish symptoms which accompany the eruption—in other words, the syphilitic fever ; secondly, in toning up the system to help us counteract the mal-action of the poison, and to favor if possible its elimination or annihilation. Our treatment varies considerably according as the cutaneous eruption takes the aspect of a secondary or tertiary syphilis, and also if it be hereditary ; and the first, or only a recurrent attack. In secondary syphilis the remedy is mercury; in tertiary disease iodide of potassium. Now I discard the bichloride, blue pill, and all other preparations of mercury, save the bicyanide, and I now use the bicyanide exclusively. It is given in TV grain doses, in pill, with extract of gentian, quinine, or opium, as the case may be, twice a day; whilst iodide of potassium, in five- grain dose, at first twice and soon thrice a day, with spirits of ammonia, is given internally. Where the disease is extensive, the calomel vapor bath twice a week may be added. This is my treatment, and I am quite satis- fied with it, especially with the bicyanide, which is a more soluble com- pound than the bichloride, and has none of the irritating qualities of the iodides. I never have salivation, nor other serious " mercurial " sequences; and, given alone in the slighter forms, it acts most effectually. The iodide of potassium is given with it at once when the disease is papular, tubercu- lar, or pustular. In all cases 1 have regard to my patient's constitution, and give remedies calculated to check its ill tendencies; if necessary, the mercurial course may be continued till the disappearance of the eruption, and a course of mineral acids or quinine should be given. In the squamous and pustular syphilides mercurial treatment is called for. In the ulcerating forms, if the patient be well nourished and pretty strong, there-is no objection to a mercurial course; but where cachexia is marked, and the patient's condition is one of evident debility, iodide of potassium with cod-liver oil, or iodide of iron and good food, is the best treatment. In cachectic subjects who are debilitated, restless, and irritable, opium given internally is of much service. In reference to iodide of potassium it must be borne in mind that its use is beneficial in direct proportion \o the duration of the disease; hence, when nodes, tubercles, caries, and secondary ulcers are present, when mercury has been fully used, or seems to fail. In all cases the exhibition of decoctions of various woods is advisable. The compound decoctions of sarza and guaiacum are the best; they keep the skin and bowels freely acting, and thus very materially help the elimi- nation of the poison. When a patient is under the influence of mercury, he should avoid stimulants, cold, and other sources of irritation and catarrh ; the drug itself acts by its effect upon the system at large ; the exhibition then should be continuous, and not interrupted. If it do not after awhile seem to produce much beneficial result, then its use should be discarded, and the iodide of potassium used with tonics. Local measures are only TREATMENT OF SYPHILODERMATA. 155 urgentl}r called for in those instances of tubercular and ulcerative syphilo- dermata in which destructive action can be thereby checked. Should sali- vation occur at any time, the mercurials must be omitted, or given cautiously and with attentive watching. In no case should it be our object to in- duce or push the drug to the point of salivation. In giving a mercurial bath, the patient is seated upon a chair and covered with flannel, and out- side this by an oil-silk 'quasi-coat or bag; beneath the chair is placed a copper bath, containing a pint or somewhat less of water; upon this is placed a tinned iron plate, which holds the mercury to be sublimed; beneath the bath is placed a spirit-lamp; the patient, after the latter is lighted, is " exposed to the influence of three agents—heated air, common steam, and the vapor of mercury; in about five minutes perspiration comes on, and the patient should be subjected to the influence of the bath for some ten or twenty minutes, when the lamp should be removed, the patient allowed to cool gradually, and made to take," as Mr. Parker further ob- serves, " a warm drink of decoction of sarza or guaiacum." If the preparation employed be the bisulphuret of mercury, about one or two drachms should be used ; if calomel, from ten to twenty grains ; if the iodide, ten to twenty grains; the oxides and the bisulphuret are the mildest, the iodides the strongest fumigants. The bath may be used once, twice a week, or even more, according to circumstances. Inunction is another mode of bringing the system under the influence of hydrargyrum. Continental dermatologists advocate a plan, which Wilson briefly defines as " a triple compound of starving, purging, and sweating," ■ and which he mentions with commendation; it is the so-called Zittman treatment, but is one which compels the patient to give up his usual employ- ment, to take to bed for a fortnight or so, and on this account is almost in- applicable in a general way. The patient who has syphilitic disease wants to get rid of it without entering upon any plan of medicine which would disclose his secrect, and take him away from his work; most men could not afford the time ; however, the plan is as follows :—First day, a purge (calo- mel and jalap), and three meals of broth ; up to the fifth or sixth day four pints of the Zittman decoction are taken daily ; of these four, two pints are made of the strong and two of the weak decoction (vide formulary), with each day two ounces of meat and two of bread: on the sixth clay an active purge, with broth as before; the seventh till tenth repeat the drinks, and meat and bread : this continues till the fourteenth day or so, and then the patient is kept on low diet, allowed to get up, but still continues to take a small quantity of the decoction. If convalescence is tardy or insufficient, the same treatment must be recommenced. It has been a matter of much dispute whether infantile syphilis should be treated upon similar principles as those above described. For my own part, I should be exceedingly sorry to be an infant affected by specific dis- ^ ease and not treated by the drug mercury, in addition to chlorate of potash, and syrup of iodide of iron. The best plan is to rub a little mercurial oint- 156 SYPHILITIC ERUPTIONS. ment into the sole of one foot at night, and where the nurse or mother is tainted, to give the iodide to her, and therefore to the child through her milk. The mercurial requires to be used only a few times, and at each rub- bing a piece of ointment about the size of half a pea. The Local Treatment of Syphilodermata.—The erythematous forms re- quire no special application, except they be obstinate, and then a white pre- cipitate ointment may be used; the squamous and papular are relieved by calomel ointment, bichloride lotion, and nitric oxide of mercury ointments. The tubercular and ulcerating forms of disease are those which require special local medication. In the tubercular form the acid nitrate of mercury: biniodide, and other mercurial ointments, are those most especially useful; the former is used to destroy the little indurations, and should be used cautiously; the biniodide in glycerine, applied with a brush, is often most efficacious in obstinate cases. Syphilitic ulcers may be dressed, if painful, with a solution of watery extract of opium, or be dusted over with calomel, or be stimulated with the nitric oxide of mercury ointment, dilute nitric acid, chloride of zinc, and borax lotions, or treated by the local application of mercurial vapor. In the appended formulary several remedies will be found in reference to the general and local treatment of syphiloderma. See numbers 13, 16, 17, 18, 41, 71-7-8-9, 81, 92, 110, 114, 121, 143-5, etc. CHAPTER XVI. LEPROUS DISEASES. Under this head I include the true leprosy or Elephantiasis Grascorum. The disease of the leg, known as elephant leg or elephantiasis arabuni, and now called bucnemia tropica, is not thought to have any relation to true leprosy. Elephantiasis Grcecorum or true leprosy is a disease of which I have seen many cases during the last few years, especially in Syria, in Egypt, and in England. Three or four cases have come under my notice in England, and at the time of penning these lines a man is under my care in Charing-Cross Hospital with the disease exceedingly well marked. Space only allows me to notice the disease briefly. Its geographical distribution I must pass over, and refer for this and other points to the recent Leprosy Report of the Col- lege of Physicians. The disease is specially marked by the occurrence of discolorations and tubercular deposits in the skin, accompanied by anaesthesia. In some cases the deposit is well marked; in others it is less; only the anaesthesia is comparatively a more prominent feature—hence we have two forms, tubercular and non-tubercular (or anaesthetic as it is often called). These are merely varieties of one form of disease. Those cases that present them- selves to the physician in England (and which are mostly mistaken in the early stage for syphilis) give some such history as the following:—That they have lived a long time in parts of India or elsewhere where the dis- ease is endemic ; that they have had repeated attacks of " ague and fever," which has pulled them down very much ; and that some years afterwards brownish stains began to appear in different parts of the body, and upon these small brownish tubercles formed, first of all about the nose and eye- brows, or ears or neck. The next thing noticed was a loss of sensibility about the little finger and corresponding side of the palm of the hand, with wasting of the muscles between the forefinger and thumb. The first change in the skin has been described by the patient I have had under my personal observation as a dark dull coppery discoloration ; one that should never be regarded as syphilitic, for the simple reason that syphilis never induces staining per se over an extensive area of surface. The two phases of leprosy must be described in detail apart. The tubercular form commences with malaise,—an indefinite feeling of something wrong—rheumatic pains—a falling asleep of a limb frequently (generally referred, says Dr. Bowerbank, to some chill or sudden change of temperature), or with pricking sensations about the hands and feet. But some authorities declare that brown patches come first, or that there is a 158 LEPROUS DISEASES. numbness about the hands so that the patient cannot grasp so well as usual. At all events very soon there is a dull red discoloration in patches, then the face begins to flush and swell; it looks over-heated; then the limbs and trunk brown, and little tubercular formations make their appearance, first of all about the face, especially the ears, on the discolored patches. From this moment the disease steadily progresses. The tubercles vary in size, from that of a pea to that of a walnut; they are soft, smooth, shining, of a dusky- red color at first, becoming presently brownish-yellow, or bronzed. In the early stage, the sensibility of the part is often rather increased, in conse- quence of the pressure exerted by the blastematous effusion upon the nerves; but after a while this morbid sensibility becomes altered in character, and, from the greater degree of morbid change, diminished sensation sets in, and increases until it becomes decided anaesthesia. On stripping a patient after the disease has lasted some time, we notice deep-brown staining or patches varying in size from a shilling to the area of the hand over the front and back of the trunk, the arms, all round the neck, and of course all over the face, separated, save on the face, by healthy skin. Upon these patches are the tubercles in little parcels, or collected into one or more flattened elevated masses studded over the surface. The tubercles are most marked in situations where there is much lax, cellular tissue; therefore about the face, nose, lips, eyes, mouth, and ear. The disease may be more or less partial. The sebaceous glands now take on a hyper-action; hence the skin is oily and shining. The increase in the development of the tubercles produces terrible deformity; the surface feels thickened, knotty, or uneven; the face is altered completely; the edge of the mouth and lips, the eyebrows, the alae of the nose, the eyelids, are all distorted and thickened, the whole integument being dirty and sallow-like and the various aspects presented by the patient have been described by the terms leonine, satyr-like, etc. The sebaceous glands become enlarged. When the lower limbs are affected, the disease is generally most marked about the lower part of the thigh and ankle. Coincidently with these changes anaesthetic points appear in the centres of the oldest patches. In the cases I have seen, the parts supplied by the ulna nerve were insensible and this has only been discovered by accidentally burning or scalding which has not been felt. The ulnar nerve can be felt enlarged and cordy above the elbow; a good deal of pain of a neuralgic character accompanies the anaesthesia. The muscles of the hand waste, the finders cannot be op- posed, nor the hand grasp properly or pick up small things in consequence, even in an early stage of disease. Not only the cutaneous but the mucous membranes participate in the same change. The mouth, the palate the fauces, the trachea, the nose, the eye, are all affected by deposition of ma- terial in their mucous surfaces. The internal glands—e. g. the liver__in- deed, all the internal organs, with the exception of the pancreas, are finally affected ; the system is generally infiltrated. The patient's general condi- tion all this while is not serious. He is morose, low-spirited, dull, and care- LEPROUS DISEASES. 159 less ; but now his troubles are commencing in earnest. His voice, his sense of smell, of taste, etc., are affected, and the time has come for ulcerative action to set in: the tumors soften, ulcerate, and pour out an unhealthy, offensive secretion, which crusts over the sore from where it comes; the attempt at healing often fails. The eye is destroyed, the mucous surfaces of the internal parts ulcerate—e. g., the nose and its bones are destroyed. Diarrhoea from intestinal ulceration is a sad complication: the bones become carious, hectic sets in, and the patient dies. Ulceration is not so common in India as in Europe. The duration of tubercular elephantiasis, according to Drs. Danielssen and Boeck, is nine and a half years. But twenty or even more is common in other climates. Elephantiasis Anassthetica (Anaesthetic Leprosy).—In the tubercular form the deposit shows itself in a marked manner, implicating the nerves more or less; but in the anaesthetic variety the disease affects primarily the nervous trunks, and leads to a lowering of nutrition, anaesthesia, and subse- quent destructive changes. There may be little of the tubercular aspect: anaesthesia is the great sign; the muscular power is deficient, but paralysis is not a marked feature ; " in a word," as Mr. Wilson has it, " insensibility and atrophy are the distinguishing features." [It is not rare, however, to see anaesthetic leprosy partaking of the characters of the tubercular form. This is the mixed form of disease, and it occurs in India in about 15 per cent. It generally commences with eruption, which is usually of the white (morphcea alba) variety: it also begins in one-third of the cases under 20, and is rare after 40. The face exhibits the tubercles ; two-thirds of the subjects attacked are males; and it is a fatal form, hereditary transmission being strongly marked. (Carter.) This is the general character of the anaesthetic variety, as compared with the tubercular. There are then transitions between the different forms of leprosy. It ap- pears that the blastema effused in the anaesthetic variety is somewhat more transparent, not so opaque as in the other forms.] The anassthetic variety commences with much the same general symptoms as the tubercular form. It appears to originate, so far as local symptoms are concerned, by many subjective sensations of heat, shooting, burning, pricking sensations about the hands or feet, with more or less weakness, fol- lowed by tenderness, pain, and '■ welling along the course of the chief cutane- ous nerves—e. g., the ulnar, the median, the saphenous, etc., ending in numb- ness and insensibility to irritants. The integuments get parched, dry, shriv- elled, perhaps covered by a clammy sweat, and desquamate. Subsequently to this, the eruption makes its appearance : it consists not only of erythema- tous patches, but especially of bullae, which are of large size, occurring on parts previously anaesthetic: these break, and their place is supphed by superficial ulcerations, which, after scabbing, leave behind white, hard, hair- less, glandless patches of morphcea alba. Dr. Vandyke Carter has specially studied this morphcea, and I therefore append his description, in which I 160 LEPROUS DISEASES. agree, thus :—" Patches or spots of a circular or annular form, three-quar- ters to three inches or more in diameter; edges raised, of a pinkish hue ; free from scales, slightly cracked or wrinkled: centre depressed, pale, dry, glistening, having a tendency to spread and join so as to cover larger spaces." The central part of these patches is always anaesthetic, completely in cases of some duration, and feels hard to the touch. The patches may vary much by the presence of ccales or slight desquamation, or slight ichorous exudation ; the hairs of the part are atrophied, and it is said not whitened (Carter), they are subsequently lost. The glands also suffer in like manner. This typical form of eruption is the baras of the Arabs, the leuce of the Greeks. The result of careful inquiry seems to show that these patches are the result of changes in the nervous supply, that they run the one into the other, and vary in aspect from simple white atrophied circles to large " isolated but blended patches," with or without red vascular margins, passing through the stages in which the centre is first red, then brown or pale, and surround- ed by a distinct pink border of vessels. The centre of every patch gradual- ly becomes more and more anaesthetic. The chief seats are the back of the hip, the front of the shoulder, about the elbows, and on the forepart of the knee, over the temples, cheeks, trunks, and limbs. The eruption is symme- trical, and often precedes the anaesthetic form. It existed alone in 14 of 186 cases (Carter), and in 48 of 186 cases of anaesthetic leprosy. Coincidently with the changes above described, the body generally wastes, especially its muscular system: hence the fingers become distorted, and in a peculiar manner, the first phalanx is bent backwards by the extensor; the others are flexed: not only does this happen in the hand, but the feet and other joints also are distorted and rendered prominent. The bullae may give rise to deep, ragged, foul-edged ulceration, the base of which may be sensitive, proving the superficial character of the disease. The face is now much disfigured ; it looks haggard, shrivelled; the skin is what is termed " mummified," or lax and loose. The mucous surfaces are exposed, in con- sequence of the " sclerotic" or hardened and contracted state of skin. The deeper parts now become affected; a joint is seized with acute pain, a sinus forms, a piece of bone is discharged, and the sore heals. Dr. Carter thinks this is an unusual mode (by necrosis) ; he believes that the deep parts are removed by " interstitial absorption," without pain or reactionary activity of any kind: the terminal phalanges are the first bones to suffer, and the disease, by steady progression, removes bone after bone. The mu- cous surfaces become involved; they are infiltrated with " blastema," but not to the same extent as in the tubercular form : hence there is not so much diarrhoea or suppuration as in the latter disease; the patients live, on an average, about as long again—eighteen to twenty years. The ulcers of the surface are supposed to be due to irritants acting from without upon devi- talized (anaesthetic) parts: hence they are seen in those accustomed to hard manual labor. In the latter stages, the general health suffers very mate- rially, but not to the same degree as in the other form of leprosy. The pa- LEPROUS DISEASES. 161 tient may die, worn out by exhaustion, bodily and mental, or be cut off by some intercurrent disease. The Pathology of the Disease.—Elephantiasis is a blood disease of mala- rial origin it is now generally thought, which shows itself by the effusion into the tissues of an hyperplastic material. There is this difference, that whereas in the tubercular form the deposit, besides being more opaque, is deposited chiefly in the fibro-cellular structures, in the anaesthetic form it is more transparent, and is deposited, par excellence, in and outside the nerve-tissue. In the tubercular form, the fibro-cellular coats and structures of all the organs except the pancreas are found infiltrated by the peculiar deposit; in the anaesthetic, there is often an absence of this feature in the internal viscera and their coats. In reference more particularly to the anaesthetic variety, Dr. Carter's observations may be briefly summed up here. He found the brain, spinal cord, and the roots of the nerves healthy. Dr. Fabre, who studied the disease in Brazil, noticed the brain to be atro- phied, its ventricles to contain fluid, the glandulae Pacchioni numerous, and oftentimes a circumscribed suppuration in the membranes. Drs. Danielssen and Boeck differ from Dr. Carter: they state that the spinal cord and its membranes are altered; the latter being infiltrated with an albuminous deposit, a layer being found between the arachnoid and the pia mater; the cord itself being indurated, its gray matter discolored, yellowish, and devoid of vessels : the sheaths of the nerves and the various ganglia being similarly affected. They think the primary seat of the disease is the spinal cord. Dr. Carter, on the other hand, contends that the disease commences in the superficial nerves, and travels towards, but does not reach, the spinal cord. The sympathetic nerves are healthy; the heart, lungs, and intestinal canal healthy (Carter); the liver and kidneys fatty—in which all agree! The muscles generally are wasted and " fibrous," but not fatty, as the rule. The blood contains a more than ordinary quantum of albumen. The most important changes are observable in the nerves themselves. Dr. Carter says the nerve is swollen, dull-red, or gray, or semi-translucent, rounded and firm. The funiculi, not the connective coat, is the seat of disease; the nerve is evidently very tense. The place of " the clusters of nerve-tubules " is supplied by the albumino-gelatinous infiltration which has pressed upon them; the deposit surrounds the nerve-tubules, " mapping out, as it were, the area into polygonal or rounded spaces, in each of which lie the remains of one or two altered nerve-tubules." Hence the chief features are firm- ness, opmcity, and enlargement, from foreign deposition. This is chiefly marked in the compound trunks which are situate most superficially, and in the "cutaneous nerves just after perforating the deep fascia:" those chiefly diseased are the ulnar, radial, and musculo-cutaneous; and they may exhibit these changes over the space of an inch or more; sometimes, indeed, a greater distance along the parent trunk towards the spinal canal. Dr. Carter sums up the microscopic appearances thus:—The funiculus is " unchanged or slightly thickened, and marked by fusiform granular masses, 11 162 LEPROUS DISEASES. or more distinct oval granular nuclei of full size ;" from its inner aspect " septa pass, which map out so curiously the area of the diseased funiculus. These are composed of a nucleated fibrous tissue, very distinct and clear: the nuclei, varying in size, are granular; they have occasionally appeared to be free, and, when small, resembled at first sight the ends of the wasted nerve-tubules in a transverse section. The space inclosed by the septa is polygonal in shape, and from ^^ to y-gVir in. in diameter. It is occupied by a clear homogeneous, refractile substance, in which the altered nerve- tubules are imbedded; the latter are usually much changed, their medul- lary sheath corrugated, and their contents granular, uniform (?), and firm:" there may be simply empty walls, or " no trace at all." The Paccinian oontahi the same deposit, and the tactile corpuscles are atrophied. The skin is infiltrated by the same blastematous fluid, forming after a while a delicate network of fibres, in the interstices of which lie whitish granular and fatty matter; after a while the fibres go, and the foreign material is wholly cellular, the cells being oblong, with a very large nucleus, nearly filling the parent cell, and containing several distinct granules. The vessels and sweat-glands are after a while destroyed. G. Simon believes that the skin, the hair, sweat, and sebaceous follicles hypertrophy at the same time that there is a deposit of corpuscles, containing granules scattered through- out the meshes of the fibrous tissue. The bones are " rarefied " by " mole- cular destruction." As to the origin of the nerve disease, "it appears that, first of all, a clear material, probably albuminous, is deposited between the nerve-tubules, and in this nuclei, and subsequently fibres, are de- veloped, and the deposit itself may become fibrillated. The nuclei are often large, j^WJf, ygVo in- hi length, and -g-fo-Q in. in diameter, clear, round, and very numerous." The Causes of Elephantiasis are not well made out. The disease, accord- ing to Dr. Carter, appears in India to be most prevalent, as regards social standing, in the following classes:—Native Christians, Marathas or low- caste Hindoos, Mussulmans and Parsees, vegetable-feeding Hindoos, etc.; Europeans are generally exempt. There is some little difficulty in ascer- ' taining the influence of sex. The seclusive life of the females in countries where the disease abounds may explain in some degree the fact of its being more frequently seen in males. " In some of the leper asylums of the West Indies the number of the two sexes is about the same." The general opinion, however, is that males are much more usually leprous than females. Of 543 deaths in Bombay during twelve years 409 occurred in males; and yet of 906 leprous patients treated in St. George's Hospital at Bergen, Norway, from 1841-6, 461 were males, 445 females. It is common in Norway as in India, in the fish districts, where the folk eat quantities of foul fish; and Dr. Carter further observes, with regard to occupation, that many of the lepers " are fishermen, many ryots, all of whom lived more or less on rice and dried or salt fish;" but then it is common where these LEPROUS DISEASES. 163 conditions are not fulfilled. It is generally now regarded as havin^ a malarial origin. Hereditary tendency is certainly an efficient cause, and is most marked when it is on the male side, and if children are begotten by lepers far ad- vanced in the disease. Of 623 cases to which reference is made in the Leprosy Report of the College of Physicians, including those of Dr. Day, Dr. Porteus, those reported from Pooree, Nagpore, and Boeck's, in 287 cases an hereditary taint could be established, and many, it is well known, deny its existence in families where it is afterwards discovered. Age has some influence; the baras generally appears before the age of twenty, the tubercular sooner perhaps than the anaesthetic form, which gen- erally commences before the age of thirty. Damp and humidity, uncleanly habits, filth, and poverty, are conditions favoring the occurrence of elephan- tiasis. The anaesthetic disease is most common in India. Of 186 cases (Carter), 67 were anaesthetic, 40 mixed, 17 tuberculous, 14 exhibited the " baras" only, and 48 were cases of anaesthesia complicated with baras. There is no reason to think that syphilis has any relation to elephantiasis. In 64 of the 90 reports of Indian medical officers on leprosy, this connec- tion is absolutely denied. Leprosy is not contagious, it is believed. If it be so, it is held only to be so when the discharge from a leprous sore is in- oculated. The cause is probably a mixed one: it is a compound especially of bad hygiene, exhibited in the bad damp dwellings, the putrid and innu- tritions food, and the pernicious action of a malarial climate. There is, and always has been, a very wide-spread belief that the fish-eating population is peculiarly prone to the disease. Treatment.—This is preventive and curative. I only indicate the princi- ples here. AVe must prevent the inter-marrying of actual lepers; remove them from humid malarial localities; alter and correct bad modes of living in every particular; secure good exercise and a dry air ; if possible, a change of climate. In the actual disease, repeated venesection, counter-irritation of the course of the nerves, various baths, arsenic, mercury, cantharides, &c, have been tried, but with no avail. Hydrocotyle Asiatica, Ginocardia odorata, or chaulmoogra (used by Dr. Mouat), the Asclepias gigantea or mudar, are looked upon as specifics; lately Veronica quinquefolia has been praised : but all have failed. The local treatment by arsenic is recommended: an ointment, gr. x.—xxx. of arsenious acid to § j. of lard is rubbed into a patch about six inches large, for a fortnight, so as to produce pustulation. This is often followed by great relief, and the disease is treated bit by bit until it disappears—so it is said. I have seen much benefit produced by aperients, and subsequently large and continued doses of quinine. The leper is an outcast who is thought to deserve no comfort and very little\ attention; hence the treatment is of the most unsatisfactory kind. The whole gist of the latter part of the Leprosy Report is to show the de- cided benefit to be derived from the adoption of means to improve the physi- cal and moral condition of the leprous poor. There is no cure for leprosy; 164 LEPROUS DISEASES. medicine must therefore aim at its prevention. " It seems indisputable that as the agricultural and horticultural condition of Britain advanced and the diet of the working classes was bettered .... leprosy became less com- mon," &c. And in reference to India, the committee observe that, " with its 150,000,000 of inhabitants, the question of the food of the people, in its probable relations to the wide-spread prevalence of leprosy and other en- demic disorders, is a matter of the highest interest in an economical as well as in a scientific point of view. That a marked change in the habits of the native population will ensue upon the increase of divers industries, the im- proved cultivation of the land, the less frequent recurrence of famines, and the consequent amelioration of their general condition from year to year; and that better food, better clothing, and better housing, with greater per- sonal cleanliness, will lead to the abatement of leprosy—may be confidently anticipated."—p. lxxv. NGERENGERE. Ngerengere of the New Zealanders has been described by Dr. Thomson, and is clearly elephantiasis. Dr. Thomson's description is briefly as follows: —" It commences with a cutaneous eruption on the extremities, which ex- tends over the trunk of the body. The eruption presents in some parts the oval patches and the copious exfoliation of a brown scaly morbid cuticle ob- served in lepra vulgaris (?) ; the irregular patches of psoriasis, and occa- sionally the innumerable fissures, the elongated and extensive cracks inter- secting each other, of ichthyosis." There is frequently severe pruritus. The aspect of the disease is chronic, with a capricious course; the hair is gradually lost from the eyebrows, eyelashes, whiskers, beard—not the head, axillae, nor pubes, however. " The tattoo-marks are not affected." The mucous surfaces suffer, the voice alters, the eye becomes inflamed, the gen- eral surface livid ; " the face, nose, lips, forehead, eyebrows, become swollen and shining; but there are no tubercular deposits in them;" the skin is not anaesthetic to any degree. In about a year the distal bones of the ex- tremities (fingers and toes) are removed one by one by molecular or inter- stitial absorption; " a small boil or blister, or dry crack, appears in the direction of the flexures .... the soft parts ulcerate by a dry process; the phalanx falls off, and the part heals." This is repeated year by year, the fingers generally being " dry, shining, and scabby-like." Death ends the scene before the wrist is reached, by diarrhoea, bronchitis, &c. The general health is not materially affected in the early stages. The disease at- tacks people under thirty years of age, generally after twenty; and the great majority (five out of six) are males. It may attack several of the same family. The fingers are affected to a greater degree than the toes; its duration ranges five or six years. From this outline we readily see that the disease is true leprosy. t The Cacubay of Jamaica is probably leprosy. Now there are several other diseases in which the main feature is the de- LEPROUS DISEASES. 105 posit of fibrinous lymph in the derma and subjacent areolar tissue, either separately or both together, and these have some features therefore in com- mon with elephantiasis. They however partake, it is believed, more of the character of a local hypertrophy of the fibrous tissue of the attacked part, and I shall describe them under the head of atrophies and hypertrophies. The apparently connecting link between them and elephantiasis will be found in morphcea, which I have already noticed as a part of leprosy, but will describe more fully in the next chapter as a separate disease. CHAPTER XVII. HYPERTROPHIC AND ATROPHIC AFFECTIONS. I need not explain the terms hypertrophy and atrophy. Under these terms may be included all cases of wasting of normal tissues on the one hand, and unusual development on the other, and in the group, hypertrophy and atro- phy are primary. Now the forms of disease ranking here are— A. Hypertrophic Diseases.—1. Epithelial, including pityriasis, ichthyosis, and xeroderma; hitherto classed with squamous diseases. 2. Papillary: warts and the like. 3. Dermic, in which the fibrous tissue of the skin is primarily hypertrophied : including scleroderma, keloid, fibroma, bucnemia tropica, or elephantiasis arabum, and dermatolysis. 4. Vascular growths, such as naevi. The two diseases, ichthyosis and xeroderma, will be de- scribed under the sub-head of Developmental Diseases, at the end of this chapter. B. Atrophic: including general wasting, to which I need not particularly allude ; and linear atrophy, which will be incidentally noticed together with morphcea. I only deal then in detail with hypertrophic affections. It will be under- stood that no reference is made to secondary or accidental hypertrophy— the consequence of congestion or inflammatory conditions; but to those diseases in which hypertrophy is the prominent or only condition. I. HYPERTROPHY OF THE EPITHELIUM. I have been in a difficulty as to placing pityriasis, in which, as a rule, there is simply hyperformation of epithelial scales. I think it best to place it under the head of hypertrophies for the present. PITYRIASIS. This common form of disease may be discussed in a very few words. It is a primary form of disease—" a superficial cutaneous affection, sometimes accompanied by a slight rosy discoloration of the skin, or even a discolora- tion of another kind, but always exempt from those alterations of tissue which have been observed in the other elementary forms which we have de- scribed ; and which scarcely presents any other characteristic phenomenon than a desquamation of the epidermis; this latter is detached in small whitish lamellae, or falls off in a fine, and, as it is called (from its analogy with wheaten flour bran—furfur), furfuraceous or branny powder." There is no exudation into the skin in ordinary pityriasis. The local symptoms are itching and heat. The redness varies much. Authors have PITYRIASIS. 167 made four main species: P. versicolor, which is a parasitic disease, and will be found under the head of tinea versicolor, P. rubra, P. simplex, and P. nigra. The only varieties we need make are P. simplex and P. rubra, wlrich is an inflammatory form. Pityriasis simplex, according as it occurs in different situations, has received the appellations capitis, palpebrarum, pudendalis, oris, labialis, plantaris, pilaris. The history in all these cases is the same, a slight itch- ing red patch appears, and then white scales form thereon, which are con- stantly detached, sometimes a slightly red zone circumscribes the scaly spot; the scales are continually shed and reproduced; there are no other changes. The disease is met with on the bodies of delicate women and children, especially the head, where it constitutes one of the varieties of " dandriff." Pityriasis simplex is mostly a disease of early life. Pityriasis Rubra.—This is a form of disease in which the skin is acutely inflamed, with free scaliness and exfoliation of branny lamellar scales, but in which no " discharge " of any sort occurs. Instead of being local it is usually general, and as far as I have seen, the general symptoms are com- paratively slight. Hebra shall speak for himself. He gives the characters of the disease as follows :—" An intense redness of the entire skin, disap- pearing on pressure with the fingers, and displaying a yellowish ground; a constant exfoliation of fine, white, loosely attached scales; persistent deep redness, without infiltration ; papulae, fissures, moisture, or vesicles; scarcely any itching, and no excoriation. The disease begins suddenly, quickly spreads over the whole body, is rarely local; and undergoes scarcely any variation of appearance throughout its course, which may be prolonged for years .... After death it leaves no trace of its existence beyond the squa- mous state of the epidermis. In the early part of the disease the patient experiences no inconvenience whatever beyond the strange appearance; he pursues his ordinary avocations, and believes himself well; he feels by de- grees a sense of weakness and incapacity for exertion; his appetite fails, his muscular power drags ; he becomes emaciated, and finally sinks from ex- haustion." I have such a case under my care now, and I have seen it in children, in whom it produces also thickened plates, as it were, in the skin, that feel like a piece of dried bladder, and look yellowish ; it is the derma- titis of Dr. Wilks. There was a possibility of its being syphilitic in some cases. In children it has seemed to me to be less severe than in adults, and to affect a large portion but not the whole of the cutaneous surface. It has disappeared in the course of a few weeks in children, under the exhibition of tonics, diuretics, and the use of local emollients. The distinction between pityriasis rubra and general psoriasis is by no means clear in some cases. Pityriasis nigra is merely a patch of pityriasis, with pigmentation, and occurs perhaps in those who have visited hot climates. A word may be said in regard to one of the local varieties—pityriasis pilaris. In this disease the epithelial lining of the hair follicles is the seat of the disease, and in consequence of the collection of the thrown-off scales 168 HYPERTROPHIC AND ATROPHIC AFFECTIONS. in the follicles, the latter stand out as it were from the surface like little white hard dry knots (something like the surface of a nutmeg-grater), and from the summit of each a hair escapes. The knots are produced by an excessive collection of cells (epidermic), which distend the follicle also, and are very adherent. This is apparent on microscopic examination; of course the follicles are distended, and this is well seen in removing one of the little knots. It is seen after pityriasis rubra especially, and, according to others, after psoriasis of pretty general diffusion. According to Divergie, it occurs in little ovoid patches on the outer aspect of the forearm, the legs, the backs of the fingers, and occasionally all parts of the body except the head. There is a great resemblance between this disease and lichen scrofulosus of Hebra, if not an absolute identity. The reader should refer to the account of that variety of lichen. In cachectic and phthisical subjects pityriasia pilaris sometimes occurs. The shedding of the epidermis is due to the general disorder of nutrition. The Pathology and Cause.—The seat of the disease is no doubt the deep layer of the epidermis, and the nature of the disease an excess in the cell formation of the cuticle. This cell proliferation is an evidence of a some- what lower type of vitality, and implies nutritive debility. This may be the result of hereditary peculiarity, and it is certainly evoked by irritants of all kinds acting upon a debilitated system ; in some cases, deficient seba- ceous secretion seems to account for the malformation of epidermis. The use of strong soap may also be a cause. Diagnosis.—This is always easy. There is an entire absence of the phe- nomena of " discharge." In the simpler cases there is a little redness, and scales are formed from the outset of the disease; they are thin, white, and shining—branny. Pityriasis may be confounded with (1) Sebor- rhoea. The scales are dull white, and dirty; they stick to the surface, and are made up of epithelial scales, with a large amount of fatty matter; whilst the sebaceous glands are often distended. (2) Tinea circinata (pa- rasitic) should be known by its circular character, its " frayed " aspect, its clearing in the centre and extension at the edge by quasi-vesiculation, and the presence of the parasite detectable by the microscope. (3) Pityriasis rubra may imitate eczema and psoriasis ; but it differs from eczema by the fact that, though the skin is sharply inflamed, there is no " discharge," and the scales are epithelial and not " blastematous " or " corpuscular." There is also little infiltration, no vesicles, pustules, and the like, and little pruri- tus. Eczema, too, in the chronic " scaly " stage, is known by its history, and the cracked and uneven fissuring of its infiltrated surface. Psoriasis differs in the fact that the skin is involved to a greater extent than in pity- riasis rubra, by the thickening therefore of the derma, the hypertrophy of the papilla? of the skin, the larger and thicker scales, the cracks and fissures that are sometimes present, the well-developed patches about the knees and elbows. In all cases of scaly disease I hold that a microscopic examination PITYRIASIS. 169 I should be made, for by it we determine the epithelial, the fatty (seborrhoea) or the blastematous nature (eczema, herpes), etc., of the scaliness. Treatment.—In the case of pityriasis simplex, local measures Avill often suffice. Where there are symptoms of local irritation, redness, and itching, an ointment made of two drachms of liquor plumbi, a scruple of borax, and an ounce of lard will suffice. The principal object, as in so many other affections of the skin, is to soothe and slightly constringe. When the dis- ease has become chronic, stimulating applications may be used—the white precipitate ointment, the ung. hydr. nitrico-oxyd., or an ointment made of two drachms of ung. hydr. nitratis to an ounce of lard, are serviceable. But when the disease is more extensive, and the scaliness free, it is necessary to adopt general remedies. In this case I use a liniment of equal parts of olive oil and lime water freely, and subsequently nitric acid ointment (TIi,x. —TT[xx. to 3 j. adeps), and commence with tonics—iron, quinine, nitro-hy- drochloric acid, cod-liver oil, or arsenic, in case there be anaemia, dyspepsia, loss of flesh, nervous debility, etc. There must always be perfect cleanli- ness, thick greasy hair should be well and repeatedly washed, the food should be unstimulating, spirits and beer avoided if there be any " heating " with them. The bowels should be made to act regularly and freely. In chronic indolent cases, the following will be of use:—ammonio-chloride of mercury, and nitric oxide finely powdered, of each fifteen grains, olive oil and adeps, each an ounce, with some scent to make the embrocation pleasant. Another form empirically successful, is liq. amnion, fort. 3 ij., sp. rosmarini ? ss., gly- cerinae § ss., aquae § viij., to be used twice a day, a little borax ointment be- ing used after each application of the lotion. The mineral waters of St. Gervais, Aix-la-Chapelle, Pyrenees, Bareges, and Luchon are recommended. In pityriasis rubra the treatment hitherto adopted has been found most unsatisfactory. In children I have given usually diuretics—calomel gr. % to 1, nitrate of potash gr. iij., and Jacob's fever powder half a grain night and morning for a few days, slight aperients, then cod-liver oil and quina, with alkaline and bran baths. Lead and calamine lotion freely applied, without any irritating application, has seemed to help the cure in the course of a few weeks. In adults, matters are different. At this moment, a case is under my care at Charing-Cross Hospital, which has been saturated with arsenic. The patient took it for two years and a half, with calomel during a portion of the time. He got much worse, emaciated, suffered from colic, diarrlnva, and sweating, without any relief. With a course of nitric acid his health improved, the heat and painful feeling in his skin went, and he moved about with comfort; the redness and the shedding of the scales lessened; a course of acetate of potash and the use of plenty of grease, and some iodide of potassium ointment, have certainly improved his whole con- dition very much. I now purpose to exhibit phosphorus internally, and to employ nitro-muriatic acid baths two or three times a day, and if this fail, to give bicyanide of mercury and iodide of potash. See Formulae 34, 80, 81, 91, 95, 111, etc. 170 HYPERTROPHIC AND ATROPHIC AFFECTIONS. II. HYPERTROPHY OF THE PAPILLARY LAYER OP THE SKIN. There are four diseases which fall under this head ; but they require very brief notice. They are Verrucae or warts, Clavus or corns, Callosities, and a state called by Mr. Wilson Pachulosis. In all, the papillae of the skin are hypertrophied, ofteii, elongated so as to form pendulous tumors, whilst the epithelial cells are likewise produced in greater quantity than usual. Verrucas, or warts, are little raised tumors, sessile or pedunculated, hard, generally round, rugose, and mammillated. They are made up of coherent and enlarged papillae, each containing a loop of blood-vessels, and more or less nerve-tissue, especially at their base. I have seen them cover the face and present the appearance of disseminated lichen. In other cases they have been large and in mass. The pedunculated warts, the so-called acro- chordon, are often the emptied sacs of sebaceous glandular enlargements— e.g., molluscum. The sessile warts, or the true hypertrophous papillae, are seen mostly on the hands in children; they may be multiple, solitary, or aggregated in clusters, forming a flat mass or digitate. Warts are often the result of syphilis about the anus, vulva, penis, but may also arise from simple irritation. Verruca necrogenica is the name given by Dr. Wilks to the warty growths which occur on the back of the finger-joints of those who are much engaged in making post-mortem examinations. " They are brown circular raised patches of morbid epithelium, giving the appearance somewhat of epithelial cancer," and curiously enough, if removed, they grow again; they are caused by the acridity of the fluids of the dead body. I have seen one or two very curious examples of warts. On the little finger (at its outside) of a woman, for instance, a mass of warts packed closely together, and forming a patch If inches long and -1- inch in breadth; around the base it was hard, elevated, reddened, something like lupus; it might be called verruca granulata. The causes of warts are unknown; they appear sometimes to be conta- gious. The treatment consists in destroying the abnormal growth by caustics—the acid nitrate of mercury, caustic potash, arsenical paste, per- chloride of iron, or chromic acid ; the best is potassa fusa. Corns are simply a like condition to warts, only that the epithelium is peculiarly affected: they are brought about by pressure and friction; they are of three kinds—laminated (tylosis), fibrous (clavus), and soft corns.— (Wilson.) The laminated are the ordinary; the fibrous, the well-marked, old-standing corns; the soft occur between the toes, and being saturated with the secretion of the part, are moist and soft; generally tnere is some serosity effused under the upper layers, and this is discharged from a little central aperture. Mr. Wilson gives the name of pachulosis to the thick- ened state of skin which follows the healing in elderly people of ulcers of the legs; the skin is harsh, thick, and dry, etc. The treatment of these minor affections need not be detailed. The papillae of the skin may some- times enlarge so extensively as to produce horns—this is uncommon, how- HYPERTROPHIC DISEASES OF THE DERMA. 171 ever. Horns are usually sebaceous in origin. Mr. Edwards says that the microscopical appearances denote them to be an hypertrophied condition of the papillae, each containing one or more vessels and being covered by epi- dermis ; on section they have a " granular texture pierced with small ori- fices, and when dry, numerous concentric cracks." The orifices, on further inquiry, are found to be the sections of little blood-vessels; "a clear amber-colored circular area surrounded each of the vessels, which were separated by the general granular structure of the mass, incapable in the compact part of the horn of being reduced to its ultimate original elements." The structure appears to be best seen at the edge of the horn, where " the vessels are seen occupying the axis of the papillae, which are indicated by the clear cylinder area surrounding the vessels, the limit of the clear cyl- inder appearing to be the basement-membrane of the papillae, and pre- senting on an oblique section a somewhat jagged outline. The central parts of the horn are more compact and less vascular than the outside." I have seen several cases in which the individual papillae of the skin, especially in the face, have become enlarged, their vascular part being in- volved, yet not sufficiently (in excess) to make the disease naevus ; it was a general equable hypertrophy of the structures composing the papillae. Con- dylomata are hypertrophied papillae moistened by secretion, and containing rather more fibrous and elastic tissue than usual. Formulae will be found for caustic applications elsewhere. Callosities are merely hardened conditions of the skin produced by pres- sure, differing from corns rather in the fact that they are on a larger scale than anything else. I have seen them very large and hard on the front of both shins: blistering and iodine paint caused their absorption. We come now to III. HYPERTROPHIC DISEASES OF THE DERMA. Under this head are included all those diseases in which the fibrous tissue of the skin is in excess, and in which the disease extends to or involves the subjacent cellular tissue. They are (1) morphcea ; (2) scleroderma; (3) keloid; (4) fibroma; (5) bucnemia tropica; and (6) dermatolysis. My reason for placing morphcea in the group has been given. I repeat that it occurs in connection with veritable fibrous hypertrophy of the derma. MORPHffiA. This disease sometimes complicates anaesthetic leprosy, but may exist as a separate disease. It involves the whole thickness of the skin in all its parts. The disease occurs in non-elevated patches, in size from half-a-crown to several inches, wdiich, originally red, quickly becomes white, hard, dense, and anaesthetic in the centre. They are ofteii edged round with a network of vessels in the form of a lilac ring. The disease is caused by a deposit in the skin of a substance like lard, which presses on and obliterates the ves- 172 HYPERTROPHIC AND ATROPHIC AFFECTIONS. sels, hairs, glands, and nerves. When it is very white it is called morphcea alba; sometimes pigment is deposited, and then we have morphcea nigra. The whiteness is, however, generally very decided ; the patches look waxy, or like alabaster. Though there is no elevation, the skin is evidently thick- ened by the dense white deposit. The deposit is followed by considerable condensation. The epidermis is horny and sometimes yellowish, rarely dis- quamating. Once seen, the disease is never forgotten. In some cases the deposit of material is not so marked as in others, but there is atrophy to- gether with condensation; still, however, the erythematous circle. This is called morphcea atrophica. The skin is not polished, but white, dry, shrunken, parchment-like, anaesthetic, hairless. This variety is seen about the neck and the inner side of the legs. When it occurs in bands or lines it constitutes the " linear atrophy " of authors, which is seen about the fore- head, arms, legs, or even body. Of twenty-five cases collected by Wilson, "ten were atrophic, seven tuberous, five mixed, three melasmic; " eleven were unilateral, fourteen bilateral; the trunk of the body was affected in eleven, the legs and thighs in seven, the arms in six, and the submammary region in three. When it occurs on the forehead it takes the course of the supra-orbital nerve. In the last case I saw, separate grooves, the one in which I could lodge my little finger, the other a piece of ordinary stick pencil an inch long, were formed ; the edges of the spots were red, the cen- tres sunken, white, dense, and insensible. The nature of the disease is clearly a retrograde metamorphosis of the texture of the skin; a fibro-cellular degeneration. Where the deposit is well marked it might be called lardaceous disease. Morphcea occurs in ele- phantiasis, but also as a separate disease, and in connection with scleroderma. In some cases it is found to be associated with fibrous hypertrophy of the skin, taking the form of large bands or masses, and this associated form was clearly what Addison described as keloid. An examination of the models in Guy's Hospital has satisfied me on this point. In morphcea there is no elevation. We now come, however, to a disease in which the fibrous de- posit produces distinct elevation—viz., SCLERIASIS, OR SCLERODERMA. In some cases it is associated with the morphcea I have just described, and in others it exists alone as a separate disease. We find extensive de- posit in the skin in bands or lines, with condensation, and subsequent con- traction. This scleroderma is also called " hide-bound " disease. The hard- ness and stiffness may come on suddenly over a large extent of surface— from groin to knee, for instance. The disease generally commences by an induration or horny plate, and subsequently spreads in the form of bands ; these are raised, dense, often yellowish in the centre, fading away through a white color at the borders, into the hue of the surrounding skin. Pain may accompany this stage. There may be a partial border of vessels at the out- side : much distortion of contiguous parts, with puckering of the tissues SCLERIASIS, OR SCLERODERMA. 173 results from the contractile nature of the deposit; this is very well marked about the face and joints. The sensation of parts is impaired. The disease affects several parts of the body successively. After a while the skin becomes hard, shrivelled, parchment-like, the sensibility being distinctly diminished. The disease is more frequent in the female than the male, in thirty-seven out of forty recorded cases; it may attack infants, especially about the hips, thighs, back, buttocks, and elbows. In adults it occurs at a tolerably early age. A very good description of a case runs thus in the Lancet, 1855, vol. i. p. 239 :— " The induration and cicatrix-looking condition of the left arm and fore- arm peculiar to the disease. The appearance is not that of a tumor, but rather as if the arm had been burnt, and had left a leather-like hardness, which required surgical operation, as after a burn, to remove it; or it seems as if a bad erysipelas had become turned into cartilage and bone." Morbid . Inatomy.—More information is needed on this point. The following is a description of a case given by Forster, and quoted by Fagge :— " The affected parts are described as being of a yellowish or brownish color. The thickness of the skin was at least 3'" over the sternum and the clavicles, 1—1£'" on the abdomen, and 2—3'" on the anterior surfaces of the thighs, legs, and feet. " The state of the skin was essentially the same in all the affected parts. It could not be raised into folds, and was not in the least degree movable on the subjacent parts. It could be cut only with great difficulty, being in fact almost as hard as the sole of a boot. On the cut surface the first thing observable was that the distinction between corium and subjacent tissue seemed to be obliterated, a homogeneous, white, shining surface presenting itself. On closer examination, however, an upper layer of more uniform texture could be distinguished from a lower stratum, in which the fibres were arranged in meshes. It might have been supposed that the subcutane- ous tissue had entirely disappeared, but investigation showed that, besides the proliferation of the connective tissue of the corium itself, the areolar stratum beneath also had undergone a similar process by which it was con- verted into a substance resembling corium. The fat, however, had really completely vanished, a few rows of fat cells only being seen here and there in the microscopic sections. The elastic fibres seemed to have multiplied in the same ratio as those of the connective tissue, for they were present in due proportion. Except in the cicatrices, the papillae were normal; the cutaneous glands and hairs were unaltered, but seemed decidedly fewer than usual. The capillaries appeared not to have increased with the tissue in which they lay, but on the contrary, to be fewer than natural; but they had not undergone any morbid changes. Very few nerves were seen, but it is probable that they were merely hidden by the increase in the connective tissue. The insensibility of the affected parts during life was most likely due to the nerves being so closely enveloped in this substance, for when the 174 HYPERTROPHIC AND ATROPHIC AFFECTIONS. thickening had subsided at any spot, the sensibility had returned. The sclerosed connective tissue was firmly bound to the muscles, fasciae, and ten- dons, the normal loose intervening tissue being entirely absent." Recently Dr. Rasmussen has written an admirable essay upon the sub- ject, and in the post-mortem of one case affecting the chest he found the epidermis thick, and beneath it a dense whitish fibrous substance, extending down in some places to the ribs; the glandular tissue of the left breast and some of the intercostal muscles were replaced by fibrous tissue. The pleura costalis opposite the locality of the changed skin, the diaphragm, and the capsule of the liver, were indurated in little tubercular masses. On micro- scopic examination, the epidermis was found to be of the ordinary thickness, the papilhe normal, the corium rather broader than normal, the connective tissue below much hypertrophied, and studded with spindle-shaped cells; the small arteries were surrounded by closely aggregated cells, like lymph corpuscles; the peripheral oblong, the outermost spindle-shaped and separa- ted by a homogeneous or slightly fibrillating membrane. Indeed, the vessels were ensheathed in this lymphatic tissue. The hair ducts and nerves ap- peared to be unchanged. It is clear that the seat of the disease is the con- nective tissue and the corium. The disease, too, is an hyperplasia of the areolar tissue, invading the normal structures, and gradually obliterating them—ex., papillae, nerves, vessels, hair-sacs, etc. But what is the origin of the hyperplasia ? Rasmussen thinks the dis- ease commences by infiltration from the lymphatic vessels (lymphatic oedema of Virchow) into the connective tissue, the hardness being produced by the free development of cells in the fluid effused. This second stage, he thinks, is the only one generally mentioned, the first, or erysipelatous inflammation of the lymphatics, being overlooked. Rasmussen declares that the changes in scleroderma are the same in kind as those seen in the bucnemia tropica, or elephantiasis arabum, and he thinks the seat of the disease is in the lymphatic system. The small arteries are surrounded by a sheath of lymphatic vessels, which furnish the lymph out of which cells are formed in the connective tissue at a very prodigious rate. He has accordingly proposed to call the disease elephantiasis sclerosa. But what of the relation of " morphcea," which is common apparently to true leprosy and to scleroderma ? Is it simply lardaceous disease ? Is it that the deposit affects especially the nerves, and sensibility goes as a con- sequence; or is it that the deposit is the consequence of disorder primarily in the nerves ? I incline to the former of these two opinions. The cause of scleroderma is not understood. The Diagnosis offers no difficulty ; the indurated, hard, tense, contractile bands are sufficiently distinct. It is certain that the morphcea may be the early stage of scleroderma. Treatment is not promising. The opportunities of seeing scleroderma are so few that no definite principle of treatment is laid down. The pre- parations of iodine with iron, cod-liver oil, nitric acid in large doses change RHINOSCLEROMA. 175 of air, chalybeate baths, and inunction with black oxide of copper, gr. ij. ad 3 j. (Rasmussen), are those most usually employed. In regard to morphcea, tonics, especially the mineral acids and iron, by improving the health, help its removal, and as the general condition im- proves so does the local. Exception may be taken to the position which I have assigned to mor- phcea and scleroderma, but I regard it as a tentative one for the present. RHINOSCLEROMA.* Hebra has described in the Wiener Medizinische Wochenscrift, January, 1870, a peculiar new formation about the nose, which he has named Rhi- noscleroma. He says:—I have had occasion, in the course of several years, to observe a skin disease in nine individuals (four men, five women), which, by having its seat either on the nose or in its immediate vicinity, as also by the peculiarity of its phenomena, presented itself as a malady sui generis. To form an idea of it, a substantial syphilitic sclerosis of the prepuce, in optima forma, may in imagination be transplanted to the external nasal structures, in one case even to the alae nasi, and in another to the nasal ridge; to the mucous surfaces which form the borders of the nasal cavity; or lastly to the skin of the parts surrounding the nose, as the upper lip, skin, forehead. Among the nine observed cases there were only two which presented the disease on the nose, cheek, and forehead simultaneously; in the others it was confined to the nose and upper lip alone. As a flat swell- ing, it projected as much as 14; lines in some places, its extent being always limited by a sharp border, with steep edges. The color of this new forma- tion varied from normal skin color to a dark reddish brown. The upper surface of the diseased places was always smooth, rarely shining. The most striking objective symptom consisted in the extraordinarily complete indu- ration of the affected places, which had an almost ivory-like feel. Besides this, the patients experienced but little pain, and usually only when the formation presented itself localized on the inner surfaces of the nose, and when these prominences were pressed. In all cases the development progressed very slowly, requiring several years before the trouble had acquired dimensions which obliged the patient to seek medical aid. The impression made upon me by the first case I saw, was that of a syphi- litic disease, as the brownish-red, pea-like elevations had localized themselves partly on the upper lip, partly on the inner surface of the alae nasi and sep- tum, after the manner of a circumscribed tubercular syphilide, and only differed from the ordinary characteristics of that affection by the unusual hardness of the morbid production. It chanced that soon after, during treatment of the first, a second case was admitted to my division in the General Hospital, which, besides the hard tubercle of new formation on the * From the American Journal of Syphilography and Dermatology, April, 1870. 176 HYPERTROPHIC AND ATROPHIC AFFECTIONS. nose, also presented all the pathognomonic symptoms of an acute specific ulcerative angina, so that I was only the more confirmed in my opinion, and looked upon the malady as the result of syphilis. The treatment by inunc- tion was now introduced in both cases, with the daily administration of two pints of Zittmann's decoction, with the local application of emplastrum hydrargyri to the hard protuberances on the nose and upper lip, a treatment by which, if, however, sometimes only temporarily, syphilitic products are always induced to undergo retrograde metamorphosis. But in the cases mentioned, this treatment was entirely insufficient; for although the pha- ryngeal ulcerations of the second patient healed and cicatrized in the usual manner, the extent and induration remained undiminished. A similar in- effectual result was experienced from a continued treatment with iodine, so that my opinion of a syphilitic origin of the malady wavered. It was, how- ever, more shaken by further observation of cases. Thus, the third case was that of the mother of a royal officer of high rank, an elderly lady, who had suffered from this malady for many years, and had been treated at dif- ferent places and times and in manifold ways by other physicians,—with mercury, iodine, arsenic, and nevertheless presented a slightly enlarged nose, of the hardness of ivory, and of a bluish-red color. The fourth and fifth cases again occurred in men, with the same symptoms, course, and similar obstinacy to all medical treatment. On the upper lip there were several tubercles partly crowded together, and partly connected, having the size of peas and the hardness of ivory, from which a portion was removed to ex- amine their structure microscopically. At the same time in this case, the whole of the left nostril, skin, and cartilage had the ivory hardness, and was distorted upwards and outwards, not, however, differing in color from the healthy skin. The most beautiful and instructive cases of this rare disease are, however, those which at the present time are under my observation. Two of them present the tuberculous indurations principally on the nose, especially on the inner surface of the alae nasi—in one female patient a tubercle is also situated on the outer surface of the right half of the nose ; the third female patient, however, not only presents a completely indurated nose of a dark- red color, but also three ivory-like pale-red protuberances surrounding it. Two of these are situated, one on either side of the nose, extending from the inner canthus to the upper lip—which remains intact—and not only completely fill the depression between the side of the nose and the cheeks, but also overlap with their particularly hard sharply-margined edges, the surface covering the zygomatic arch, from whence they slant towards the nose. The third protuberance is situated on the os frontis, has a length of one and a half inches, and width of a half inch, and extends from one eyelid to the other; it is similar in color to the normal skin, and somewhat less indurated than the two lateral ones, but pressure on the eyelids prevents their opening. When I saw this last-mentioned case, I recollected having seen a fcimilar RHINOSCLEROMA. 177 one in Paris in the year 1852, in an elderly lady. As I did not visit the lady as a physician, but was only introduced to her as a guest, I could make no inquiries concerning her history or the physicians who attended her, in order to consult with them about this, at that time, to me, puzzling disorder. I afterwards ascertained that her attendant was a homoeopath, a powerful invasion against the malady had, therefore, not been instituted, and that the trouble remained in statu quo up to her death. After having given a sketch of the cases observed up to the present time, we find the following characteristics common to all:— 1. In their constant seat on the nose, and sometimes also in its immediate vicinity. 2. In the extraordinary induration of the affected parts. 3. In the exceedingly slow development of the pathological product, which appears either in the form of dark, brownish-red tubercles or knuckles, or as induration of the normal appearing tissue. 4. In the sharp margination of these indurations, and the absence of all oedema or inflammatory symptoms in the vicinity. 5. In the absence of all apparent metamorphosis of the new formation, as it neither degenerates, ulcerates, softens, nor is absorbed. 6. In the failure of all internal treatment, even with the strongest agents. 7. In the absence of all danger to the system at large, even in case of its existence for many years. 8. Lastly, in the insensibility and painlessness, when the diseased parts are left untouched, severe pain on the contrary, when the dark red tubercles are pressed. As the localization of the trouble in the face in eight out of the nine cases rendered it impracticable to remove even small particles of the new forma- tion with scissors, we had to defer the microscopical examination until the acquisition of an appropriate case. When, at length, such an one presented itself, the apex of the isolated tubercle was removed, and carefully examined by my assistant, Dr. Moriz Kohn; he found the epidermis and the layer of the rete Malpighii of nor- mal appearance. Between the elements of the latter especially there were no abnormal occurrences. The papillae were somewhat longer than usual, conical or knobby ; their external connective-tissue structure markedly wasted ; the connective tissue of their body only present as a network of delicate fibres and small inter- vals ; their blood-vessels scarce and thin. The connective tissue of the vas- cular stratum also present only as a pale, thin, delicate network of fibres. This network of the vascular layer and of the papillae was filled with small cells, crowded closely together, and the infiltration of cells, at different places extended down deep into the corium, was, however, found regular, . and close only in the vascular stratum and in the papillae, which latter es- pecially appeared stuffed with cells. The cells were smaller, especially in 12 17S HYPERTROPHIC AND ATROPHIC AFFECTIONS. the protoplasma, than the granulation-cells as a rule are, as we meet them in acutely or chronically inflamed tissues, and in places where the formation of new connective tissue is in progress. The nuclei of the cells were small, little refractive, and finely granulated. The cells appeared simply stored away in the delicate connective-tissue structure of the papilhe, and the upper layers of the corium, and by agita- tion were easily displaced. The deeper layers of the corium showed a close connective-tissue arrange- ment, which had remained more free from the described formati ve elements. The layer of fat-cells normal. Only spare cells in the fibres of the connec- tive tissue net here present, and there principally in the vicinity of the vessels. Sebaceous and sudoriferous glands could not be found in the sections ex- amined. The hair-bulbs, external and inner root-sheath of the hair, were free from all foreign formative elements, while the papillae bordering on the hair follicle appeared crowded full of the above-described cells. The above-described sclerosis of the skin is, therefore, by this explana- tion a cell-infiltration of the upper layers of the corium and the whole papil- lary body. The normal structure of the affected tissues has thus far suf- fered* by the massively accumulated new formative elements, so that the connective-tissue structure of the papillae, and of the upper part of the corium, is forcibly separated and crowded out, and its elements are re- newed. The cells of the new formation nowhere exhibited that pale, dusted (fine- ly granulated), indistinctly nucleated, not sharply contoured appearance (so-called degeneration) of the cells in syphilis and lupus; but they ap- peared well preserved, with sharp contour and distinct nucleus, and imbibed carmine well. We believe, on the strength of the above microscopical characters, which certainly made the clinical facts in the character and course of the new for- mation intelligible, though only imperfectly explainable, that this rhino- scleroma may be placed histologically next to the glio-sarcoma or granulation- sarcoma (Virchow, Billroth). In conclusion, I may be allowed to state something regarding treatment, hitherto of but little avail. In two cases, where the tubercles projected from the inner surfaces of the nostrils into the nasal cavity, and effectually prevented the ingress of air, I have destroyed the tubercles with caustic potassa in substance, and after separation of the slough, have produced cicatrization by a, frequent coating with concentrated solution of nitrate of silver (aa. p. aeq.). Compressed sponge introduced was effectual in pre- venting contraction of the cicatrix, and thus the perviousness of the nasal entrance, and the possibility of unimpeded ingress and egress of air, was maintained. It is of importance to observe that after destruction of the new formation with caustic potassa no regeneration took place, as this is observed in other formations, as for instance, epithelioma, and also that the KELIS AND KELOID. 179 neighboring morbid product was neither disposed by the induced action to retrograde metamorphosis, nor to more rapid development. KELIS AND KELOID. There is another hypertrophic growth of the fibrous tissue of the surface having a close resemblance to scleroderma, and called kelis or keloid. The kelis of Addison is the morphcea I have described. The difference between keloid (as I shall continue to call it) and scleroderma consists in the fact that in keloid the corium, and not the cutaneous areolar tissue, is the seat of the disease, the hypertrophy forms a distinct circumscribed raised tumor; the disease is more limited, and it is more vascular. It was described by Alibert as cancroide. It is not cancerous; it is rare ; does not ulcerate ; does not implicate the glands; and is not destructive to life. The name keloid was given to it from the resemblance of offshoots to the claws of a crab. It is characterized by the occurrence at first of flattened swellings, generally oval in shape, palish, or deep rose in color, and shining; the cen- tral parts generally become depressed, and processes (claw-like) run away from the edge of the patch into the surrounding part. Sometimes at other parts small, flat, pale, red, or sand colored elevations, the size of split-peas, or a small nut, make their appearance. It is usual to describe two forms— the keloid of cicatrices, or false keloid, developed in old scars, burns, wounds, etc., and the true keloid, or kelis, a form of disease which is primary, and very frequently possesses many distinct localities of disease (it is described above). It is often seen on the chest. The false or spurious keloid—viz., that which follows scars—ex., those of burns, scalds, rupia, boils, or even the use of acids, is the commoner variety. The keloid of cicatrices usually begins as " very hard, small, shining, tubercu- lar-looking elevations, of a roundish or oval shape, somewhat firmly set, of a dusky or deep red color, and generally attended with itching and pricking, shooting or dragging pain in the part," which is the seat of a scar. These tubercles increase in size and grow pale, flatten out and become depressed in their centre, which is marked by white traversing lines or bands, and a few straggling vessels. The increase takes place by means of offshooting lines, which run away from the edge of the tumor, claw-like processes ; they are £ to 1 line broad by 1^ to 1 inch long; the growth is slow, and may affect the whole area of the burn or scald, the site of which, in fact, becomes hard, leathery, and raised. Dr. Longmore describes it thus, in a case which occurred after flogging: —A small round tubercle, which became a flat mass nearly as large as a man's hand, without pain; there was some irritability, and it was tender where pressed upon by the cross-belt and the weight of the knapsack : on the front of the chest several small tumors, evidently of the same nature, were observed. So that we get in this form a result which is admirably described in a case of keloid following a burn, under Mr. Curling's care, as follows :—" The whole has assumed a keloid state ; it is thick, bossy, indu- 180 HYPERTROPHIC AND ATROPHIC AFFECTIONS. rated, looking remarkably as if very luxuriant and elevated granulations had healed over, and then, instead of shrinking, had undergone consolidation and some increase." As Mr. Wilson has it, " false kelis appears to be the joint result of hypertrophy, condensation, and concentration of the white fibrous tissue of the skin, and by a special power of contraction would seem to draw the rest of the cicatrix to itself, and produce a puckering of the adjacent surface." In fact, the keloid of cicatrices is but the hypertrophied fibrous tissue of the scar. Morbid Anatomy.—Keloid is merely hypertrophy of the white fibrous tissue of corium. The growth is made up of closely-packed fibres with many nuclei, but few vessels. The fibres of the areolar tissue do not " con- stitute curly bundles but thick trunks, the firmly compressed fibres of which run at first in an almost straight direction, gradually separate from one an- other, and finally fall into several distinct bundles, which, vibrating in curls, after repeated subdivisions, are at last in nothing distinguishable from nor- mal areolar tissue:" the trunks are closely compressed and interlace. " The tumor is supposed to be formed by a few vessels passing through a capsule of areolar tissue, supplying the plasma from which the fibres are developed." (Dr. Benjamin.) Diagnosis.—The elevated tuberculous tumor, with the claw-like processes, the puckered state of the skin, the absence of ill-health, of glandular enlarge- ment and ulceration, are diagnostic. The false keloid of cicatrices and true keloid, or kelis, only differ in the fact that one is idiopathic and the other secondary to cicatrization following lesions of the skin. Some observers have noticed yellowish points at the apices of the tubercles—a commencing fatty change. The Treatment of keloid consists in improving the general health, and then a course of liquor potassae, or the iodide of ammonium or arsenic. Locally, the use of steady and continued pressure, iodine frictions, the pas- sage of electric currents through the tumor, and iodide of lead ointment. It is useless to remove the tumor by caustics or the knife; the less inter- ference the better. BUCNEMIA TROPICA. Elephantiasis, as I have before noted, in its widest signification, includes two very different diseases; the one E. Arabum or Arabica, or Barbadoes leg, properly Bucnemia tropica; the other E. Graecorum, the true tuber- cular and anaesthetic leprosy. The former (bucnemia) is essentially a hyper- trophy of the cellular structures : it attacks the lower limb particularly, and is said to have no relation to true leprosy. Bucnemia tropica, Spargosis, or Barbadoes leg, probably sporadic every- where, as its name expresses, is common at Barbadoes; and especially in Cochin China, West Indies, Egypt, Malabar, some parts of South America, Abyssinia, and the Polynesian Islands. The disease usually attacks the legs, and is mostly confined to one; but it may affect the face, neck, belly, BUCNEMIA TROPICA. 1S1 breast, pudendum, the arms, and scrotum—in Egypt it is called sarcocele. It lasts a variable time, possibly a lifetime ; attacks all classes, and is non- contagious. It is marked, when fully developed, by three features:—(1) Hypertrophic growth of the cellular tissue ; (2) alteration in the aspect of the skin; (3) more or less deformity. And these are brought about as the result of intermitting and repeated attacks of inflammation of the lymphatics. In well-marked cases the disease is ushered in by distinct febrile symptoms, vomiting and headache at times, and locally, redness, pain, and tension over the course of the lymphatics, which presently feel knotty and corded; the glands are swollen and tender. The constitutional symptoms soon vanish-T- in a few days; but the limb does not resume its natural size; the glands especially remain enlarged. A repetition of fever occurs at uncertain inter- vals, and after each attack the enlargement is permanently greater; and it has been ascertained, from careful observation, that the size of the affected part bears a direct relation to the frequency of the acute attacks of fever and local inflammation. The pain, in the first febrile attack severe, is slight in subsequent ones. During the progress of the disease, deposit and thick- ening have been going on in the skin and subcutaneous tissue—hence the sensibility of the part is somewhat lowered; but, unlike that, in the true. form of elephantiasis, is never annihilated, nor indeed seriously lessened. The swelling in the disease may be pretty uniform or partial; sometimes it is enormous, as when the disease attacks the scrotum; then it has been known to produce a pendulous tumor of sixty pounds weight. The skin undergoes distinct change; it is tawny, hard, dark, livid, thickened ; often scaly and fissured or grayish ; presenting warty projections, especially about the joints; the veins are varicose, the surface then closely resembles the skin of an elephant. The subsequent changes are ulceration, with sprouting granulations (fungous), suppuration, and foul discharge. The glands par- ticipate in this action. The disease may carry off the patient by hectic. Frequently its progress becomes stationary, and the patient gets about as best he can with his unsightly deformity. The palms of the hands and the soles of the feet generally escape. In this country a similar condition fol- lows chronic ulcers of the leg; the limb enlarges, and its fibrous element hvpertrophies so that it is nearly twice its usual size. The average size of 340 cases, round the ankle, Mr. Waring found 11T\ inches. Here are the particulars of a scrotal tumor removed successfully by Dr. Thebaud. It reached to within five inches of the ground; it was 28 inches long, 20 inches in its bilateral diameter, its widest circumference 48 inches; and it weighed G3| lbs. when removed, and the opening of the penis was 18 inches from the surface. The Pathology of the disease appears to be well made out. It is, as shown by actual observation, a hypertrophy of the derma and subcutaneous tissue, with the effusion of a blastema, of homogeneous aspect, mixed up with a large number of molecules, granules, free nuclei, and nucleated cells. The epidermis is more or less affected—thickened ; but this varies in many 182 HYPERTROPHIC AND ATROPHIC AFFECTIONS. cases. The cutis is thickened, the papillae are distinct and prominent, the subcutaneous cellular tissue (areolar, fatty, and elastic elements) is present in excess, and infiltrated by the blastema just spoken of. The veins are distended, the lymphatics obliterated; the muscles often pale and fatty. The internal organs also are frequently in a state of fatty degeneration. The blastema, when first effused, is slightly milky, and contains albumen, some fibrine, etc. The primary seat of the disease is the blood ; locally the lym- phatics are primarily affected. Causes.—The disease is not hereditary, and not contagious. It attacks males more than females; according to Mr. Waring's observations 75 per cent, of cases were males and 25 females. It is most frequent between the ages of twenty-five and fifty. Of 945 cases collected by Mr. Waring, 729 occurred in people whose ages ranged between twenty-six and sixty; 139 between five and twenty-five; and 77 after the age of sixty. In 5*65 per cent, true leprosy is conjoined. The date of its first appearance is noted also: existing since childhood in 16 cases; appearing before the fifth year, 7 cases; between six and ten, 33 cases; between eleven and fifteen, 111 cases; between sixteen and twenty, 222 cases. As to the part affected, it was the right leg alone, or with other parts, in 307 cases, or 32 per cent.; the leg alone, or with other parts, in 287, or 30 per cent.; both limbs, &c, 344, or 36 per cent.; other parts alone in seven cases; the upper limb in four cases. This agrees with Mr. Day's researches in Cochin China. He found that the disease attacked the lower limb in 93 per cent. In 224 out of 226 cases in which the point was • examined, Mr. Waring found the febrile attack primary. Euroj)eans are less liable than natives to be affected. Among the causes, hot climate and malarial emanations are supposed to haA~e some influence. Mr. Waring thinks that the character of the water used by the inhabitants has much to do with the disease: " the sea-water, penetrating through the porous sand, renders the water saltish and brackish, and as the generality of these pools are surrounded by trees, it in addition soon becomes loaded with dead vegetable matter, which undergoing decomposition, renders the water dark (almost black) and highly offensive to the taste and smell, which even boil- ing and filtering fail to deprive of its unwholesomeness." Prognosis.—The disease is chronic. Mr. Waring found, in 218 cases, the duration of the disease range between twenty-six and fifty-five years. If the disease is rapid, the febrile paroxysms severe and quickly recurrent, if there be much suppuration, and the general health be indifferent or bad, the prognosis is grave. Treatment.—\w the acute state, venesection, leeches to the lymphatic ves- sels, fomentations, rest, position, cold lotions. Internally, salines, mercuri- als. In the chronic state, friction, pressure (continuous), bandaging, blis- tering ; and, mternally, iodide of potassium, liquor potassae, bromide of potassium: and, as a last resort, ligature of the main artery running to the limb or tumor; pressure; and rest. Mr. Waring recommends quinine. Dr. FIBROMA. 1S3 Vanzetti has successfully employed compression of the arterial trunk sup- plying the affected part. Dr. Buchanan explains the action of this proced- ure thus:—Tying the main artery does not reduce the size of a normal leg, but does that of an elephantiasic one, because the organs of absorption act differently upon normal and abnormal tissues. The activity of absorption, as a general rule, is in inverse ratio of that of circulation. When the force of circulation is weakened, the process of absorption is unusually energetic. This applies particularly to non-malignant deposits ; and absorption being once started will often go on of itself. Thus, when a blister starts the ab- sorption of an old effusion, that absorption will sometimes continue on un- aided, and this is why in elephantiasis, after the operation, collateral circu- lation being soon established, absorption of the morbid material goes on. FIBROMA (MOLLUSCUM SIMPLEX). As in keloid we saw that as compared with scleroderma, there was a ten- dency to greater prominence of tumor and less condensation, so in fibroma another stage is reached, for the outgrowth of fibrous tissue is freer, and there is little condensation. This form of cutaneous hypertrophy has gen- erally been classed with sebaceous disease, but wrongly so; it is not due to dilatation of a sebaceous gland, but is simply an hypertrophic growth of fibrous tissue, which becomes more or less pedunculated—it is in fact a polypus of the skin. In the early stage there is a softish tubercle of the same color and consistence as the natural skin; it may be sessile, but soon gets pedunculated, and then gradually increases in size until it may at last assume the bulk of an orange. There may be one or several tumors. Pro- fessor Ebert records the case of a man in whom there were 107. I saw a case of Hebra's, at Vienna, in which the whole body was covered by these tumors (of all sizes) ; one was nearly as large as a fist. The tumors are seen especially on the neck and chest, more uncommonly on the legs. The dis- ease occurs in elderly people, and is not attended with any special danger. When small the tumors resemble warts. Pathology.—Dr. Beale, some twelve or thirteen years since, gave a de- scription of one of these small tumors, and nothing could indicate more clearly the nature of the disease—viz., an hypertrophic growth of the fibro- cellular element of the skin. He found that the gland-ducts could be traced independently of the tumor, being, however, often pushed aside or other- wise interfered with. A section of the tumor exhibited spaces left by the separation of fibres, and these were filled with cells. Dr. Beale concludes that neither the sebaceous nor sweat glands, nor their ducts, were concerned in the formation of the tumors;—that the disease is really a morbid altera- tion of the structures concerned in the formation of the hair, particularly the deep cells of the follicle. Dr. Beale also noticed that the subcutaneous areolar tissue was hypertrophied. I should add that the hair-follicles and hair are only altered by the pressure of the tumor. The main characteristics, as compared with keloid and scleroderma, are, 1S-4 HYPERTROPHIC AND ATROPHIC AFFECTIONS. the free outgrowths and the absence of any condensation—the new tissue is lax and open. The Diagnosis must be made from sebaceous cysts especially : in a cyst the origin from a fat gland : the central aperture or entrance to it, and the fatty contents which can be squeezed out, determine the nature of the disease. The Treatment is simple : when small, remove. In elderly men they are sometimes small, flat, and numerous, especially about the back, over the shoulders, and on the chest. I have never had the least trouble in getting rid of them all by the use of acid nitrate of mercury caustic to the smaller, and the joint use of that remedy and the ligature to the larger ones. I generally, after applying the acid, give an oxide of zinc paste to be used, to prevent too much irritation. There is yet another form of fibrous hypertrophy, in which greater laxity of tissue is observed. It is called— DERMATOLYSIS. In this affection the skin hangs in loose folds. Its fibro-cellular element is greatly increased. The affection really includes all pendulous conditions, from obesity, parturition, the state of skin in lax and enlarged mammae and the like. Valentine Mott has called it pachydermatocele. In the uncomplicated form of disease, the hypertrophic growth arranges itself in layers like the folds of a tippet; there is little vascularity; the sensibility of the part is diminished. Five chief seats of disease are mentioned by Alibert—the eye- brows, the face; the neck, the abdomen, and the labia. Mr. Furneaux Jordan has described what appears to be the same disease, occurring in a collar-like mass around the ankle. I saw at the Orthopaedic Hospital, some few years since, under the care of Mr. Adams, an instance of this disease affecting the whole leg, and associated with pendulous folds, lax and soft, on different parts of the body. GENERAL REMARKS ON THE GROUP. Now the six diseases that I have placed together in this section of the work are specially characterized by hypertrophy of the fibrous element of the skin; in morphcea there is no elevation, but condensation is specially marked, and the whole derma, and probably the cellular tissues, are affected. In scleroderma, the corium and the cellular tissue beneath are affected, whilst the papillary layer remains apparently uninvolved : there is still con- densation, but more prominence. In keloid the corium is specially affected ; there is less condensation, and the papillary layer of the derma is more or less involved, whilst in dermatolysis we have still less condensation and more prominence. The essential nature of the change appears to be the same in each case : the quantity of lymph and its contractile quality varying much. GENERAL REMARKS ON THE GROUP. 185 But what I wish to insist upon is this: that microscopic examination (especially that made by Rasmussen) has shown that the changes in parts other than the fibro-cellular element and the lymphatic system are second- ary. For some time the blood-vessels, nerves, and glands are unaltered, and they are only changed by the accumulation and pressure of the foreign deposit. The disease does not commence in them; but then comes the question, what is the origin of the change in the fibrous tissue ? Does it originate in it? and what is its connection with disorder in the lymphatic system ? Some few years since I attempted to prove, and the papers are published in the " Obstetrical Transactions," that the fibrous deposit ob- served in phlegmasia dolens is connected with disorder of the lymphatic system, as contrasted with the oedema that arises from venous obstruction simply, and I argued that the lymphatics were specially concerned in the nutrition of the cellular tissue; that there was a constant flow of lymph from the arterial capillaries to the cellular tissue, to meet any unusual re- parative demands (the cellular tissue being the material for the repair of wounds), that the lymphatics seem to regulate the supply, and remove all that is not required; lymphatic obstruction, therefore, means hypertrophy of the fibro-cellular tissue (if suppuration do not occur). To that opinion I hold: the history of bucnemia tropica (which lymphatic inflammation is the first and necessary stage), and the researches of Forster and Rasmussen (showing in scleroderma, alterations in the lymphatics) clearly point in the same direction, and I am convinced that we shall some day connect these hypertrophies of the dermal tissue with some disorder of the lymphatic vessels. In fact, Rasmussen notices that an erysipelatous attack precedes scleroderma. It is thought that the changes in the skin in morphcea, sclero- derma, and the like, are the result of primary disorder of the nerves ; but I think in that case we should have more evidence of disordered sensation as an antecedent, and more atrophy ; and, moreover, we should not have hyper- trophy. That is my difficulty in allowing that the mischief is in the nerves primarily; as it is, the anaesthesia or perverted sensation is a late feature, and follows the deposit in the skin. Upon the supposition that the lym- phatics are mainly concerned in the regulation of the nutrition of cellular tissue, it is easy to see that keloid may very likely arise in cicatrices, the material of which is cellular tissue. However, I am quite convinced of one thing, that lymphatic obstruction means the collection of a large amount of fibrinous lymph in the meshes of the cellular tissue (supplied by the blocked-up vessels), which may be utilized to form the proper fibrous tissue. We see this on a small scale, as the result of the obstruction to the lymphatic circulation that occurs, in cancer. This same theory of the office of the lymphatics accounts for the. similarity that exists between the skin changes in bucnemia, morphcea, scleroderma, and keloid. Some author- ities believe that elephantiasis Graecorum is an ally. As a result of those special conditions that generate elephantiasis, deposit may take place in the whole skin, which hypertrophies; the deposit is found round the nerves 186 HYPERTROPHIC AND ATROPHIC AFFECTIONS. and the vessels, and morphcea results ; atrophy and anaesthesia do not result till the vessels and nerves are seriously involved. The primary change is in the areolar tissue, rather than the nerves. It will be recollected that Dr. Carter has pointed out that the site at which the nerve-trunks are specially affected is the spot where they perforate the fas- cia. On the whole, then, we must agree that an examination of the pathol- ogies of elephantiasis, scleroderma, keloid, morphcea, show a close similar- ity in the seat and character of the changes in the skin, tend to prove that the lymphatics in each case are specially concerned, and that the material of infiltration by its presence and pressure produces anaesthesia, serious dis- turbances of the nerves (marked in elephantiasis because of the degree of disease), and more or less obliteration of the vessels and ducts. Whether the material deposited is the same in kind in all cases cannot be fairly de- cided at present. As I have said, I feel sure some of the diseases, which I have described under this head, will come to be regarded as in great[measure diseases of the lymphatic system. I regret that we are so much in the habit of ignoring the influence of the lymphatics in the production of disease. DISORDERS OF THE VESSELS, OR VASCULAR AFFECTIONS. This group includes those diseases of the skin which are called naevi, and also varicose veins. A naevus is simply a hypertrophied state of the vessels of the skin, occupying a greater or less extent of surface, from a pin-point to a whole region, or almost limb. They may be congenital or acquirea. When the venous tissue predominates they are called venous, and when the arterial capillaries are most concerned, arterial naevi; the color is brighter in the latter case. In both classes the depth of surface affected varies. When it is superficial and slightly raised, and the venous radicles are affect- ed, we have the port-wine mark or claret stain. Naevi are oftentimes asso- ciated with pigment deposit in them, and may be covered with hair. Some undergo little change; -some steadily increase by the hypertrophy of old, or the development of new tissue; the latter- assume the aspect of what are called erectile tumors. Microscopic examination shows that the coats, cali- bre, and radicles of the vessels are all hypertrophied and enlarged. Nae- vus araneus is the. name given to a small naevus of accidental origin, in which there is a central prominent red spot—an aneurismal dilatation of an arterial loop—with veins radiating therefrom. Hypertrophy of the veins proper is frequently seen, and may be caused by obstruction to the onward flow of blood, or a natural want of tone in the vessels. It occurs about the nose very frequently, and in the veins of the leg, as varicose veins. Treatment.—If small, naui may be destroyed by caustic. If they show a tendency to enlarge, nitric acid should be applied to the extending edge, and the patch destroyed by degrees. In some instances excision is the most easy and rapid mode of cure. When the naevus is extensive and venous, DEVELOPMENTAL DISEASES. 1S7 we may pass threads through various parts of the mass, leave them for twenty- four or forty-eight hours, till some slight irritation is set up; then remove them, so that the growth may be obliterated by inflammation. Or we may inject perchloride of iron ; but the silk-thread treatment is much the best. Hence nitric acid, excision, and the use of silk sutures are the chief means of cure. So-called pigmentary naevi are rightly described under the head of Maculae. It should not be forgotten that purpura has been shown to be probably connected with special morbid changes in the capillary blood-vessels; this is referred to under the head of Purpura. Under this head may be noticed another mixed form of tumor, to which the name of naevoid lipoma is given. Mr. Erichsen has described it as fol- lows :—" It is a tumor in which the naevoid structure is conjoined with or deposited in a cellulo-adipose mass. This disease is invariably seated upon the nates, back, or thigh. It occurs as a smooth, doughy, indolent tumor, incompressible; not varying in size or shape; without thrill or pulsation of any kind, possibly having a few veins ramifying over its surface, but no dis- tinct vascular appearance. It is usually congenital, or has been noticed in early life." After removal it is found to be composed " of a cellulo-adipose base, having a large number of veins ramifying through it, so as to consti- tute a distinct vascular element communicating-with small cysts containing a bloody fluid." DEVELOPMENTAL DISEASES--VIZ., XERODERMA AND ICHTHYOSIS. I thought it unnecessary to make a separate group of the two forms of the same disease—xeroderma and ichthyosis—the main feature of which in each case is the free formation and accumulation of epithelial scales, inter- mingled with more or less fatty matter, and forming branny scales, or hard, horny, platy masses. It has been usual to describe a true and false ich- thyosis according as the scaliness was made up of epithelial cells mainly, or associated with fatty matter in large amount. I quite agree with Mr. Hutchinson that the distinction is less real than is generally supposed—the difference is one of degree, not kind. Now ichthyosis as a primary form of disease is not inflammatory, but often hereditary, and mostly congenital. In it the perspiratory function is arrested, the whole tone of the skin is lowered, and, as before observed, the epithelial cells are not properly though freely formed, and together with the fatty matter of the glands collect into plates or masses. The dry state of skin is remarkable. A caking on the surface may result from sebaceous flux, and this will be described under the head of glandular diseases; it is different from ichthyosis, a congenital disease associated with a generally disordered state of skin, which is not present in sebaceous flux. The least expressed form of the disease is called :— XERODERMA (DRY SKIN). In this variety of disease the surface is peculiarly dry, harsh, ill-nourished, 1S8 HYPERTROPHIC AND ATROPHIC AFFECTIONS. and wrinkled, instead of being soft, elastic, and smooth. It seems as if the skin had not been developed so as to keep pace with the growth of other parts. There is less subcutaneous fat than usual, and therefore the natural lines and furrows are mapped out very distinctly. The skin looks dirty, the nails are ill-formed, but, more than this, the surface is covered by thin cuti- cular scales or plates, free and loose at their circumference, but attached in their centre. The aspect of the scaliness varies somewhat; it is mostly fur- furaceous on the head, in plates on the face, farinaceous about the eyelids, the neck, and the trunk, where it is also scaly. When the scaly condition is well marked, the variety is termed ichthyosis squamosa, or simplex. Now the whole skin is involved in this want of development. The glands, there- fore, do not secrete properly—the perspiratory, hence the dryness ; the se- baceous, hence the collection of altered sebaceous matter with the epithelial scales into large plates or horny masses. The disease when marked consti- tutes :— ICHTHYOSIS. But it will be understood that xeroderma and ichthyosis are degrees of one and the same thing, only in the former there is chiefly epithelial squama- tion and less fatty matter secreted; in the latter the sebaceous secretion does not pass away insensibly as usual, but gets incorporated with the epi- thelial cells into plates, which are hard, dry, and dark-colored, and vary very considerably in thickness. I have lately had two patients in whom the xerodermal form coexisted with the horny variety of ichthyosis. Now, ichthyosis may be divided into I. squamosa, I. spinosa, I. cornea, or hystrix. These terms sufficiently explain themselves. The disease may be in large plates, or in spines (porcupine disease), or in extensive patches, dark or black, having the aspect of the bark of a tree. The masses can be picked off, and the skin beneath looks dry and shrivelled; in some cases the openings of the sebaceous follicles are seen to be somewhat dilated, and on the under surface of the detached plate are seen little plugs which have fit- ted into the ducts of the sebaceous follicles. In. other cases, about the ankle, etc., the papillae of the skin may be considerably hypertrophied. Pa- tients affected by any form of ichthyosis are somewhat thin perhaps, they feel the cold weather terribly, and when this is severe or windy the skin becomes irritable, tender, and often cracks. The parts especially affected are the knees, elbows, and those about the ankles, the wrists, and the axillae. But the degree of surface over which the disease is marked varies; it may be pretty general or local, but however extensive it is, the skin generally is dry, harsh, mapped into small spaces, and scaly. When the disease is local- ized, the legs, ankles, and forearms, and parts about the elbows, are specially the seat of the horniness. Etiology.—Ichthyosis and xeroderma are often congenital, at all events develop very soon after birth. Ichthyosis is frequently hereditary, and affects the same sex through different generations. ICHTHYOSIS. 1S9 Pathology.—The scales are made up of epithelial cells, intermingled with a varying amount of fatty matter, with or without hypertrophy of the pa- pilhe of the skin. It is the general want of development and arrest of nutri- tion of the skin which makes the disease a separate and distinct disease, as contrasted with pityriasis and the like. Treatment.—I have been pretty successful in getting patients into a con- tinuously comfortable condition. In the first place 1 am careful to see that patients are cleanly, that they are well fed and clothed. I then give cod-liver oil, and such remedies as quinine. I don't exhibit arsenic. Lo- cal remedies are the most important. In xeroderma, any plan which sys- tematically keeps the surface greased and slightly stimulated will benefit. It is immaterial what grease is used, elder-flower ointment is as good as any. In the homy forms of disease, a clean surface may be very readily obtained by careful soaking with glycerine, by poulticing, or foment- ing. The best plan is to use an alkaline bath, or, if the disease be too extensive, a warm alkaline (potash § ss. to § viij.) lotion, to soften up the masses. After these are removed in part by picking them away, the whole surface can be greased, and an alkaline bath used twice a week, § iv. to § vj. of carbonate of soda and bran, to the usual quantity of water. In this way the disease may be controlled so as to prevent it being not only a dis- figurement but a discomfort, save with occasional attention in winter. SPURIOUS ICHTHYOSIS. I had better repeat that the spurious ichthyosis is that form of disease in which the amount of fatty matter is large as compared with the epithelial. CHAPTER XVIII. PARASITIC DISEASES. These are such as are necessarily connected with the development and growth of parasites, and they may be divided into two classes :— A. Dermatozoic, or those produced by, or associated with, the presence of animal parasites. B. Dermatophyte, or those in which vegetable parasites are concerned. I do not now refer to disease connected with parasites found in the interior but only the exterior of the body. We are ignorant of the exact kinds of soil which are favorable to the growth of parasites. The attacked surfaces are certainly not those furnished by healthy people. In animal parasitic diseases uncleanliness plays an active part. Vegetable parasitic diseases occur in "lymphatic" subjects. The parasitic animal or vegetable having found a congenial soil, produces certain results, which are diagnostic. Independently of this, in all instances the parasites act as local irritants in common with a host of other things. Parasitic disease is really composed of three conditions :— a. A suitable soil. b. The parasite. c. Certain lesions produced by the parasite (whatever it may be which is present) which are characteristic, as the acarian furrow in itch, or the brittleness and dryness of the hairs in ringworm. In addition there may be secondary or accidental features, such as ecthy- matous spots in scabies, chronic lichen sometimes following an attack of itch, suppuration of the sebaceous glands in ringworm, &c. The characteristic lesions of course will be fully detailed in the descrip- tion about to be given of the various forms of parasitic disease. A. The Dermatozoic, Ectozoic, or Animal Parasitic Diseases. These are as follows :—Scabies or itch : trichinosis (? disease of the skin) : phtheiriasis, morbus pedicularis or pedicular disease : those associated with, the development of " bots," the chigoe, the dracunculus, the leptus, the flea, the bug, various gnats, and lastly the steatozoon folliculorum. The latter parasite is referred to under the head of acne. Some of these require but little notice. The flea (Pulex irritans) makes its bite and produces a little circular erythematous spot, with a dark speck in the centre, marking the wound made by the insect; the irritation may extend, but generally quickly subsides, leaving a little dark ecchymosed point smaller than a pin's head behind. The bug (Cimex lectularius ANIMAL PARASITIC DISEASES. 191 or Acanthia lectularia) produces a rather more marked condition of things ; there is a good deal of swelling, a little infiltration of the subcutaneous cel- lular tissue, in consequence of which the part or spot feels tumid, hot, and tender: little " bumps" of this kind are noticed oftentimes all over the body. The central point is not dark but light, and exhibits the bite of the insect. It cannot well become the subject of mistake. The best treatment is the application of a little spirit lotion. A form of urticaria may be caused by the impaction upon the surface of the little hairs of some of the larvae. The attacks of the leptus autumnalis, or harvest bug, are well known as producing erythema and papulation. Sometimes the skin, especially in the South Americans, is the seat of the development of the oestrus, the " bots," or " gadfly," as it has been variously termed. The larvae burrow under the skin, giving rise to " circumscribed furunculoid tumors " the size of a nutmeg, which appear to give exit by a small aperture to a sanious discharge. Presently these open and leave ul- cers behind. The insect is called the mosquito-worm : it bears close resem- blance to the oestrus bovis. In a case reported by Dr. Duncan, there was " a little lump at the back of the neck, which slowly changed its position in various directions ; then a hole opened over it, and a worm was squeezed out." Two or three similar occurrences took place. It appears that the patient (a girl) had herded some cows in Perthshire. The larvae were those of oestrus bovis. Dr. Spence has seen people in Shetland attacked by the same thing. " The larvae occur in exposed parts of the body, and in those who are loosely dressed." The disease is essentially characterized by the presence of little painful lumps, which shift about: a little red ecchymotic line marking the track of the insect. The parasite is the oestrus bovis, order Diptera. The chigoe (Pulex or Sarcopsylla penetrans), or chiggre, is a common cause of disease in the West Indies. The chigoe attacks the feet and hands, entering the skin beneath the nails or betwixt the toes, either by a channel made for itself, or by the ducts of the skin: it takes an oblique direction under the epidermis, and its tract is said to be traced as an " elongated brown spot." As the insect gets deeper, this goes. " The hands and feet of the parasite then become hidden beneath its own stomach, which enlarges rapid- ly, the upper part alone of the insect being perceptible through the epider- mis, under the form of a milk-white spot. This spot enlarges considerably daily, until it looks like a large freckle, insensibly meanwhile changing its milk-white color to a pearly gray. By the time the animal is ready to de- posit its eggs, it has become, says Dr. Guyon, literally all stomach, and this period may be known by the ashy-gray color of the eggs, which are visible through their transparent envelope. The eggs now come forth one by one with astonishing rapidity, following each other through the layer of the epi- dermis, wlrich reopens for them the passage previously made by the entrance of the parasite. The departure of the eggs brings to a termination the existence of the insect. It then perishes, attached entire, head, feet, and 192 PARASITIC DISEASES. stomach, to the epiderm which had enveloped it, and with which it is carried finally from the individual in whom it had fixed itself. The best time for extracting the insect is just before the emission of the eggs; if they are left to be hatched beneath the skin, great irritation and painful sores are sure to result." Some curious facts have been further noticed. In some cases of elephantiasis ('? which) certain little openings are seen in the skin, and it is said that from thence chigoes make their exit. When the insect reaches the dermis with his proboscis, " it establishes between it and the dermis an intimate circulation, which is demonstrated by the movements of the systole and diastole of the heart of the subject being seen in the whole parasitical body, and by the vascular connection which is wonderfully perceptible as the vessels are becoming distributed for the nourishment of the eggs." The vascular supply springs from one main trunk, and vessels run off from this; the main supply terminates in the end of the head or sucker, and, curiously enough, the movements exhibited by it are synchronous with those of the heart of whatever animal the chigoe fastens upon. The treatment consists in dilating the original channel of entrance, and carefully removing the chigoe bodily. THE GUINEA-WORM DISEASE. This affection is due to the presence and growth subcutaneously of the Dracunculus, or Filaria Medinensis, and is found only in certain tropical parts, chiefly of Asia and Africa; it does not acclimatize itself to cold climates. The chief places where it is found are Senegal, Gaboon, the East Indies, Bombay, Persia, Arabia Petraea, the shores of the Ganges, Upper Egypt, Nubia (especially about Sennaar, Kordofan, Darfur), and Guinea and the Gold Coast. It has also found its way to Grenada and the Island of Curacoa. It has been met with not only in man, but the dog and the horse. It is much more prevalent at some times than others, especially in wet and rainy seasons, and after inundations, when it gives rise to epidemic disease. [According to recent observations, it is rendered probable that some of the microscopic filaridae or tank-worms, as Dr. Carter styles them, gain an access to the skin, and there develop into the Filaria Medinensis. These worms are found in stagnant waters of pools and swamps, where the dis- ease is endemic. At the time of entry into the body, their size is about tsVo °f an inch. The bare-footed natives are mostly attacked, and in above four-fifths of all instances the full evidence of the affection shows itself in the legs below the knees. These worms possess a greater or less degree of boring property. After the first entry into the skin, a " latent period," as it is termed, of from six to fourteen months is passed before any perceptible result takes place. The head begins to make its way to the surface and local irritation is set up, and an abscess threatens ; this presently forms opens, and part of the worm protrudes; the worm is solitary hi the sac though there may be several abscesses or foci of disease. The worm can be THE GUINEA-WORM DISEASE. 193 drawn out a little way. Its average length is eighteen inches ; it may be much longer—three or four feet in the African species. It is milk-white, cylindrical, slightly flattened laterally, and tapers towards either end. It is about y'gth or T'^th of an inch in thickness.] The Mode of Attack.—When the worm is very minute it finds its way to some part of the surface, generally the bare feet, and " bores " its way deeply into the skin, where it takes up its abode. It grows in six months or so in a perfectly quiescent state, as far as the patient is concerned, till it reaches a length of from six inches to two feet or more, half or two-thirds of a line in thickness, and looks like a bit of whipcord, pointed at either end. When it reaches a largish size, the worm begins to find its way to the surface. A boil appears, this breaks, and the worm protrudes; a good deal of irritation of the general system follows, and the sufferer is disabled for a while. The worms have the power of travelling from place to place over the body. It is generally felt under the skin as a " cord." The particular Part of the Body attacked.—In the vast majority of cases the lower extremities are the seat of guinea-worm disease. About 1,000 cases have been collected together by a writer from the Indian jour- nals, and in more than 98 per cent, the worm was found in some part of the lower extremities, and in the largest proportion about the feet and the ankles. Kuchenmeister quotes 172 cases of Mr. M'Gregor, and in 124" of these the feet, 33 the lower part, and 11 times the upper part of the thigh, and twice the hands were affected ; exceptional conditions are readily explained either by the migration of the worms or other circumstances. The water-carriers, or Bheestees, in India, who carry a " mushuk " or leathern bag suspended from the shoulders, according to Ninian Bruce, are most subject to the guinea-worm in those parts which come in contact with the mushuk. This is presumptive evidence of the strongest kind that the worm is derived from without, and that it takes up its abode first of all in those parts which come in contact with the ground, or with articles that have been in contact with the ground. Of 300 cases noted by Dr. Horton, in 206 the disease was in* the feet. The Immediate Cause.—Much difference of opinion has been held in regard to the true cause of guinea-worm disease. Two things are nowa- days accused of the mischief—1. The soil and the pools; and 2. The drink- ing water of the localities where the disease is found. If the drinking water had any influence, the worms should be found in the stomach and adjoining parts, and generally distributed over the body; besides, the dis- ease occurs in persons who drink water of the very best kind, and in those who never take it at all. Kuchenmeister relates the case of a friend " of Jacquin who, when in Curacoa, did not drink a drop of water, which, as a lover of spirituous liquors, was not very hard upon him; but he was at- tacked by the worm, whilst Jacquin, who drank much water, remained free from it. A Dutch general in Angola ate and drank nothing but food and beverages brought with him from Europe, and yet he acquired the worm." 13 194 PARASITIC DISEASES. There seems little reason to doubt that the worm finds its way almost invariably—practically always—direct from the ground to any unprotected part which is brought in contact with it, and, in virtue of its boring pro- perties, it effects an entrance. The leg is the part usually unprotected and exposed, and the frequency with which it is affected points to this view as the correct one. Then, where are the worms originally found ? They would seem chiefly to abound in stagnant pools and swampy places, for there is a large amount of evidence to show that bathing in ponds and pools where tank-worms and creatures of a similar kind exist is followed by the development of guinea-worm disease. Dr. Carter has given valuable evi- dence on this point, and Dr. Balfour, in his health report of the Secun- derabad troops. In a very philosophical account of the Structure of Guinea- Worms, by Dr. Bastion, a case is related which illustrates the way in which the disease is contracted. A surgeon who had been many years in Bombay, and who had drank freely of the waters of the wells without ill, says:— "At last, however, I one day discovered that I had what at first appeared to be varicose veins, but which in a day or two I found to be guinea-worms in my legs. At first I was at a loss to account for the presence of a guinea- worm in my body, till I remembered that one day whilst out shooting, one of my boots burst, and being too impatient to wait till another pair was brought, I took off my boots and stockings and went on shooting barefooted over a piece of swampy stubble ; and I believe that the worms entered my feet on this occasion." The entrance of the worm to the backs of water- carriers is explained in a similar way. But though the germs of the worms exist in stagnant pools and ponds, there is abundant evidence to show that the worms may be got from damp and swampy places ; so that sleeping on the ground bare-skinned would suffice for the purpose. It has been stated that Europeans are not subject to the attacks of the dracunculus. This is altogether a mistake. The immunity of Europeans is to be ascribed to the fact of their feet and legs being protected by proper coverings. It is the experience of those who have seen much of the disease, that where Euro- peans adopt the habits of natives and go shoeless, they are equally liable to be infested by the dracunculus. Treatment.—When the worm has lodged itself in the body for several months, as before stated, it makes its way to the surface, and should then be seized and traction gently made; as much as will come forth readily is bound round a stick, or a piece of card, and fastened over the wound. This operation of "winding" the worm is repeated daily, and at the end of several weeks the whole is removed, and the wound heals. If the worm be broken, and any portion be left, the seat of disease is attacked by severe inflammation. Dr. Horton states that the use of assafcetida at once deter- mines the cure; it destroys the worm, and prevents inflammation and sup- puration. In the case of the leg, amputation may be required to be per- formed to save life. The secondary results are, according to Dr. Horton, stiff joints, contractions of the muscles, talipes, swellings about the malleolus, PEDICULAR DISEASE. 195 mortification of toes, enlargement of the scrotum and testicles, enlargement of the breast, and bucnemia. Dr. Horton has recently written an admirable essay on the subject, con- taining his experience of the disease on the Gold Coast, and I heartily recommend it to my readers. THE TRICHINA DISEASE. This disease, which is attracting so much attention, I have no right to discuss here. I name it for completeness' sake. PEDICULAR DISEASE, MALIS PEDICULI (WILSON), OR PHTHEIRIASIS. There are three species of pediculi or lice infesting the body,—the P. capitis, the P. corporis vel vestimenti, and the P. pubis, or head, body, and pubic louse. It is a disputed point whether they be the real cause of dis- ease or only a complicating source of irritation. The pathognomonic evi- dence of the presence and attack upon the skin of pediculi is the louse bite—the' flat and reddened papule with the central dark puncture or wound made by the insect. Whatever else occurs (excited, it may be, by the irritation set up, and the consequent scratching) depends in greatest measure upon the special nutritive condition and tendencies of the attacked in each particular case. In one instance it will be -pig. 3. prurigo, in another ecthyma, and in a third, urticaria; or an impetigo in the case of the scalp. Pediculi, be- yond the production of louse bites, acts in a precisely similar manner to irritants in general; and the im- petigo following or evoked by the presence of pedi- culi, depends upon the impetiginous tendency, just as much as the urticaria so produced is due really to a hypersensitive condition of the sympathetic nerves of the skin. Some additional remarks will be found under the head of prurigo. Sometimes lice are produced in great numbers, and, it is said, subcutaneously. This is certainly incorrect. I i i i i ..... The P. corporis is whitish, and gives rise to erup- 100th parts of an inch. , , .,, „ ™ n / r± aj \ Pediculus corporis (female). tions, already described. See Fig. 3 (after Anderson). The Pediculus capitis is seen mostly in children, and in association with impetigo. See Fig. 4 (after Anderson). The P. jiubis grasps the hair, a little way from the surface, and gives rise to pruritus, erythema, and eczema. See Fig. 5. The Treatment consists in the use to the head of ammonio-chloride of mercury ointment; the same, indeed, to the body and pubes ; or bichloride of mercury lotion, with baths, plenty of soap and water, and, if necessary, sulphur or cinnebar fumigation. I have not thought it necessary to enter. more fully into details. 196 PARASITIC DISEASES. SCABIES, OR ITCH. This a most important disease to be well acquainted with. Its frequency is extreme, its features definite, and its facility of cure is certain. But mis- takes are very frequently made in its diagnosis. Scabies is a contagious disease, depending essentially on the burrowing of the acarus scabiei : and the female is the burrower. In from ten to thirty minutes after being placed on the surface, she gets beneath the skin, and busies herself with the commence- ment of a canal, or cuniculus, as it is called, in which she lays her eggs, from about twenty-four (Hebra) to fifty (Gudden). She, of course, gradu- ally enlarges her canal (which is arched) until it reaches a quarter to four Fig. 4. Fig. 5. ' eggS 0f the acarus ln v™* "taees of de- velopment 6 ft, egg-shells; c c, fragments of acari; a, female acarus; e, larva. The little oval or irregu- larly shaped masses are supposed to be excrement. • [I have met with a small species of tick in man. Various species of gnats are apt to inflict wounds, especially in the summer-time, which resem- bles musquito bites. Musquitoes have not been known to exist in Eng- land. The so-called musquitoes, whose existence in England and other places has recently been asserted, are all British gnats. The females of the common gnat ( Culex pipiens), every summer, after hatching out from water tanks and open ditches around houses, attack the exposed parts of the body, and there are many other species of the same genus Culex. The musquito of the Riviera is also a Culex. But there are midges, some of which are called sand-flies, which inflict wounds on the body. Such is the opinion of Professor Westwood. The treatment of erythematous « bumps," caused by the bites of gnats, may be relieved by a weak solution of bichloride of mer- cury or carbonate of ammonia.] THE SO-CALLED " ARMY ITCH." 203 THE SO-CALLED " ARMY ITCH." It has been asserted by army medical officers of late years, that there ex- ists a special form of disease amongst soldiers, which has not been described hitherto. It is engendered mostly by a camp life, but is also seen in recruits, and amongst the poor in the vicinity of camps. To this disease the term " army itch " has been applied. It is said to have no relation to scabies. The American military surgeons are reported to have seen a good deal of it during the recent civil war in their country, as the following quotation from Dr. Hartshorne's handy little work, entitled "Essentials of Medicine," shows:—"During and since the late war in this country, the inevitable filth of camp-life begot, among other evils, a very troublesome contagious skin-disease, called by the above name. Itching, without any eruption ex- cept small papula?, characterizes it. Outside of the army it has extended to a considerable number of persons. No better remedy for this affection, I believe, has been found than a lotion and ointment, composed of iodide of potassium and glycerine; with water or rose-water for the lotion, and lard or cold cream for the ointment. Mercurial ointment, and sulphuric acid ointment, are also efficacious for it." Dr. Hartshorne, it would appear, does not think that the disease is scabies. Being desirous of obtaining as many particulars as possible, I wrote to sev- eral of the leading men of the army to ask for special information touching the existence and nature of this so-called " army itch." Professor Maclean "has been kind enough to reply as follows : " I know nothing of the so-called ' army itch.' The disease (scabies) as seen in soldiers, presents no peculiari- ties of which I am aware. I have shown your note to several experienced and very careful medical officers at Netley; they all agree with me." In- spector-General Dr. Lawson, C.B., remarks : " In reply to your question regarding itch in the army, so far as I have seen, the disease which is usually so denominated is really scabies in the first instance, but under the influence of irritating applications, whether ung. sulph. comp., sulphuret of lime, or carbolic acid, etc., too long continued, a new eruption is brought out, occasionally like prurigo, more frequently eczematous in its character, which may be mistaken for scabies, and if under this impression the treatment be continued, the secondary affection may be- come troublesome, and continue for a long period. Occasionally there is an inadequate diagnosis, and a case really of prurigo is treated as if one of scabies; but this, in my experience, has not been very frequent. " Thirty years ago, when I first entered the army, the usual treatment for scabies was inunction of the whole body with compound sulphur ointment, and the usual period of treatment was three to four days. I soon found that the ointment caused much irritation of the skin in many persons, and brought out an eruption of eczema, and in consequence, with my own regiment, diminished the period of treatment in nearly every case to two days only, which overcame the original disease, and did not develop the other to any troublesome extent. 204 PARASITIC DISEASES. " We tried carbolic acid for several months last summer, for the treat- ment of scabies, at Aldershot, but the opinion of the medical officers was by no means favorable to it. It seemed to be less certain in destroying the in- sect, and more apt to excite eczema than either the sulphide of lime or the sulphur ointment, and was at last abandoned. " I trust this statement will meet your desires." The facts mentioned by Dr. Lawson are most important, and entirely coincide with similar experience of my own in regard to the treatment of scabies. It will be seen, then, that scabies offers no peculiarities when it occurs in soldiers. It is, however, often followed by various secondary eruptions. But these latter are not those which constitute the so-called " army itch," of American authors especially. That is a primary form of disease, having no relation to scabies, so it is affirmed. Dr. Hartshorne observes that it is contagious. I am not aware that this is thought to be the case by English army medical officers. But allowing that the " army itch " is not scabies, how does it arise ? In many cases it seems to follow the undue physiological excitement of the perspiratory function, caused by residence in hot climates, especially in those who are possessed of the rheumatic diathesis. There is considerable disorder of the sensibility of the skin, succeeded by a lichenous, prurigi- nous, or eczematous eruption. Through the courtesy of Dr. Gordon, C.B., I am enabled to give the fol- lowing interesting particulars relating to the disease, which he has been so kind as to obtain for me. The account of " army itch" given by Dr. Perry is especially interesting and valuable. Dr. Sinclair writes touching the disease : " Nothing of this kind was noticed in the men of the 33d Regiment in Abyssinia, though they wore one suit of clothes by day and by night for nearly two months, only taking them off to wash occasionally. A good deal of redness and scalding was produced by the friction of the trousers at the fork—nothing more." Dr. Lamprey writes:—" No case of ' army itch' occurred in the 67th Regiment while serving in China, although the reputed cause of that disease was in excess there, no Asiatics being more troubled with pediculi than the Chinese, who have a saying that not one man in ten, no matter how high his rank may be, is exempt from body lice. Of course our men, who were much in contact with the Chinese of the poorer sort, were not exempt from lice, especially during the winter months, but I did not notice any prurigi- nous results. I fancy the good sanitation observed with regard to housing, clothing, general cleanliness, exercise, and more especially abundance of good wholesome food, and of fresh meat in their dietary, kept the skin in good order, and proved good preservatives against the disease. For the same reason, cases of common scabies were not frequent, though the Chinese are particularly addicted to that disease also, their food consisting chiefly of vegetable ingredients, and meat being rarely and sparingly used. It is THE SO-CALLED " ARMY ITCH." 205 generally believed that Chinese itch is particularly virulent and difficult of cure. I have certainly seen some very angry-looking pustules arising from it, but I have not found any case resist the ordinary sulphur treatment." Dr. Perry's experience is contained in the following letter to Dr. Gordon dated Royal Artillery Hospital, Portsmouth, 29th September, 1868 :—"In relation to our conversation respecting what is called ' army itch,' and the information Dr. Tilbury Fox seeks regarding it, I now send you an extract from my reports for the year 1862-3 :—< Speaking of the sanitary condition of the 6th Brigade Royal Artilleryv as relates to the bedding, supplied to it, I am still of opinion that the substitution of hair, fibre, wool, cotton, or even sea-weed (zostera marina), for the straw now used for stuffing the beds, would be beneficial, and, in the end, justify the expense. Considering the very frequent change entailed by straw beds, and the uncertainty of the straw used being perfectly free from parasitic or insect life, it becomes an open question whether or not one of the diseases affecting soldiers may not be referable to its use. For some time past a complaint closely simulating itch in many of its characters, but which is not amenable to the ordinary treatment for that disease, has been very prevalent among the troops in this district, and has by some medical officers been confounded with scabies. It appears, however, to be a composite affection, having several different symp- toms, and being a mixture of ordinary lichen and prurigo with herpes and eczema, occasionally taking on the graver form of impetigo. At present no cause can be discovered for the affection, and though diligently sought for, no acarus has been discovered. The impression among the men is that " the blankets have something to do with it," and it appears to be just such a complaint as might have become induced by some irritating agent derived from the straw composing the beds. The suspicion that it was so induced arose in my mind from my having seen many cases of a similar description in the workhouses of Hampshire, the disease occurring amongst tramps and navvies who, as the nightly occupants of the casual wards, had nothing but straw to lie upon, and in whom, to my own knowledge, the sulphur plan of treatment proved useless. It might have been but a mere coincidence, and atmospheric influences alone the cause of the complaint, but to a certain ex- tent these views have been borne out by observation lately made in America, where in the Federal army a bastard kind of measles was apparently in- duced by a fungoid condition of the straw used by the soldiers as bedding. Careful examination of the straw used by the Royal Artillery in Ports- mouth was made, but the microscope failed to discover any parasitic growth attached to it. Still the interesting fact remains that in all probability a diseased condition of straw is capable of exercising evil effects upon those using it as bedding, if the American observations are correct.' Some time after the above remarks were written I had a conversation with Mr. Eras- mus Wilson upon the subject, and his opinion was that the complaint had been introducd into England by the army from the Crimea, that it had at first attacked the poorer population, but was gradually affecting persons of 206 PARASITIC DISEASES. higher social status. He was under the impression that the persulphide of calcium (which has been used for so many years past in the army for the cure of scabies) would also cure the complaint in question ; but my experi- ence is against such, as although I have found sulphur occasionally do good (probably where, also, there is a complication of scabies itself), yet that it would not'entirely eradicate the disease so closely simulating it. The best remedy for the complaint I found to be the following as an external appli- cation :— " !>. Zinci oxidis 3j-, hydrarg. ammon. chl. 3j., acidi hydrocyanici diluti 3 ss., glycerinse ^j.: ft. lotio; and the following mixture internally:—1$ Ext. taraxaci § iij., liquor hydrarg. bichloridi § xvj., vini colchici f ij., tinct. cardam. co. § iv., aqua ad Oij.: ft. mist., a dessert-spoonful twice daily in a wineglassful of water. The above mixture was made in the quantity named because so many men suffered from the complaint. " Occasionally I have found the disease prevail among the recruits drawn from the neighboring counties, and uppn one occasion I well recollect a young man telling me that it had become known amongst his friends by the name of' Dorsetshire itch,' and that a doctor had also told him it was so. At the present time the complaint is hardly known amongst us; but at the time I have alluded to, it was so prevalent, and its character so little known, that many medical officers were considerably troubled with its treatment; and to my own knowledge one medical officer recommended that the bedding of a whole battery of artillery should be burnt, in consequence of its pres- ence amongst the men." Dr. Marston, of the Royal Artillery, amongt others, obtained various specimens of suspected straw from different sources at Portsmouth, and sub- mitted them to careful microscopical examination, but did not discover the presence of any fungus or other cause in the straw for disease, which was then in existence, I suppose the same to which reference is made by Dr. Perry. Dr. Marston informs me that he is of opinion that the disease has been erro- neously connected with the condition of straw used. Dr. Marston adds: —" The name is an absurd one : scabies in the soldier is the same that it is in the civilian, and many of the cases I saw at Portsmouth were really those of itch; but the affection of which I write is, however, different and almost equally common." It is chronic ; neither insect nor ova can be de- tected, and sulphur does not cure it. It is often accompanied by symptoms of dyspepsia, or preceded by the tropical form of prickly heat; by hyperes- thesia or disordered innervation of the skin, and is aggravated by the use of flannel, by sea-bathing, and by beer. The most successful treatment appears in Dr. Marston's experience to con- sist in the exhibition of bichloride of mercury, taraxacum, and liquor po- tassse. The disease is a mixture of prurigo and lichen. Putting these facts and opinions together, I should be disposed to think with him that the disease will be found to be a prurigo, in the true sense of the word, mixed with eczema and lichen. VEGETABLE PARASITIC DISEASES. 207 With regard to the influence of mouldy straw in producing disease in camps, I think a little confusion has been made. Some American physicians (especially Dr. Salisbury) assert that a form of " measles " may be produced by soldiers sleeping on damp or mouldy wheat-straw. I do not gather from my reading that they attribute the pruriginous affection styled " army itch " to that cause, but only " camp measles "—a different thing. Dr. Sahsbury's account of the matter will be found in the American Journal of the Medical Sciences for July and October, 1862. It is entitled on "The Influence of the Fungi of Wheat-Straw on the Human System, and Origin of Camp Measles," and, perhaps, of measles generally. Dr. Salisbury records many facts to show that the inoculation of the system with the elements of the fungus of wheat-straw gives rise to the development of a disease which does not differ from measles. He says that sleeping on damp and " mouldy " straw is the cause of camp-measles. He also produced it artificially by in- oculation, and suggests that the origin of measles is to be sought for in some such manner. Dr. H. Kennedy (Dublin Quarterly Journal of Medi- cal Science, February, 1863), gives a case in confirmation. Dr. Salisbury observes also, that measles was not known till 1518 (Rayer) in the New World; and this was the date at which wheat and small grains were intro- duced into the New World ; and measles are most prevalent in cold weather —in other words, at the time straw beds are disturbed and thrashed. If there be anything in this view, the agency possibly must be a poison gene- rated by the mouldy straw, of which the fungus is an evidence. We now come to the second great division of parasitic diseases—viz., those produced by the development of vegetable parasites belonging to the genus fungi, and named B. Dermatophyte, Epiphytic, or Vegetable Parasitic Diseases, Or, as I have called them genetically in the group, Tinea?, a plan accepted and adopted in the new nomenclature of the College of Physicians. Now it may be expected that I should give an elaborate account of these diseases, but it would occupy the space of an entire book to do this satisfactorily. I shall therefore content myself with a practical account of the subject. Now fungi getting upon the surface may or may not flourish. When the soil is suited to their growth, they produce most definite lesions, perfectly characteristic, especially on hairy parts. The same fungi invade the hard structures of a very large number of the lower forms of animal life, and attack parts—the hair, nails, and epidermis—analogically the same as those in man. Nothing but the ravages of a fungus can produce the peculiar changes which we see in the hairs and epithelial tissue in the tineas. I do not know the disease in which fungi are present, and in which the hairs are loosened and rendered dry and brittle, or in which the epithelial cells are affected in such a way as to give rise to such a condition as that observed in chloasma. 208 parasitic diseases. Fungi are found accidentally in very many diseases, but the one action they have peculiarly their own is to attack the hair or the nail, luxuriating in it, absorbing to themselves its moisture, rendering it dry and brittle, and by their growth helping to break it up more or less. Where there are few, practically no hairs, then the growth of the fungus acts as a local irritant, invades the epithelial cells however in a characteristic manner, and in consequence of the centrifugal growth of the mycelium, the eruptive patch is generally circular in form. As to the relation, then, of parasite and eruption: the latter is not necessarily a part of parasitic disease (as seen in tinea tonsurans, one of the varieties), but may arise as a conse- quence of the local irritation set up by the fungi in common with other agents acting from without upon a surface predisposed to erupt. I repeat that the characteristic effects of tinea, the damaged hairs and epithelium, are never produced by an eruption per se. Fungi will not flourish on a healthy surface, but grow upon those that are most prone to non-specific eruption; and for this reason vegetable parasitic diseases occur in young life, diminishing rapidly into frequency as adolescence advances; the least expressed form, tinea decalvans, being most common in adult life. We see then, as stated at the opening of the chapter, that parasitic disease consists of a suitable soil, the fungi growing upon it, and the effects of such growth —i.e., the pathological lesion of the hairs and epithelium. What are the fungi like ? I speak now generally, reserving the descrip- tion of individual parasites to be included in the several diseases in which they are found. They are often made up of minute cells alone, but as a rule of— 1. Spores.—These are round or oval, having an average size of .006 mm., but vary, much: solitary or arranged in rows which are single or many filed, or collected together in groups of varying sizes. The spores often show a dark spot, an actual nucleus, or granular nuclei, in their interior. They are double contoured, often constricted, and the halves may be unequal or equal in size. 2. Chains of the same spore, which have a more or less beaded appearance. —There is a real union between the component cells, and the rows are mo- niliform, or multiple, and branch in various directions. These forms usual- ly receive the name of sporidia, or sporule-bearers. Within them are found, clear contents, or granules, or, if large, sporules. 3. Threads (mycelium) of very various shapes and sizes.—The least ex- pressed form is that of a fine transparent filament, and there are stages be- tween this and large doubly-contoured tubes. The contents are usually granules and cells. The tubes are often not uniform in diameter being more or less constricted, and the interior space is partitioned by septa. The filaments sometimes interlace in a very free manner, and may bear in rare instances, at their extremities various forms of fructification, either an enlarged terminal solitary cell or a shortly jointed tube, or a clustering of spores, seated upon a receptacle, or a radiate arrangement of spores etc. These tubes and threads are called thallus-fibrils. VEGETABLE PARASITIC DISEASES. 209 4. Stroma.—This consists of an infinite number of minute cells, and is the early condition or nuclear form of the fully developed fungus, accompa- nies all fungi in a state of active growth, and is oftentimes well seen in tinea favosa. It is generally overlooked, and requires a high power for its detec- tion. It is very potent for evil. The structure of the spore is very simple. It has an outer coat or en- velope composed of cellulose, and an inner one, or utricule, enclosing a liquid which contains floating granules, and is colored blue by iodine. These spores may be confounded with many other cells. With fat glo- bules, blood discs, corpuscles of various fluids, young epithelial cells, or rather nuclei, pus, and earthy particles. The effect of reagents will, how- ever, prevent error. The spores are unaffected by ether, chloroform, and spirit of wine, which dissolve fatty cells, and render epithelial tissues trans- parent. Ammonia renders the spores a little more colorless perhaps, whilst it dissolves pus and the secretion of many eruptive diseases (which contain small granules and cells somewhat resembling large spores) " con- verting them into a gelatinous mass." Impetiginous crusts, fat, pus globules, hair, and, epithelium are dissolved when heated in a hot solution of potash, especially if a little alcohol is added. The greatest care must be taken on every occasion to distinguish between fatty cells and spores, and diffused molecular fat and sporules or the nuclear form of fungus; indeed this is the important practical point requiring atten- tion clinically, and really it is a difficult thing oftentimes fairly to get rid of the fatty matter. If we suspect the presence of much fat, it is advisable to al- low the hair or other object to soak for some time in ether if any doubt ex- ists as to the nature of any particles, cells, or granules. The fat-cells always exhibit a wide variation as regards size, and have a duller aspect; the cells of the fungus, on the other hand, are uniform in size in any particular ease, refract the light very perfectly, and then- outline is more defined and con- toured ; they are not affected by ether. In old-standing cases of tinea, the epithelial cells take on a kind of fatty degeneration, and look very like cells invaded by sporules. When the mycelium is well developed no mistake can well arise, but. there are one or two foreign matters and modifications of normal structure that offer appearances similar in aspect to some of the less flourishing examples of mycelial threads. I have known the fibres from handkerchiefs or towels which have been used to cleanse the object-glass to be recognized as mycelial filaments. Sometimes some of the fibres of the hair will be stripped of the shaft and curl back like mycelium. The edges of cells are dark, and never have a clear central line, do not branch, and do not contain granules. The safeguard is to get the mycelium free from surround- ings, and then no error can arise. The imbrication of the epithelium is sometimes irregular, and the edges of the scales present exactly the appear- ance of mycelium running transversely through and across the shaft of the hair, and it is really difficult to imagine that filaments are not present, more especially if there happen to be a few sporules scattered throughout the in- 14 210 PARASITIC DISEASES. terior of the hair. By careful observation the outlines of the cells may be traced not only over, but beyond the area of {he hair. In examining for the fungus, extract a hair from a diseased patch, and place it at once in a little diluted liquor potassse (to render the parts trans- parent), then drop a piece of thin glass over it, without the use of any pressure, and put it under the microscope. Then if it be necessary to ex- amine more minutely, dissect the parts carefully with a needle. As a rule, harm is done by rubbing or squeezing the preparation between the two glasses. To get rid of the fatty matter, it is best to soak the hair in ether, and then to wash it thoroughly before adding liquor potassa?. With regard to the furfuraceous desquamation, those scales which are situated at the edge of the diseased patch should be selected and treated in like manner, without using pressure, and as small an amount as is convenient should be subjected to examination. The stromal or minute form exists in abundance very frequently, and is not discovered; the fibres of the hair conceal the small cells. If the hair is allowed to soak for a while in alkalies, the cells are seen, and in warm weather the minute form of fungus will develop in glycerine and water in a few days to a recognizable size. This stromal form may be mistaken for pigment-granules ; but the latter are uniform in size, do not refract, and there is no accompanying damage to the hairs when they are present, and with a high power granules do not appear translucent. When in doubt, I am in the habit of employing artificial germination to assist. The following figure represents the appearance, presented by the stromal form of fungus after being " put up " in glycerine. On the first ex- amination only the faintest trace of the cellules was present. Many persons find the discovery of the fungi in i|iS||if parasitic disease a difficult matter. The reasons for WS their non-detection are mainly as follows:— ^^^^^^P^^ (1.) From having too large a mass under exami- nation. Thin sections or layers of epithelium or hair should be taken. (2.) The non-use of reagents to render the suspected tissues more or less transparent. (3.) Too much manipulation. In this way spores are sometimes rolled up, as it were, in epithelial layers softened and altered by reagents, and thus concealed. (4.) The presence of pigment in large quantity. (5.) Ill selection of hairs and scales. We may possibly extract for examination a healthy hair which stands in the midst of dis- eased ones; diseased hairs are loosened in the follicle, and altered in texture, dry, and brittle. (6.) The fungus may be left behind in the follicle, the hair coming away without it. (7.) Secondary changes are often mistaken for the real disease; scales may result from the irritation of a fundus not in them, but in parts near, and its absence from the same scales is no silication of contents of spore-cell with further subduplication of their interior, e. Spore and sporidia formed. /. Spore bursting, g. Sporidia more magnified to show shape and nucleus, h. Spore embraced by a condensation of small filamenLs, very common, if not constant. 2. Felt-like form of the layer of Red Fungus as it grows in the bottle, a. Filamentous layer. 6. Layer of spores, c. Filamentous layer below. 'i. Filament to show that it is composed of cells with a nucleus in the upper end of each. ONYCHIA PARASITICA. This disease, called also onyoomycosis, or parasitic disease of the nails, re- quires a few words. ' Now, in any of the tinea of the head, especially favus, the nails may be attacked by the fungus present. It acts upon the nail in the same manner that it does on the hair; it thickens and dries it, destroys its polish, renders it brittle, and the parasite can be seen growing into and amongst the com- ponent elements of the nail. I may as well relate the cases by Dr. Purser recorded in the Dublin Quarterly Journal, for November, 18G5. He gives two cases. The first is shortly as follows :—Nail dirty brown, streaked ONYCHIA PARASITICA. 231 with lines of a darker color, greatly thickened, and at its free extremity sep- arated from its bed by a mass of soft nail-substance which could easily be picked out. The entire nail was somewhat roof-shaped, a prominent ridge running along its centre; its surface was uneven and traversed by rough lines; longitudinal stria? well marked ; the nail had a tendency to split up ; and the microscopic appearances of a bit of the nail were as follows :—(1) spores like those of trichophyton; (2) filaments tortuous and branching, jointed and containing nuclei; (3) larger, less branched, brownish filaments, containing spores, walls of many indistinct-looking like moniliform chains; (4) granular matter. In the second case the appearance of puccinia was simu- lated. Dr. Purser describes the fungus as trichophyton, and by his courtesy I am enabled to give a figure of one of the specimens (see Fig. 25). In the Report of the Clinical Society of London for the 13th March, 1868, the fol- lowing occurs in reference to the achorion (favus parasite) attacking the nail: " Dr. Hilton Fagge exhibited three patients affected with parasitic disease of the nails. These cases were re- Fig. 25. markable not only on account of the rarity of such affections, but also because that they had an im- portant bearing on the question of identity or non-identity of the vege- table parasites which attach to the skin. The first case was that of a child aged eleven, who had for some years suffered from favus in a very severe form, affecting the head and limbs. The disease of the nail—of the left little finger—however, had only commenced about three weeks before she came under observation. There was, therefore, an unusually good opportunity of observing the course of the affection. The tubes and spores of the fungus were seen to penetrate the substance of the nail, gradually invading it till they reached its root. The lamina of the nail then became loose. The progress of the disease thus dif- fered entirely from the description given by Bazin, and English writers who had followed him, according to which description a favus-cup forms beneath the nail, and gradually perforates it. The affected part of the nail was of a sulphur-like color, and when the lamina had been removed the bed remained covered with an irregular striated mass of nail-substance of a yellow or a brownish hue. This appearance was precisely that of the diseased nails on the other two children, and on microscopic exami- nation they too were found to present sporules and beaded tubes as of achorion. Yet these two children, who were sisters, displayed no cups nor masses of favus on the scalp or other parts of the body. Dr. Fagge en- tered into some further details respecting these cases, from which he stated he was led to regard them as affording strong confirmation of the view maintained by Hebra and by Dr. Tilbury Fox that the fungi found in the 232 PARASITIC DISEASES. different forms of favus are in reality mere varieties of one microscopic plant." A less severe form of similar changes may be produced by the microsporon Audouini (tinea decalvans). The Diagnosis must be made from psoriasis and syphilitic onychia. Sus- picion is aroused by concomitant parasitic disease of the head, and the microscopic detection of the parasite is conclusive. Treatment.—The nail should be removed if the disease is deep and exten- sive. If superficial, scraping away the lamina is needed, and strong carbolic acid lotion perse veringly used, or glycerine and hyposulphite of soda lotion, will be the best remedies. MYRINGOMYCOSIS. Another disease to note under this section is one caused by the growth of a fungus within the meatus of the ear. It has been re-described by Wre- den lately, in the " Comptes Rendus," August 26th, 1867, and named myringomycosis or mycomyringitis—outlandish terms both of them. The fungus is the aspergillus nigrescens and flavescens, having all the characters of a glaucus, save in color, or an ascophora elegans. In four out of ten cases, Wreden found the disease on both sides. There was much derange- ment of the function of hearing and a good deal of irritation. The fungus tends to form an interlaced mass of fibres or rather a white shining tissue, studded here and there with black points (aspergillus nigrescens), or brown- ish yellow (A. flavescens). The injection of a weak solution of hypochloride of lime or arsenite of potash is recommended by Wreden. The same au- thority suggests that the source of these moulds may be the walls of uncleansed and stuffy rooms. Lastly, in pruritic irritation of the vagina, oidial forms of fungus may be present as the cause. This has been called vaginal mycosis. A parasiticide at once stops and cures completely the pru- ritus, which otherwise might be troublesome. Anal irritation in children after thrush may arise from a similar cause. CHAPTER XIX. NEUROSES OF THE SKIN. Disorders of the nervous element of the skin come under this head. They are characterized by alteration in the sensibility or by structural changes, the immediate result of disease in the nerves themselves. Now disorder of the nerves of the surface may be secondary to various morbid conditions, and so we find altered sensibility, itching, pain, and the like, in many general diseases, in local inflammations, and indeed skin affections generally, whilst structural changes, due to nerve-change, may be part of a well- marked general disease, like elephantiasis. Nerve-disorder occurring under such circumstances is secondary, and in one sense accidental: it is therefore described in connection with the several affections in which it occurs. In other cases the nerve-disorder is the prominent, primary, and practically the sole disease—and this independent form of disease will be described here. The affections then truly comprised under the head of neurotic disease are— 1. Increased sensibility, or hyperesthesia. 2. Diminished sensibility, or anaesthesia. 3. Perverted sensibility, including pruritus and prurigo. The changes in the skin in prurigo are secondary to nerve-disorder. It may be asked, why not rank urticaria and herpes under the head of neurotic disease? What is the objection if that term be extended in its meaning ? For the present I have described urticaria as an erythematous disease, and herpes under bullous disorders ; for though these cannot be produced without the agency of the sympathetic or cerebro-spinal nerves (and their excitability is a sine qud non), yet the nervous element is not the only one, though it is prominently involved in these diseases. Herpes occur in catarrh, as a critical eruption.in fevers: urticaria from the circula- tion in the blood of special articles of diet or medicinal bodies, and for these reasons I have left those two diseases, the one under erythematous, the other bullous affections. I think that if herpes is neurotic, so is pemphigus. Then again, if we widen out the meaning of the term neurotic, we must include under it elephantiasis, in which nerve-disorder, that can be felt in the case of the superficial nerve-trunks, precedes the alteration in the skin, but is itself the consequence of the effusion of a special fibrinous material into the cellular structures generally. In neurosis the disorder of the nerves is the primary and the real disease, the other changes are secondary. Hyperesthesia, or exalted sensibility of the skin, if general, is secondary 234 NEUROSES OF THE SKIN. to brain and spinal diseases; occasionally it is idiopathic, and when this is the case, it partakes of the nature of a neuralgia, or is hysterical in origin. The skin is morbidly sensitive to all impressions, the clothes, the air, pres- sure, even that of lying. Anaesthesia is a secondary symptom of other, diseases, such as morphcea, atrophia cutis, and I name it here for the sake of completeness. PRURITUS. This disease is characterized by the occurrence of what is termed " itch- ing." This may coexist with, or be entirely unaccompanied by, change of structure. The word pruritus is generally used in common parlance to signify itching, whensoever and. wheresoever it occurs. As a secondary disease, it is produced by general causes—e.g., the rheumatic diathesis, the circulation of morbid elements, as bile, excreta; by alterations of tempera- ture, gastro-intestinal disturbance, nervous diseases, genito-urinary and uterine derangements, sedentary habits, rich stimulating diet; by local causes—ascarides, piles, parasites (animal or vegetable); by various skin eruptions, especially lichen, prurigo, psoriasis (in its early stages), eczema. When pruritus is spoken of in the abstract, itching, as constituting the primary and sole disease present, is signified, and the nervous character of the itching is frequently shown by its sudden appearance, its almost as sudden disappearance, and often its marked tendency to periodicity. Pruritus may be general or local, and it is very usually followed by secon- dary changes in the skin. When general it may be due to an inactive state of the skin, by which the nerves are irritated, or it may arise from reflex irritation. The local forms are the most important. They are P. ani, P. scroti, P. pudendi, P. prseputii, P. urethra?. Pruritus prseputii is merely itching of the glans, connected with an ab- normal secretion of sebaceous matter by the follicles there. Pruritus ure- thras is itching connected with disease of the bladder. But in P. ani, scroti, and pudendalis, we have marked itching as a primary feature with secondary eruption, and other changes, such as discoloration of the skin, excoriation, etc. These are the features of prurigo, and therefore these three varieties of pruritus should really be regarded as local prurigos. I shall describe them accordingly as such; these local varieties are often as troublesome as the general disease. PRURIGO. I have read with very considerable regret that which has been expressed in England of late in regard to this disease. The leading dermatologists are agreed on clinical grounds that the neurotic character of the disease is suffi- ciently marked to classify it under the head of neuroses of the skin. Since the intense itching is often the sole as it is the primary and important thine present—other phenomena observed in the skin are secondary. Prurigo is.a disease of advanced life. When fully developed it is char- PRURIGO. 235 acterized by three sets of symptoms:—(a) intense pruritus, which' is in- creased by heat of all kinds, the warmth of the clothes, and is generally described as a creeping sensation, such as would be caused by a multitude of insects; (b) a peculiar unhealthy, yellowish, infiltrated, but yet wrinkled' and flabby state of skin; (c) the presence of papules, which are not promi- nent, but flattened more or less, disseminated, and showing at the summit of each a black speck, caused by the drying of a drop of blood, which is effused in consequence of scratching. The pruritus is peculiar ; it is burn- ing, creeping, tingling. Friction aggravates it, and yet the patient tears the skin with his nails, and thus induces secondary changes (erythema, pustules, wheals, and ulcerations); and a peculiar quasir-urticsLtion is frequently seen, and produced by exaggeration of the little areas of skin enclosed by the natural furrows. These are the broad papula? of prurigo. In addition, the skin becomes more or less pigmented in chronic cases. Prurigo may be par- tial or general; it occurs generally about the back and outer aspect of the limbs ; about the shoulders, the clavicles, and the belly; it is often localized to the anus or genital organs. The pruritus may cause sleeplessness, loss of appetite, and a condition of general discomfort and misery. Now in hospital practice especially, in connection with these changes, pediculi are observed. This is a very old fact indeed; and it has been thence concluded that pediculi are always the cause of prurigo. Clinically this is not true. Prurigo, as I have described it, may exist without the vestige of a pediculus, as an essentially neurotic disease. It is not common to have prurigo without lice in uncleanly persons, in hospital practice ; but to say that every man who has prurigo is "lousy" is not a fact. Neligan, speaking of prurigo in old people, says—" the chief peculiarity, however, in prurigo senilis is that it is invariably attended with the appear- ance of innumerable pediculi ; " and he styles this " a complication never ab- sent in the poor and in persons of filthy habits. Their presence aggravates the other symptoms." This form is often called prurigo pedicularis. The relation between the two I will speak of directly. The varieties of prurigo are—Prurigo milis,formicans, and senilis, with local varieties before referred to under the head of pruritus. Prurigo mitis is the least expressed form of the disease ; occurs in sum- mer, about the back, the outer part of the limbs and shoulders, under the clavicles, and about the thighs. It is seen in the young sometimes; the skin after a while becomes muddy and thick. Prurigo formicans is a more severe form of disease, and attacks elderly people : the main peculiarity is in the sensation, which is that of the creep- ing of innumerable insects over the skin, accompanied by a burning feeling that keeps the patient awake, and distresses him. Scratching gives rise to pustulations, with subsequent discoloration of the skin. The eruption is pretty general. J Prurigo senilis is the fully-developed disease as I have described it, and in this form pediculi are mostly present in uncleanly people; they are found 236 NEUROSES OF THE SKIN. in the folds of linen, especially about the armpits, and require to be care- fully looked after for detection. Contrasting those cases in which pediculi occur with those in which they do not, we notice " louse-bites " in the former and not in the other. The louse-bite being a flat, at first palish elevation, with a central dark spot where the wound has been inflicted. These have long been recognized. Local Varieties.—In these the papules are not very numerous, but the pruritus is oftentimes terrible. P. podicis is seen about the anus, chiefly of adults, and is sometimes produced by irritation from ascarides: it attacks sedentary people, or those who suffer from hemorrhoids ; papulae of charac- teristic aspect are seen, the skin gets thickened, and in consequence of the contiguity to the mucous surface, gives out a moist discharge. P. scroti is the same disease in another situation. In consequence of the moist secretion and excoriation, an eczema is simulated. In P. pudendalis the redness of the mucous surfaces of the vulvas and vagina is accompanied by paroxysmal pruritus of burning and distressing kind; the parts swell, the surface dis- charges, and the acridity of the fluid causes redness (intertrigo) of the sur- face outside the passage ; nymphomania is induced, and occasionally papules are detected. Besides these varieties, there are some mixed forms of disease. Prurigo often complicates scabies ; in which case the papulae of prurigo are noticed, scattered over the forearm, the abdomen, and thighs—not on the face: this may be called scabies pruriginosa. Strophulus pruriginosus and pemphigus pruriginosus occur, and have been described. Pathology and Cause.—The basis of the disease is a paresis, a disorder o% the nervous element of the skin—a neurose. This disorder is brought about in young people by bad diet and bad keeping; in old people, it is a part of commencing decay signified too plainly in the loss of elasticity, and the semi- atrophy of the skin tissue. The neurotic aspect of the disease prurigo is well shown in the burning, tingling, formicant character of the disordered sensa- tion. The importunate character of the itching has been ludicrously ascribed to the large size of the pediculus; the explanation of this theory is not given. The burning has been attributed to the " contact with the air of the chafed and excoriated surface of the skin;" (But how account for this burning before any chafing or excoriation occurs ?) the formication, to the fact that the pediculus is the same size as an ant, and " to the formidable-looking claws with which the feet of the pediculus is armed, and with which it clings to the skin"(? clothes). The reason that pediculi occur in prurigo is this— viz., that the state of the secretions is that exactly suited to their develop- ment. The concomitance involved in the presence of pediculi in prurigo does not imply cause and effect, else might we ascribe the decay of organic matter solely to the influence of fungi, when the development of the latter takes place in consequence of certain antecedent alterations in the decaying material by which the way for its death and destruction is paved ; the germs PRURIGO. 237 of fungi being ever present to take advantage of the opportunity to grow and help onward the process of decay. The following are the arguments against the necessarily pedicular origin of prurigo. I do not say that pediculi may not be the exciting cause in un- cleanly persons; they may, in common with other agents, act in that way, but unless there be a disordered state of the nervous plexus of the skin, and an unhealthy state of the integument itself, no prurigo would result. Now, first of all, a necessary consequence of the pedicular hypothesis is the denial of the relation of the local forms of prurigo—in which no pediculi certainly occur—to general prurigo, yet in these all the features of prurigo are present. The peculiar pruritus may be present as the primary disease. I have seen in prurigo all the symptoms of disordered sensibility in the extreme, preceding the occurrence of an eruption, followed by special papular changes and excoriations, and no "louse-bites" whatsoever : and in all these cases of prurigo there were signs of a decay in the skin, its vitality was low- ered, it had lost its elasticity, firmness, and fat, it was stained, its sebaceous secretion was disordered—the condition was favorable to pediculi. A wain, there is no relation between the amount of eruption and the degree of disordered sensibility. The " louse-bite " can always be detected if the pediculus cannot, so that the difficulty of detecting the presence of the latter is only an assumed one. Pediculi placed upon a healthy surface will not give rise to prurigo. For example, a man may sleep with a lousy bedfellow, and«the lice may seriously attack him, but he exhibits a quantity of what appear to be flea or bug bites, with some excoriations from scratching, and he complains of itching, but he soon gets well, and the active repair, and the absence of the dark crusts, etc., are very striking. To call this prurigo is wrong. If a man is old, unhealthy, and dirty, prurigo may be evoked by pediculi, or slighter forms of the dis- ease appear in those who are out of health, as in overworked students, or jaded medical oflScers of workhouses, or sickly children. But pediculi only act the part—beyond the infliction of the bites—of local irritants. A pru- riginous condition occurs in scabies, lichen pruriginosus, strophulus prurigi- nosus, pemphigus pruriginosus. In these cases we have no lice or louse-bites; the pruriginous condition is clearly due to the lowered state of nutrition. The last clinical fact I will mention is this : that a patient with prurigo shall go to bed after using parasiticides, after taking his bath and putting on clean linen, and yet he shall have an intensification within a few minutes of getting to bed of all his pruriginous itching and burning. Does not this show clearly the nature of the disease ? Whenever pediculi are present in prurigo, they unquestionably play an active part in intensifying the disease ; they superadd to prurigo the special features of the " bites," and conduce to increase irritation (and one of the chief points in treatment is to destroy them as early as possible), but I con- tend that they simply act as irritants and not as primary producers of what has really a general origin. A recent writer has observed that one-sixth of 238 NEUROSES OF THE SKIN. all cases of diseases of the skin in public practice are prurigos of pedicular origin : that they are more numerous than scabies : these two classes together including one-third of all cutaneous maladies. Mr. Wilson states, that of 5,000 consecutive cases 36, or -72 per cent., were those of prurigo, 66, or 1*32, pruritus, and 148, or 3"68, scabies. This wide difference requires explana- tion. I have merely glanced over some of the points of interest, and I do protest against that doctrine which takes no cognizance of the general state of nutrition in prurigo, which declares that louse-bites are characteristic of prurigo, that general remedies are of no good, that the only cure is the use .of mercurial ointment to the skin and baking the clothes, and that one-sixth of the persons afflicted with skin diseases are lousy. All ages are affected by prurigo, but the advanced by far the most. Pru- rigo is mostly seen among the lower orders. Neglect of cleanliness, moral depression, change of season, bad living, bad clothing, bad food, and such like, are peculiarly predisposing. Amongst other excitants are pregnancy, local irritation, the free use of stimulants, and unquestionably the presence of pediculi. Diagnosis.—Prurigo is known by the peculiar dark aspect of the papula? at their apices, their dissemination on the outer and posterior aspects of the limbs and back; by the peculiar pruritus, the unhealthy, flaccid, dirty state of skin, and the uniformity of the eruption. In lichen, the papula? are light- colored, and without dark apices; the disease occurs on the inner aspect of the limbs, etc.; there is no " urtication," the surface is not withered, but dry, thickened, harsh, not flaccid. In scabies, the eruption is multiform, seated about the interdigital spaces, on the front parts of the arms and body; the skin is apparently healthy, there is no burning pruritus ; it also occurs on the seats of pressure, especially the tuberosities of the ischium, and exhibits the characteristic vesicle and furrow; in addition prurigo occurs not only on the outer aspect of the limbs, but also generally above the level of the nipple-line and below the upper part of the thigh; scabies, on the other hand, is seen mostly between these two lines of demarcation. In prurigo, pedi- culi are detected. Scabies and prurigo may be conjoined. Here the characters of the two diseases coexist. Treatment.—Speaking generally there are three main objects: the first to improve the tone of the general health ; the second to allay the irritation of the skin, when the secondary charges of papulation and the like subside; and the third to destroy any pediculi that may be present; and this latter point must always be attended to. Pediculi are readily destroyed by chanc- ing the clothes, which should be baked or thoroughly scalded, by careful tepid bathing night and morning, and the use of ammonio-chloride of mercu- ry ointment, stavesacre ointment, or a solution of the pyrethrum roseum and the removal of flannel from next the skin. I never find any difficulty in getting rid of them. If I am very assiduous in their destruction, I di- rect a powder in small amount composed of equal parts of oxide of zinc PRURIGO. 239 and white precipitate to be sprinkled about the armpits and over the clothes which come in contact with these parts. I believe the main reason of fail- ure is inattention to change of clothes, and neglect in the prescription of proper ablution. The destruction of pediculi then is to be resorted to un- der all circumstances. Now, clinically regarded, the various cases of pru- rigo that occur may be fairly arranged into five groups. (1) Cases in which prurigo of a mild form complicates other diseases, frequently in young peo- ple, as in lichen pruriginosus, again in pemphigus pruriginosus, and even scabies. In these cases all that is needed is the exhibition of cod-liver oil and quinine with better food. The pruriginous element is an evidence of special mal-nutrition of nerve origin, in which probably uncleanliness, in addition to bad living and feeding, has had much influence. A better hy- giene and tonics, with perhaps alkaline baths, never fail to effect the desired change. In the case of pruriginous scabies, the cure of the itch is the first step ; and tonics are specially useful according to my experience. (2) The second class comprises cases in which prurigo occurs in middle-aged men and women, in whom the pruritus is not of so decidedly a burning, formi- cant, character as in older folk: the skin is often tolerably well nourished : the atrophous state is but slightly marked. Here we get pediculi, and in such cases the main cause of their presence and their activity is to be found in tolerably bad living, a scanty change of linen, and absence of cleanliness. In these cases the cure is easy, by the destruction of the pediculi, together with enforced cleanliness. (3) The third batch of cases is that in which old people are attacked, and pediculi are present. Here the atrophous state of integument is more marked, and independently of the destruction of any pediculi, much requires to #be done to improve the nutrition of the skin by general remedies. Arsenic is here admissible. The skin, too, is in these cases oftentimes very irritable, and, as a consequence, the pruritus is intense, and aggravated by change of temperature, by hot drinks, etc. It may be relieved by tepid and alkaline bathing. I do not commend the plan of applying tar, sulphur baths, and the like, to cases of prurigo such as these. There can but be the frequent result of over-stimulation. Inter- nally, the mineral acids with strychnine, or in severe cases aconite, axe the best remedies; where a gouty tendency exists, the iodide of potassium is of use. The action of the kidneys also needs to be encouraged, by diuretics, in some of these cases. The circulation of bile products, and their non-ex- cretion, are aggravating influences in other instances. The local irritation must be allayed by the adoption of scrupulous cleanliness, and by the appli- cation of various emollients and sedatives, which are found useful in the other varieties. The most common is one composed of from two to three or four grains of the bichloride of mercury, with two drachms of dilute hy- drocyanic acid, and eight or ten ounces of water; lotions into whose com- position watery extract of opium, belladonna, and chloroform enter are of service ; several of these will be found amongst the formula? ; a good lotion is made with cyanide of potassium. For general use, the following may be 5 240 NEUROSES OF THE SKIN. employed : liquor plumbi two drachms, biborate of soda a drachm, glycerine two drachms, and lime-water six ounces. When the pruritus is severe its cessation or diminution is rather to be expected from sedatives given inter- nally than lotions and pomades externally. Now in some of these cases ecthymatous pustules appear. This is to me an indication for the exhibition of cod-liver oil or quinine. In certain cases, where the disease depended rather upon an atrophy than the influence of pediculi, I have found the little fat glands plugged up with exuvia?, and have been startled, on examining these with the microscope, to notice the large number of fungus spores therein. I have seen good results in such cases from the use of hyposulphite of soda lotion (half an ounce to half a pint of water). (4) In the fourth group of cases the most troublesome instances of the disease are met with—those in which the pruritus is most intense, and out of all proportion to the " eruptive " manifestations; the prurigo is here sometimes clearly a part of a general disturbance of the system in which the nerves play the prominent part. For example, in con- nection with asthma or long-continued and severe " pyrotic " symptoms, or it may be a gouty tendency. The atrophy of the skin may be very well marked. These are the most difficult cases to treat, and those which puzzle the practitioner. Attention to diet, which should be unstimulating, regula- tion of the secretions, the use of opiates in connection with tonics, such as ammonia and bark, strychnine, nitric acid and quinine, as the case may be, or tincture of aconite in moderate doses, with digitalis, where this is admis- sible, are the remedies of best action. Locally, lotions of various kinds may be employed ; and here it seems that we must act empirically; in some cases dilute nitric acid lotion ( 3 j.— 3 iss. to § vj. of water), at other times alkaline lotions—ex., carbonate of soda ( 3 ij. ad § vj.), prussic acid, tobacco, the hot-air bath, etc., are serviceable. I frequently use the following:— Tincture of mix vomica, two drachms; tincture of digitalis, two or three drachms ; glycerine, two drachms ; and water, to six or eight ounces. This same kind of non-pedicular prurigo is seen occasionally in middle-aged sub- jects ; then it is pretty well distributed over the body, but especially affects the shoulders, arms, neck, belly, legs, and about the calves. I have known it associated with " drinking habits." Free excoriations are caused by the scratching. Here I have found that treatment has been successful in proportion to the degree of personal control I could exercise over my patients. I do not hesitate to purge, to give diuretics freely: to moderate the " heat of the body," declared to be present, by digitalis, and even antimonials. Colchi- cum may be also needed, reserving the mineral acids and bitters till a later stage. Locally, the attempt should be made to exclude the air by free smearing, first of all with a glycerine and zinc or lead plasma, and then " whitewashing " with oxide of zinc and water, or a whitening-paste, or even painting with glue and whitening. Saturation at night in a strong alkaline bath is another good plan. Alcoholics are to be avoided, together with PRURIGO. 241 seasoned dishes, pickles, spice, pastry, salt meat. (5) Lastly, the local varieties need to be noticed. In prurigo of the anus ; hemorrhoids, ulcers, and ascarides of the rectum are at the bottom of many cases ; the two former require surgical treatment. In other instances there is an eczematous state present, which is removed by zinc and lead lotions. In other instances the affection is purely neurotic: here, keeping the bowels relaxed, warm water injections, poppy-head fomentations, belladonna, opiate lotions, and black wash, constitute the agents of relief. In the other local varieties similar means are to be used; but there is one exceptional condition—viz., prurigo pudendalis; when the vaginal mucous membrane is inflamed and irritable, a borax lotion, or one composed of hyposulphite of soda, does much good. The observance of a rigorous personal hygiene is one of the most impor- tant points in the therapeute of prurigo : this, with good unstimulating diet, alkaline baths, astringent and sedative lotions, after destruction of pediculi, with opiates internally, constitute the basis of treatment. But I must add finally that in some instances, where debility is extreme, a free stimulating plan is advisable. See Formula? Nos. 29, 36-7-8-9, 41, 45, 47-8-9, 50-1- 2-3-4, 61, 66, 69, 105-6-8-9, 122, 141, 146, 151. CHAPTER XX. HAEMORRHAGES. I am indebted to my friend Dr. Buzzard for the following note on Pur- pura, the only disease which I have to describe under the head of haemor- rhages. The skin is liable to be discolored by haemorrhages into its structure. In typhus, petechiae or spots of haemorrhage are very frequently observed, and in other acute specific disorders purple discoloration from haemorrhage may accompany, or even replace, the natural eruption, in cases of ex- treme virulence. This is every now and then observed in variola, scarlatina, and rubeola; also in the course of chronic disorders, as of the liver, spleen, and kidneys, purple spots may appear on various parts of the skin. The term purpura is often applied to these conditions, and some little confusion has thence arisen, because by the same name is also designated a disorder which is independent apparently of specific poison, or of chronic organic disease. This disease may be very mild or (rarely) very severe. In the former case it is called purpura simplex, in the latter pur- pura hasmorrhagica. It is characterized by cutaneous haemorrhage, giving rise to spots, patches, or bruise-like discolorations of the skin; and in the severe form the haemorrhage also comes from any or all of the mucous sur- faces. " Purpura is most commonly seen in its. early stage as a minutely fine eruption of pin-point-sized specks, of a pink or purplish color, covering the skin more or less extensively. The eruption is especially apt to appear on the lower extremities, and it is usually most marked about the thighs and buttocks. In these situations there is usually a rapid aggregation of the specks into patches of irregular shape and size. After a few days there are intermingled with these, yellowish or buff-colored patches, which are the sequelae of the earlier eruptions. Here and there, too, will be seen bruise- like discolorations, extending over a larger surface. "The same words will describe also another disorder—scorbutus—which, however, can be readily distinguished from purpura, by the following char- acteristics :—1. It is always caused by privation of fresh vegetable food. 2. The gums are usually swollen, spongy, discolored, and bleeding. 3. There is always great lethargy and prostration, and the skin is of a pecu- liar dusky, dirty-looking pallor. These features are not observed in pur- pura. A purple eruption, then, which is not connected with the exanthemata nor with chronic organic disease, and the history of which does not cor- respond with the characters of scurvy just given, may be safely set down as HEMORRHAGES. 243 purpu ra. Another point of diagnosis still remains. In all forms of cutane- ous haemorrhage there is a gradual change of color. First a more or less bright pink spot appears, which becomes in succession purple, brown, tawny, buff, and yellow. It never fades on pressure. Under these circumstances the spot at one time may look a good deal like a flea-bite, but it will be found to have no central puncture. The spots may be single, or aggregated into patches. They tend to appear fresh every day, or at short intervals. Under the use of fresh vegetable food the appearance of new spots is im- mediately checked, if the case be one of scurvy ; but if purpura be the cause, this diet will quite fail to influence the progress of the eruption. "As regards treatment, the cause must first be ascertained. Nothing need here be said respecting the management of cutaneous haemorrhage occurring in the exanthemata, or in chronic organic disorder. If scurvy be the cause, the patient must be immediately furnished with fresh vegetable food, and good generous living. Lemon or orange juice, potatoes, cabbages, and let- tuces are of especial value. The skin should be kept clean. The patient should be kept for the first few days in the recumbent position. No drugs need be given to him. The etiology of purpura proper is still but ill under- stood, and any treatment for it is therefore necessarily empirical. Turpen- tine, the perchloride of iron, and quinine have apparently produced the best results." See Formula 135. I may just add that purpura is sometimes complicated urticaria, and then we have what has been called Purpura urticans. I have also seen purpura take its origin in abortive zoster. The attempt at the formation of bulla? failed, and in the place of these formations purpurous spots appeared. 16 CHAPTER XXI. CHROMATOGENOUS DISEASES—PIGMENTARY. Alterations of color are produced of course by many different conditions— by an alteration of the blood current, by parasites, and other agents. These have been classified, in speaking of maculae, under the head of elementary lesions. Reference is now made to cases in which the pigment-supply of the skin is alone concerned. Now, there are two groups of cases :—(1) Those in which the pigment is deficient in quantity (Leucorderma), and (2) those in which it is in excess (Melanoderma). These may be congenital or acquired, general or local. The seat of change is the rete mucosum. First with regard to LEUCODERMA. This may be general or partial. The former condition is represented by the albino, whose whiteness is congenital. The physician has to deal medi- cally with the partial variety. Now, there are two conditions producing a partial whiteness—the one in which the pigment is deficient in one spot, but perhaps in excess at the adjoining part; it is not equally distributed; there may be no excess on the whole, nor deficiency, but unequal scattering. In the other case the general surface of the skin is normally colored, but there is an absence in some one or more parts locally. The former condition I have seen in young men who have been exposed to the sun in hot climates, have had fever, and then returned to England ; it is not very common. The latter variety—that is, true partial leucoderma—occurs especially in the black races, and consists of circular white patches giving a piebald appear- ance. In leucodermic patches the hairs are often white. The only change in the derma is that of pigmentation. Everything else is normal, save per- haps the sensation, which may be blunted. The extent of the patches, which may be round or serpentine, or in the form of bands, varies. The disease may cover the chest and back, white and dark blotches being intermingled; it occurs in youngish folk. I cannot but think exposure to the sun's rays has much to do with its production, deranging the pigment-formation in the skin. Diagnosis.—The fact that there is simply deficiency of the pigment with- out other change, save an apparent accumulation in parts of the skin conti- guous to the white patches, must be diagnostic. Pathology.—It seems clear that the disease may arise from depressed in- nervation ; the action of the sun oftentimes sufficing to determine the occurrence of the disorder. MELANODERMA. 245 Treatment is often successful. A nutritious diet, a course of tonics, arsenic, iron, and the mineral acids, the correcting of any of the ill effects of the action of malarial poison, residence in a cool locality, and avoidance of fatigue, generally suffice for improvement. Locally, the use of friction and cold bathing, with iodine baths, are the best remedies. MELANODERMA. This term of course means excess of pigment resulting in dark discolor- ation, but the altered tint of skin may be blue, yellowish, or black, hence the terms cyanoderma, xanthoderma, and melanoderma. A short description will suffice for these. Melanoderma, or that in which the discoloration is black in color, is general or partial. The latter is sometimes called melasma. There is a general dark discoloration associated with disease of the supra-renal capsules, and now known as Addison's disease. I need not describe this. The local variety, or melasma, is important. It may be a " physiological" condition, as- seen in the staining around the nipple and the linea alba in pregnancy; this condition may be excessive. Dr. Swayne has described a case in which there was a peculiar discoloration about the face, arms, hands, and legs, which were spotted like a leopard. The same woman thus affected exhibited like phenomena in her skin during the last three months of her two former pregnancies, the discoloration disappearing after each confinement. Then in ana?mia, discoloration of the skin may occur about different parts of the body. In connection with the syphilitic diathesis the earthy and very characteristic aspect of the surface, especially the face, is a melasma. Lentigo is a variety — it is known as freckles. The seat of the pig- ment deposit is the rete mucosum; it is often congenital, and of varying extent and distribution ; generally, however, consisting of round yellowish spots, the size of split peas and less, not only on the parts exposed to the light, but also that covered by the dress, in those with fair skins, and par- ticularly red-haired folk. There is no desquamation, no itching, and no heat of any kind : freckles often disappear after puberty ; do not depend upon seasonal change; and require no treatment, except slight stimulation, ace- tate of lead, sulphate of zinc, and iodine lotions. Ephelis (or Sunburn).—In this particular variety of discoloration the pigment deposit is excited by the sun's rays. Sunburn consists of little dots the size of pins'-heads, which appear upon the parts of the body exposed to the influence of the sun, and are seen mostly in lymphatic subjects with delicate skins. Treatment is of little avail. We may, if we choose, use a little bichloride of mercury lotion. Melasmic discoloration of the skin occurs in certain states of the blood— e.g., anaemia, syphilitic cachexia—as the result of the action of local irri- tants, such as the sun, strong light, blisters. It also follows chronic erup- tions—syphilitic roseola giving rise to syphilitic macula?. Indeed all forms of syphilitic disease leave a pigmentary staining behind, of course in this 246 CHROMATOGENOUS DISEASES. group of cases the melasma is a secondary and not a primary form of disease. Another melasma is found in pigmentary naevi, which are round, small, feel smooth to the touch, covered with a number of soft hairs and pigmented brown or black. These moles occur on the body, but especially the face and back ; they are slightly elevated, are not naevoid in structure, and undergo little change ; they are merely collections of pigment in the rete mucosum; they may cover over a large extent of surface, from several inches to a foot or more. Xanthoderma.—In this disease the pigmentary discoloration is yellowish. It is characteristic of certain races, and is due to some special condition of the coloring matter of the skin, molecular or chemical. Cyanoderma, or blue discoloration, is different from colored sweat. It is a curiosity, if not, at least in the greater number of instances, a hoax. A curious disease is described by Dr. Arcken as endemic in New Granada and the northern parts of America, and is called Carate: it is diathetic, and characterized by the appearance of various colors on the body—dull white, copper, crimson, red, and dark blue—so it is said. There appear to be three varieties—the simplest, blue, which is seen between 15 and 25, and consists of oval or roundish spots on the face, extending to the neck and lower limbs even; the white, occurring between the ages of 30 and 40, rare in males, and usually associated with ovarian disease: this is leucoderma: lastly, the rose-colored, consisting of red points on the hands, face, and belly, seen in both sexes. It is said to be due to bad living. Pathology.—Mr. Wilson thinks that there is an anaemia of special features, accompanied by pigment deposit and change, due to debility of the nervous powers, and that the various colors are modified results. Especially in reference to melanoderma, he notices a peculiar condition of eye—" the melasmic eye." It consists of " a vivid brightness and brilliancy and spar- kling lustre of the eyeball, a liquid depth of color of the humors of the eye, and a strongly contrasting whiteness of the sclerotica, the effect being often increased by a more or less deep tint of a dull blackness of the integuments of the eyelids, more especially of the fold of skin of the upper eyelid which immediately borders on the eyelashes." The non-production of pigment may arise from local destruction of rete mucosum, etc.; from want of nutri- tive power, as in leucocythaemia; and, on the other hand, an excessive pro- duction is brought about by imperfect oxidation—the carbon is not burnt off as carbonic acid; by the imperfect elimination of the carbon, in deficient menstruation, diseases of liver and kidneys, deficient hair-formation, during disease in pregnancy (leucocytosis present), and by the excessive production, from the use of highly carbonized foods. Such are the causes given by Dr. Laycock. The above remarks apply to cases of true pigment-alteration. There is great distinction to be drawn between these and states of abnormal coloration, due to an alteration of the haemation of the blood, and not to the excessive production of pigment, as in sallowness, icterus, chlorosis, scorbu- tus, cancer, and splenic disease. CYANODERMA. 247 The Diagnosis of these discolorations offers no difficulty; the color is altered, and that alone. Treatment.—This is generally that of anaemia. Locally little can be done. Organic disease must have its appropriate treatment. Sometimes there is excessive waste going on in the system; in that case the diet, the use of stimulants, nerve tonics, change of air, mental rest, and the diminution of anxiety, are the points which we should look for preventing depression of the nervous innervation and for toning up the powers. In this way both imperfect oxidation and deficient elimination are met. One other important thing to do is to see that the amount of red corpuscles in the blood is suf- ficient. I think that the deficiency of the red cells may be one factor in the causation of melasmic stains, and for that reason I use iron as a remedy against them. Then I am inclined to think that the action of the malarial poison on the system may tend to an abnormal production of pigment in the blood, so that in pallid neuralgic subjects large doses of quinine are called for. Though I do not think local remedies of any direct use, yet free ablutions, and frictions with the use of juniper tar soap as a stimulant, help the skin to recover its healthy condition. CHAPTER XXII. DISORDERS OF THE GLANDS. We have two sets of organs to deal with: the sweat or sudoriparous, and the fat or sebaceous glands. I think both these parts of the skin are much more frequently disordered than is generally supposed. I shall first speak of— I. DISEASES OF THE SWEAT GLANDS. The-deviations from health may be functional or structural; the former include all those cases in which the sweat varies in amount and kind; the latter those in which the sweat follicles are likewise congested, obliterated, inflamed, or enlarged. The disorders may be arranged thus :— A. Disorder of Function, including hyperidrosis (excessive sweating), anidrosis (diminished perspiration), osmidrosis (change in odor), and chro- midrosis (change in color). B. Structural Disorder : miliaria and sudamina (congestive dis- orders), lichen tropicus (folliculitis), strophulus (inflammatory), hydro- adenitis (suppurative), and cysts, due to follicular obstruction. First, then, A—Functional Diseases of the Sweat Glands :— HYPERIDROSIS. This disease is excessive sweating. It is, however, not generally an inde- pendent form of disease; it is often the case that the circulation through the glands becomes disordered, and hence we have structural changes, con- gestion and prominence and effusion into the follicles, constituting miharia and sudamina, and other diseases, to be described in a moment under the head of structural changes. The mere excessive sweating is a functional disorder of course; it may be partial and chronic. It generally depends upon some loss of control by the nerves of the part. In excessive sweating (hyperi- drosis) the sweat is acid and somewhat disagreeable. There is generally a feeling of chilliness, and locally in the skin, pricking or burning. It may be " critical." The local forms occur about the hands, feet, and neck, and scalp. In hot weather, about the hands and feet the sweat (being free all over the body) may not be able to escape readily in consequence of the cuti- cle being roughened and hard; under these circumstances it distends the" sweat-follicles, which may be seen dilated and filled with fluid beneath a layer of cuticle. This is often mistaken for eczema; one or more patches the size of about a shilling, surrounded by redness, are seen at the sole or OSMIDROSIS. 249 side of the foot, about the fleshy part of the thumb or the palm of the hand. On viewing them with a glass, there is what appears to be vesicula- tion under the skin, whilst each patch is raised ; but there are no vesicular prominences, in fact the glands are (sub-epidermically, so to speak) dis- tended with fluid, as I have said, which cannot escape. The sensation of burning and pricking is marked : after awhile the cuticle bursts and the fluid is discharged, leaving behind a hot, red, peeling surface, which by fits and starts weeps, the escaping fluid evidently being sweat; or if there is no escape of fluid, the attacked parts swell, they become red and shining, and are exceedingly painful. There is no formation of crusts as in eczema; the cuticle peels off, and presently the redness subsides. This is not eczema; it is simply hyperidrosis, with difficulty of escape of perspiration. The fol- licles are not congested and inflamed sensibly as in miliaria. The treatment consists in careful bandaging, the application of lead lotion, the sedulous exclusion of the affected surface from the air, and the use of diuretics. In some cases the use of an oxide of zinc lotion, with an aperient, will suffice. Hyperidrosis may be an acute disease of sudden occurrence, when it is gen- eral ; or it may be local and chronic. i ANIDROSIS. This disease is characterized by a diminution of perspiration. A dry skin is part of many general diseases—ex., fevers, diabetes; in xeroderma, in which there is congenital defect of development. More commonly, it arises from allowed inaction of the cutaneous covering; and the use of fric- tion, warm bathing, alkaline baths, and the like, generally bring the skin into a proper state of action. There is of course in these cases more or less general debility, which must be specially attended to in each instance. OSMIDROSIS. This is that disease in which the odor of the perspiration becomes so offensive as to constitute "the thing to be remedied." It may coexist with other functional derangements of the sweat appara- tus. In general diseases the sweat exhibits very peculiar odors; in rheu- matism it is "rank," scurvy "putrid," chronic peritonitis "musky," itch "mouldy," syphilis "sweet," jaundice "musky," scrofula like "stale beer," in intermittent fevers like " fresh-baked brown bread," in fevers " ammoni- acal " and so on. When the feet are affected, the sweat is sometimes most offensive especially in the summer-time. Hebra describes the condition very fully. The hands and feet of the afflicted are cold without their know- ing it; they exhibit shining drops of sweat; the epidermis is macerated and presents a white wrinkled appearance; excoriation may result, and with these conditions the offensive odor exists. Hebra believes that the smell is not inherent to the sweat, but (external) in the boots and socks. This is, no doubt, true to some extent, but it would seem also that where the greatest cleanliness is observed, some people's feet are most unfortunately 250 DISORDERS OF THE GLANDS. net of the sweetest smell. There is often a blueness due to inactive circu- lation in the tissues. The treatment is a matter sometimes of great tedious- ness. Much may be done by rigid cleanliness. If the disease be due to saturation of long-worn socks and boots, with acid sweat which decomposes in them, then the removal of the cause of offence is easy. In ordinary cases the feet should be well washed and bathed in a solution of alum or Condy's fluid. The use of a light sock and shoe, lotions of creasote, or finally strap- ping each foot for twelve hours together, as suggested by Hebra and Martin, with diachylon plaster, are useful. (Some observations on foetid perspira- tion will be found by Dr. Foote, in the Dublin Quarterly Journal, for May, 1866). CHROMIDROSIS. Black, blue, and sanguineous perspiration are included under this term. Much has lately been written on the subject. Chromidrosis is often con- nected with menstrual disorder, and is due to the escape of the coloring matter of the blood, or actual blood, with the sweat. It is an unimportant disease. B. STRUCTURAL DISEASES OF THE SWEAT GLANDS. Under this head I have included miliaria and sudamina (for in these the vascular plexuses of the follicles are specially involved); lichen tropicus and strophulus, and hydro-adenitis, or suppurative inflammation of the fol- licules. MILIARIA AND SUDAMINA. These two affections really have no right to be considered as separate diseases. Sudamina is the lesser degree of disease, the contents of the vesicles being acid ; miliaria is the more developed condition, in which the contents are alkaline—in fact, inflamed sudamina, as Dr. Gull pointed out. ■Sudamina have been described as little round vesicles, produced by disten- tion of the cutis by sweat, and therefore seated at the orifices of the sweat follicles. This is an excess of the condition referred to under hyperidrosis, only that these are distinct elevated vesicles, which are never confluent, and unattended by any inflammation : when the latter is present, the affec- tion is called miliaria. Sometimes the vesicles are reddish (miliaria rubra), sometimes white (miliaria alba). These vesicles are developed about the neck, axillae, clavicles, and trunk, in diseases in which profuse sweating occurs ; their contents quickly dry, each crop is replaced generally in from three to six days by furfuraceous desquamation. The disease is seen in phthisis during summer-time, in acute febrile disease, the parturient state, in rheumatism, fevers, in the sweating disease of Picardy. Since the adop- tion of a cooler regimen in sick-rooms, the disease has been altogether less frequent than formerly. So-called miliary fever (said to occur in two forms, STROPHULUS AND LICHEN TROPICUS. 251 mild and malignant), is characterized by profuse sweating and the develop- ment of sudamina. The treatment demanded is a cool regimen. STROPHULUS AND LICHEN TROPICUS. I have already referred to these two affections, under the head of lichen, to which disease I refer for a description of their characters. I believe that they should be transferred from their present position, and placed under the head of disorders of the perspiratory glands. The part of the glands affected in the above diseases is the follicular. We now come to a disease in which the whole gland is involved. HYDRO-ADENITIS. Verneuil described this disease, which is an inflammatory state of the perspiratory follicles, ending in suppuration. The disease occurs in every region of the body where there are glands, except in the sole of the foot; but it is most frequent in the axilla, at the margin of the anus, and near the nipple. It also is seen on the face, about the ear. The disease com- mences by a crop of small inflammatory tumors, about the size of peas, of bright-red hue, and (says M. Verneuil) at first like boils; they are unlike boils in the fact that the little inflamed indurations begin not on the sur- face of the skin, in a sebaceous or hair follicle, but beneath the skin, which is reached and involved secondarily. The suppurating follicles offer no prominent "point" or "head," and there is no discharge till the swelling bursts, when the disease is brought to a sudden termination. The causes are said to be uncleanliness, friction, the contact of irritants, pus, parasites, profuse perspiration, and, according to Bazin, the arthritic dyscrasia, sy- philis, and scrofula. The disease is often mistaken for scrofuloderma. The treatment consists in the use of alkalies internally, hot fomentations, and soothing applications—lead lotion and the like—externally. I find collo- dion the best thing. The above account is taken from an article in the Journal of Medicine and Surgery for October, 1866. I have had several cases of this disease under my care. The last was that of a young woman, who had two or three red, subcutaneous " lumps " under her eye of bright red color, and the size of peas, with no central suppuration. In a couple of weeks the tumors " broke," and the face rapidly got well. OBSTRUCTED SWEAT GLANDS. In some cases one sees developed in the skin a cyst, which takes its origin in a dilated follicle or sac of the perspirating gland. The follicle of the latter becomes obstructed, and instead of the gland inflaming and sup- purating, the fluid collects and distends the follicle. The line of demarca- tion between hydro-adenitis and cyst formation in the early stage is not well-defined. I have seen " serous" cysts of this kind form on the face from the closure of the perspiratory ducts, by the cicatrices of acne in a 252 DISORDERS OF THE GLANDS. strumous subject, and most difficult the disease was to cure. I found the continuous application of collodion the best treatment; the cysts, however, may be punctured, and the contents allowed to escape; the incisions must be deep enough. I now come to II. DISEASES OF THE SEBIPAROUS OR SEBACEOUS GLANDS. As in the case of the sweat glands, we may divide the diseases of the fat glands into two groups. a. Functional—including stearrhoza or seborrhea (increased secretion), asteatodes (deficient secretion), and allosteatodes, or alteration in the char- acter of the secretion. Retention of secretion is usually accompanied by alteration of structure, and I shall describe it under the latter head. b. Structural.—Diseases of the lining membrane—ex., pityriasis, vitili- goidea: retention of secretion and its consequence—ex., comedo, sebaceous cysts, molluscum: and lastly, congestive diseases and inflammatory diseases —acne, furunculus, etc. We notice first of all, then, A. FUNCTIONAL DISORDERS--SEBORRHEA. Seborrhoea, or augmented secretion of fatty matter, sebaceous flux—the stearrhcea of Wilson—is not so very uncommon in the various diseases of the surface; in elephantiasis it is a marked feature. Some persons have naturally a greasy skin. When occurring as a separate disease, its most usual seat is some part of the face, especially the nose, and it mostly shows itself in the form of little yellowish thin crusts, which on examination are found to be made up of sebaceous and epithelial matter, the epithelial cells of the sebum being loaded with fat intermingled with free granules and cholesterine; the skin beneath is reddened, more or less thickened, and the sebaceous glands are hypertro- phied. It may give rise on the scalp to a kind of pityriasis; the scalp how- ever is greasy, not dry. There may be itching—generally there is. It often disappears after a time. The causes are not well made out; it is said to be produced by over-stimulating diet in lymphatic subjects; it occurs in either sex, generally about puberty. The treatment consists in the exhibition of cod-liver oil and arsenic, the removal of the scales by alkaline lotions, and the local use of alum, bichloride of mercury ointment, and glyceral tannin. Now the secretion may vary in consistence and quality in seborrhoea; it may be oily, and then represents the acne sebacee fluente; when it forms crusts, the acne sebacee concretee; and, in a more hardened state, the acne sebacee cornee of the French writers. These terms sufficiently explain the different appearances of the disease. In speaking of ichthyosis it will be remembered that I stated that the scaliness or horny plates were often made up of a large amount of fatty matter; the disease I now speak of occurs as a primary con- dition ; in ichthyosis it is but part of a general disorder of the skin. But a close resemblance to ichthyosis may be produced by seborrhoea; the naked- STRUCTURAL DISEASES. 253 eye appearances of the skin may be the same, only the disease is localized, the skin beneath being naturally healthy. ASTEATOLES Is deficiency in the sebaceous secretion. The skin appears to be dry and harsh, and this arises from deficient action of the sebaceous glands. Asteatodes is seen in hereditary syphilis, and in badly-nourished or uncleanly folk. The treatment consists especially in the use of the bath, oily inflictions, generous diet, and tonic remedies, especially cod-liver oil. ALLOSTEATODES. Alteration of secretion is the characteristic of this form of disease. The secretion may be of various colors—yellow (seborrhoea flavescens), or black (so-called seborrhoea nigricans). Seborrhoea flavescens is nothing more than a marked form of S. simplex ; indeed is the same as the acn with 3 2 of chloride of sodium. Use in pityriasis rubra and the syphilodermata, especially with ul- ceration. The Purton springs in North Wilts are bromo-iodated and sulphated waters, having a temperature of 584;° F., and would appear to be very useful in strumous subjects. CAUSTICS. 10. Iodine.—Iodine 3 \, iodide of potassium 3 1, distilled water 3 5. Use in glandular enlargements, lupus. 11. Nitrate of Silver, 3 2 to § 1 of spirit of nitric ether. (To be kept ex- cluded from the light.) Use in the chronic forms of erythema, eczema, and lepra vulgaris, ringworms. 12. Chloride of Zinc (Startin).—Chloride of zinc 3 4, chloride of antimony 3 2, starch 3 15 and glycerine q. s. Use in ulcerous and tuberculous affections. 13. Arsenical (Startin).—Calomel § 1\, bisulphuret of mercury ±) 2, and arsenious acid 3 1. Use in lupus, scrofulous ulcers, and syphilis. 14. Vienna Paste.—Unslaked lime and caustic potash, of each equal parts; when used, mix with alcohol. Use as above. 15. Bicyanide of Mercury.—gr. 2 or more to § 1 of water (Burgess). Use in acne rosacea ; to be painted on for two or three minutes and then wiped off. 16. Biniodide of Mercury.—gr. 10 to gr. 20 to 3 -1- of glycerine. Use in lupus especially. FORMULARY. 271 17. Plencks.—Alcohol and acetic acid, of each | ^; bichloride of mercury, alum, camphor, and carbonate of lead, of each 3 £. Use in syphilitic warts ; pencil twice a day. 18. Savin (Langston Parker).—Powdered savin, bichloride and nitric oxide of mercury, of equal parts. Use in condylomata and warts. 19. Coster's.—Iodine 3 2, and colorless oil of tar 3 1. Use in ringworm in the early stages; one or two applications suf- fice. SOAPS. 20. Hendrie's Dispensary petroleum soap. Use in eczema. 21. Juniper-tar Soap) (recommended by Velten of Aix-la-Chapelle). Use in the squamous diseases especially. 22. The common Soft (potash) Soap, used in chronic infiltration—e. g., lichen circumscriptus or chronic eczema. It may be dissolved in boil- ing water, § 1 of the soap to § 2 of water, and scented with some aro- matic oil. 23. The Sulphur Soap, of use in scabies and prurigo. 24. Sapo Laricis (Moore, Dub. Hosp. Gazette, March 15,1859).—Wheaten bran f 4, glycerine § 3, white curd soap § 24, extract of larch bark § 6, and rose-water § 12. Use in pityriasis, psoriasis, chronic eczema, and herpetic eruptions. 25. Pear's transparent Soap.—The best soap made. 26. There are many other kinds of soap, but I am not in the habit of using them very much—ex., sulphur, carbolic acid, oxide of zinc, etc. Soaps, and other preparations from the formula? contained in this work, are beautifully made, and kept on sale by Messrs. Caswell, Hazard & Co., the well-known Druggists of New York. 272 FORMULARY. ASTRINGENTS. 27. IJ Tannic acid........................... 3 ij. French vinegar......................... 3 ss. Distilled water......................... 3 viiss. M. Neligan. 28. R Tr. krameria........................... 3 ij- Creasote.............................. gtt. viij. Prussic acid, dilute..................... gtt. viij. Distilled water........................ | iv. M. Neligan. 29. R Opium................................ gr. viij. Creasote.............................. gtt. x. Lard................................. | ij. M. Use in prurigo and lichen. Neligan. 30. R Tincture myrrh........................ gtt. xxx. Oxide of zinc.......................... gr. xx. Cold cream............................ | j. M. Use in prurigo, erythema, and lichen. Neligan. 31. R Borax........."....................... 3i. to 3 i. Glycerine............................. | j. Rose-water............................ | viij. M. Use in squamous diseases. 32. R Oxide of zinc........................... 3 ij. Glycerine............................. 3 ij. Lead-water............................ 3 iss. Lime-water............................ 3 vj. to viij. M. Use in the secretory stage of eczema, in acne, in lichen, foul ulcers, impetigo, and herpes. 33. R Dilute hydrochloric or nitric acids........ 3 ss. to 3 ij. Sugar lead. ........................... gr. v. to x. Water....................... - vi ........ 0 *j" M. Use in eczematous and lichenous affections. 34. 1} Alum................................ 3ij_ Infusion roses.......................... z xvji M. Use in acne, pityriasis, and eczema (sine crustis). Cazenave. FORMULARY. 273 35. R Sulphate of copper..................... 3 j. Sulphate of zinc....................... | ss. Distilled water......................... | xvj. Cherry-laurel water..................... | ss. M. Use in mentagra. Dupey. SEDATIVES--LOTIONS AND OINTMENTS. 36. IJ Carbonate of soda...................... 3 ss. Conium juice.......................... | j. Elder-flower water...................... ^ j. M. 37. IJ Bicarbonate of soda.................... 3 j. Glycerine............................. 3 iss. Elder-flower water...................... 3 viss. 38. R Biborate soda.......................... 3 ij. Cherry-laurel water..................... 3 j. Elder-flower water...................... 3 xj. M. Neligan. 39. R Soda or potash........................ 3 ij- Water................................ I vj. to 3 viij. M. Uses—Either of the above is useful in the early stages of vesicular and papular dis- eases to allay itching. 40. R Borax................................ I ss. Sulphate of morphia.................... gr. vj. Rose-water............................ 1 viij. M. Use in pruritus vulva?. Meigs. PRUSSIC ACID. 41. IJ Bichloride of mercury.................. gr. j. Prussic acid, dilute..................... 3 J- Emulsion of almonds.................... 1 vj- M. Use in itching, in lichen, in the syphiloder- mata, and pruritus. 12. IJ Prussic acid, dilute..................... 3 j- to 3 ij- Infusion of marshmallow................ 1 v. to § viij. M. 43. R Acetate of ammonia.................... I \j- Prussic acid, dilute..................... 3 J- Tincture of digitalis.................... 3 nj. Rose-water............................ 3 v- lhomson. M. 18 274 FORMULARY. 43. R Prussic acid, dilute..................... 3 ss. to 3 j. Water............................... 3 ij- to ! viij- M. Use in the prurigo of old people. 44. R Borax................................ 3 ss. Prussic acid, dilute..................... 3 ij. Rose-water............................ o viij. M. Use in lichen agrius. Neligan. 45. R Cyanide of potassium................... gr. vj. Cold cream............................ 3 j. Cochineal............................. gr. j. M. Use in pruritus urticaria. Anderson. 46. R Cyanide of potassium................... gr. v. Sulphur.............................. 3 ss. Bicarbonate of potash................... 3 ss. Cochineal......................•....... gr. j. Lard................................. ij. M. Use in eczema with pruritus. Anderson. 47. R Cyanide of potassium................... gr. xv. Water................................ 1 viij. M. Use in pudendal irritation, lichen, and pru- rigo. (To be kept in a dark place.) Hardy. CHLOROFORM. 48. R Chloroform............................ TTi vj. Cucumber cerate....................... 3 j. M. 49. R Carbonate of lead....................... 3 ss. Chloroform............................ TH, iv. Cold cream............................ § j. M. 50. R Chloroform............................ TH, viij. Glycerine............................. 3 j • Simple cerate.......................... 3 vij. Cyanide of potassium.................... gr. iv. M. Neligan. FORMULARY. 275 R Chloroform............................ 3 j. Glycerine............................. 3 iv. M Duparc. R Glycerine............................. ~ ij. Bichloride of mercury................... gr. iss. Chloroform............................ f\[ Xx. Rose-wat aa 3 iij. Cardamoms.........................) Liquorice............................. 3 vj Infuse and strain sixteen pints. Use in ter- tiary syphilis. Zittman. 134. R Tincture guaiacum...................... 3 j. Tincture aconite........................ TTi. xx. Camphor mixture....................... 3 vj. ' M. Dose : | ss. three times a day in chronic skin diseases. 135. R Turpentine rectified.................... 3 ss. to 3 iss. Creasote.........,.................... TTX iij. Spirits of rosemary..................... TTi, xl. Water, q. s. ad.......................... | iv. M. Dose : Two teaspoonfuls ever}7 three or four hours. Use in purpura. Budd. 136. R Borax............................... 3 j. Bitartrate potassa...................... ? ss. White sugar.......................... 3 ij. Water............................... z xvj. M. Dose : Two tablespoonfuls every six hours. Use in erythema nodosum. Neligan. FORMULARY. Os7 137. IJ Almond oil......................... z ss# Olive oil.............................. =ij.' Iodine................................ ■ , . ',. v ' ) skin diseases. 7. Wildbad....................\ Gastein....................I Prurigo, psoriasis, and lichen, where Pfaeffers....................[ there is nervous debility. Teplitz......................J 8. Spa........................\ Schwalbach.................! Skin diseases connected with or ow- Pyrmont...................( ing to ansemia. Franzensbad................J 9. Aix-la-Chapclle.............> Baden (near Vienna)........ Baden (in Switzerland)...... Aix-les-Bains ............ An sulpllurous waters useful in Bacneres de JLucnou..........I x ., . '. . :r o, y acne, pityriasis, psoriasis, pru- S™::::::::::::::::' **>, <*«>*•■ Eaux Bonnes............... Nenndorf.................. Sandefjord (Norway)........ B. English Waters :— 1. Sidpthnrovs.—Harrogate, Moffat, Cheltenham (sulphur spring). 2. Saline.—Cheltenham, Buxton, Bath, Scarborough, Leamington (New and Old Bath). 3. Chah/bcafe.—Tunbridge, Cheltenham (chalybeate), Brighton, 296 MINERAL WATERS IN SKIN DISEASES. 4. Bromo-iodine.—Purton, in North Wilts, temperature 584° F., useful in strumous subjects; and the Woodhall Spa in Lincolnshire. " It is probably unknown to many of our readers that midway between Boston and Lincoln there exists one of the most valuable and remarkable spas to be found, not merely in Great Britain, but in Europe—namely, the Woodhall bromo-iodine spa. It is one of the very few spas in this country which contain in any medicinal quantity those potent and most beneficial agents, bromine and iodine. Amongst the Continental mineral waters, it most closely resembles that of the celebrated Kreuznach Spa, to which in- valids of a certain class resort from nearly all parts of the world. It dif- fers from and is superior to the waters of that spa in the very much larger quantities of bromine and iodine present in the former, and which are stated to be some three or four times as great. " The water of the Woodhall Spa has been more than once very carefully tested, and, as there can be no doubt of the substantial accuracy of the analy- ses made, we have thought it unnecessary to make a full quantitative ex- amination ; we have, however, verified the presence of bromine and iodine in large amounts. The late Mr. West, who very carefully tested this water, stated that the presence of iodine might be detected with the starch and sulphuric acid test, without the water undergoing any preliminary evapora- tion. " In the bromo-iodine water of the Woodhall Spa we have therefore a very powerful remedial agent, especially valuable in the very large class of cases of scrofula and chronic rheumatism, tumors, etc."—The Lancet, Feb. 22,1865. And I may add tertiary syphilis. The water of the spa at Wood- hall contains a proportion of 54/ grains of iodine to 10 gallons; and 20-1 grains of bromine in 10 quarts. I should think that the Woodhall Spa may turn out to be a valuable remedy in skin diseases. GLOSSARIAL INDEX. PAGE Achor (a^wp scurf) is a term at one time applied to a small acumi- nated pustule of the scalp, containing straw-colored pus, and succeeded by a thin brown or yellowish scab. The word has now fallen quite into disuse.................................. 11 Achorion. The generic name given to the vegetable parasite in tinea favosa. It is probably a form of penicillium glaucum....... 215 Acarus. A genus of minute insects belonging to the acarides in the division of arachnides. The following two varieties are found on man :— (1) Acarus autumnalis—-the harvest bug..................... 190 (2) Acarus scabiei, or itch insect............................ 198 The so-called acarus Stockholmii is probably a species of tick, and the acarus folliculorum is now termed steatozoon follicu- lorum . •............................................... 254 Acarus scabiei (difference of sex).............................. 198 " habits of...................................... 196 " selective seat of............................... 19T " male......................................... 198: " female....................................... 202: Acne should really be acme, from the Greek dx/x^. Dr. Greenhill believes that in the Avord " acne " the n is by mistake placed for m, and that this error arose with Aetius. By acne is meant an inflammation of the sebaceous follicles due to retention of sebace- ous matter, and this was thought to occur at the acme of the system................................................ 256 Acne, general description of, &c............................... 257 " syphilitic............................................ 149 Acrochordon (aKpovextreme, and xnP$V a string). A wart which has a pedicle or a thin neck by which it hangs from the skin: a pedunculated wart........................................ 170 Acrodynia (aKpov the extremity, and 68vvrj pain). The name given by Alibert to an epidemic erythema as occurring in Paris some years since, in which there were severe pains of rheumatic char- acter about the wrists and ankdes.......................... 48 Acute Specific Diseases (eruptions of)......................... 32, 42 Addison's keloid........................................... 179' 298 GLOSSARTAL INDEX. PAGE Age (influence of).......................................... 126 Agrius, an adjective signifying inflamed, derived from aypios angry, fierce, etc. See Lichen Agrius.......................... 79 Aleppo evil............................................... 110 Alopecia signifies baldness—derived from aXuTrrji a fox, in whom the hair falls out in mangy places............................ 2>tff 0 I Alopecia areata............................................ 224 " syphilitic......................................... 153 Allosteatodes (aAAos other, ariap fat, altered sebaceous secretion. . . . 253 Alphos (a\ likeness), the disease usually called keloid, which consists of an indurated mass putting forth processes at its edge that resemble a crab's claw. See Keloid. Chigoe................................................... 191 Chionyphe Carteri.......................................... 230 Chloasma (xA.oa£w to be pale green), generally applied to the brown- ish stain of pityriasis (or tinea) versicolor, one of the ring- worms, but used by Hebra to signify pigmentary discoloration.. 227 Chromatogenous (^pwp.a, xpw/xaTos color, yeWaco to produce), a term applied to the group of diseases in which the color of the skin is changed............................................. 244 Chromidrosis (xpwp.a and iSpocris sweating), colored sweating....... 250 Cicatrices.................. ............................... 13 Cimex lectularius, or bed bug................................. 190 Cingulum, the Latin for a girdle, and applied to herpes zoster or shingles. Classification. See Summary................................. 21, 23 " Willan's....................................... 21 Clavus (a nail), a term signifying a corn or callosity.............. 170 Cnidosis (kvi'Scoctis an itching, caused by the nettle or kviSv), the term used by Alibert to designate nettle-rash. Cochin-China ulcer.......................................... Ill Color, alterations of, in disease................................ 244 Comedones (comedo a glutton), the small sebaceous plugs or concre- tions that form in acne ; they are also called grubs........... 254 Condylomata............................................... 171 Contagious impetigo........................................ 94 Corns..................................................... 170 Couperose, the French for copperas. Goutte rose, signifying acne, in which the color is reddish. Cow-pox, a synonym of vaccinia. Crusts.................................................... 13 Crusta lactea, literally milk crust. This is a term that is generally applied to an impetiginous eczema in children, in which the crusting is free and light-colored; but it has been made to in- clude many different affections, and has no definite signification. See Eczema. Cyanoderma (Kvdveos blue, 8epp,a skin), a blue discoloration of the skin. See Chromidrosis. GLOSSARIAL index. 301 PAGE Cyanopathia (/cudveos blue, 7rd0os disease), the blue disease, or cyanosis. Cysts of perspiratory glands.................................. 251 " sebaceous glands.................................... 254 Dandriff, or Dandruff, signifies scurfiness, pityriasis of the scalp... 190 Dartre (Saprds flayed), a term applied by the French to the group of diseases including eczema, lepra vulgaris, lichen, and pity- riasis. These are supposed to depend upon a " dartrous diathe- sis." The word dartre is equivalent to tetter. Dartrous diathesis........................................... 69 Demodex folliculorum (8wp.6s fat, Sukvo), Byfrpal, to bite (Hoblyn). The term given by Owen to the insect found in the sebaceous matter ; called by Wilson steatozoon folliculorum............ 251 Delhi Boil................................................. 108 Dengue, or Dandy fever..................................... 41 Depilatory (de from, pilus a hair), a remedy which causes the hair to fall off; it is usually made up of quicklime, subcarbonate of potash, and sulphuret of antimony. See Formulary......... 293 Dermatitis (8ep/xa skin, and itis signifying inflammation), inflam- mation of the skin. Dermatalgia (8epua skin, and dXyo? pain), neuralgia of the skin. Dermatolysis (Sepua skin, and Averts looseness), of the skin when it hangs in folds.......................................... 184 Dermatology (8ep/xa skin, and Aoyo? a discourse) ; that branch of science which concerns the physiology and pathology of the skin. Dermatophyton (Sep/xa skin, (fivrbv a plant,, a vegetable parasite). The diseases in which these occur are called dermatophytic.. .. 207 Dermatophytic diseases...................................... 207 Dermatospasmus, means spasms of the skin. Dermatopathia, diseases of the skin in general. Dermatosis is used in the same way to. designate diseases of the skin as a whole. Dermatozoa (Sepfxa skin, £G>ov an animal), animal parasites......... 191 Dermic means relating to the skin ; Dermoid, skin-like. Diagnosis (Sidyvaxns, a distinguishing), the art of distinguishing dis- eases. Diagnosis of skin diseases (generally).......................... 25 " indications from mode of onset....................... 26 " temperament of patient............................ 26 " duration of disease................................. 26 " recurrence........................................ 2d " occupation of attacked.............................. 26 302 GLOSSARIAL INDEX. PAGE Diagnosis, age of patient..................................... 26 " seat of disease..................................... 26 Diagnostic features of eruptions............................... 27 " " of syphilitic eruptions...................... 143 Diathesis (Sidfocis a placing in order, a disposition), the general term for certain constitutional tendencies, such as the rheu- matic, scrofulous, hsemorrhagic. Discolorations, or maculae, varieties of......................... 6 Dracunculus (deriv. of draco, a dragon), the Guinea-worm........ 192 Dyschroma^Svcrxpoia), discoloration of the skin. Dyscrasis (SCo-Kpacrca bad state of body), a faulty state of the fluids of the blood. Ecchymosis (eK^p,uo-ts), extravasation of blood. Ecphyma (eKvrbv a plant), a fungus attack- ing the epidermic cells. Epinyctis (e7rt upon, vv£ the night), a pustule painful at night. The term was applied by Sauvages to ecthyma. Epiphyta (iiii upon, ov an animal), animal parasites living upon the surface, such as acari, lice, «fcc.............................. 190 Equinia (equus the horse), the equine disease. Erysipelas (ipvOpbs red, 7T€\Xa skin), a peculiar kind of skin inflam- mation dependent on a special poison...................... 37 Erythema (Ipvdnjxa redness), simple redness of the skiu............ 44 " an elementary lesion............................... 7 Erythemata, diagnostic features of............................. 27 Erythematous diseases....................................... 44 Esthiomenon (from ecr&'w to eat), eating; an ulcerating or eating out sore ; generally applied to lupus in olden time. Etiology of skin diseases..................................... 11 Exanthem (iidvOrj/xa a breaking out). A term applied to febrile dis- eases which are accompanied by erythematous eruptions. Exanthem, syphilitic........................................ 145 Exormia (i$op/x^ a going or breaking out). This is an old appella- tion of ecthyma, probably. Farcy (from farcio to stuff). The disease is a variety of equinia or glanders............................................... 40 Farcy and glanders.......,.................................•. 40 Favus (a honeycomb, one of the parasitic diseases in which the fun- gus grows up into mass like honeycomb; it is properly called tinea favosa........................................... 214 Ferruginous mixtures, see Formulae. Fibroma (fibra a fibre), the disease in which tubercles formed by hypertrophy of the white fibrous tissue of the skin occurs. This is often called fibroma molluscum.......................... 183 Filaria medinensis, the guinea-worm........................... 192 Fish-skin disease—i. e., ichthyosis............................. 188 Framboesia or yaws, a disease seen in hot climates, in which tuber- cles like raspberries appear; hence the derivation, framboise a raspberry.............................................. 42 Flannel, its action as an irritant.............................. 18 Freckles.................................................. 245 Frequency, relative, of skin diseases........................... 20 Funoi, parasitic, detection of, structure, ic...................... 208 "° of favus............................................. 213 " tinea tonsurans...................................... 215 " tinea circinata....................................... 220 " tinea sycosis......................................... 223 " tinea versicolor (chloasma)............................. 227 " decalvans........................................... 224 Fundus foot of India, Madura foot or podelkoma, or ulcus grave. A 304 GLOSSARIAL INDEX. PAGE disease of the foot and hand, due to the presence and develop- ment of a fungus allied to a mucor, and named Chionyphe Car- teri................................................... 228 Furfuraceous (from furfur, bran), branny, scaliness. Furunculus (a boil), supposed to be derived from/wr, a thief...... 100 Furuncular affections........................................ 100 Gale, the French for itch. Gelatio (from gelare, to freeze), frost-bite. Gown-red, tooth rash or strophulus. Grando (a hailstone). See Chalazion, a small sebaceous cyst of the eyelid, like a hailstone. Grocer's itch............................................... 81 Grutum, the term signifying grit, and meant to express the millet- seed or pit-like appearance of enlargements of the sebaceous glands of the face. Glands, diseases of— " sebaceous.......................................... 252 " perspiratory........................................ 248 Guinea-worm disease........................................ 192 Gum-red, a synonym of strophulus. Gutta rosacea, literally a rosy drop; in French, goutte rose; Latin, gutta, a drop; a term applied to acne rosacea. HjEMATODYSCRASIA (dlfxa, dluaros, blood; Svo-/cri<; sweating), excessive sweat- ing................................................... 251 Hyperplasia (virtp above, and -rrXdats conformation), excessive forma- tion of tissue. Hypertrophy (v-irep and rpocfar], nutrition), an excess over and above the standard nourishment of a part, by which change of size and form are brought about—in a word, excessive growth. Hypertrophia venarum...................................... 1 S(J 1 lypeitrophic and atrophic affections........................... 1C>*! Iatraleptic method (larpos surgeon, aXeidxa to anoint), the mode of medication by friction of medicines. Ichthyosis (lx&vs a fish), the fish-skin disease, from the resemblance of the scales of the disease to those of a fish................. 252 Idrosis, same as Hydrosis. Impetigo (impeto to attack, or impetire to infest). It has been ap- plied to very many different diseases in past times. It is now used as designating one of the pustular diseases.............. 91, 97 Impetigo contagiosa......................................... 94 Importance of studying skin diseases-.......................... 1 Inflammation, cutaneous..................................... 5 Intertrigo (inter between, tero to chafe), a chafe gall or fret. The excori- ated surface produced by the friction of two surfaces of the skin. 45 Introduction............................................... 1 lonthos (from iovdos the root of the hair, allied to dv$ew to bloom, according to some, from iov violet, and dV0os a flower). It was applied to the acne of the face that appears at puberty when the hair of the beard is forming. Iron, preparations of, see Formulary. Italian leprosy.............*.....-......................... 58 20 306 GLOSSARIAL INDEX. PAGE Itch, psora of the Greeks, scabies of the Latins.................. 196 " insect, the acarus scabiei................................ 198 " baker's, bricklayer's, grocer's, washerwoman's itch, see Lichen Agrius............................................. 81 Kelis, Keloid (K-qyq a tumor, and e'809 like). Others derive the words from XV^-V a seabank or mole, or ktjXis a stain. By these terms are signified a hypertrophous growth of the fibro-cellular tissue of the skin. See also Cheloid....................... 179 Keloid of cicatrices......................................... 179 Kerion (Kvpiov a honeycomb), a form of vegetable parasitic disease allied to tinea tonsurans. The follicles are inflamed and pour out a viscid secretion.................................... 218 Lentigo, Lenticula (lens, lentis, a lentil), a freckle; lentil-shaped maculae ; they are not seasonal like sunburn................. 245 Leontiasis (Aeovnao-is lion-like), a term applied to the lion-like aspect of the face in tubercular leprosy. Lepra (AeVpa leprosy, from Aerrpds scaly). A term applied at one time to true leprosy, but now to the scaly disease lepra vul- garis................................................123, 129 Leprosy................................................... 157 Leucasmus (Aeuxos white), the same as leucoderma, a whitening of the skin from deficiency of pigment........................... 244 Leuce (Xcvkos white), lepra leuce, the white anaesthetic patch of true leprosy............................................... 160 Leucoderma............................................... 244 Leucopathia (Acukos and 7rd$ovrbv a plant), parasitic sycosis, see Mentagra. .. 224 Mercury in syphilis......................................... 154 Mercurial formulae, see Formulae. Microsporon (/xiKpos little, o-iropos a seed), a generic term for certain vegetable parasitic fungi found in chloasma and alopecia areata. Microsporon Audouini, the fungus of tinea decalvans............ 224 " • furfur, the fungus of chloasma..................... 227 Miliaria (milium, a millet seed)............................... 250 Miliary fever, an eruption of spots the size of millet seeds, due to vesicles produced as the result of excessive perspiration. Suda- mina is the same disease................................. 250 Molluscum (molluscus, mollis, soft), small soft tumors produced by distention of the sebaceous glands by secretion. The resem- blance to molluscous animals is stated to have suggested the ap- plication of the term.................................... 256 Molluscum contagiosum..................................... 260 Morbilli (morbillus distemper), measles. Mineral waters in skin diseases............................... 295 Morplnea (fxoprj form), special diseases of the skin, in which a sub- stance like hard wax is formed in the skin.................. 171 Jloi've, a synonym of glanders. Mycosis (ixvkw<; a fungus), a synonym of framboesia or yaws; so used by Alibert. Mycetoma, the fungus foot of India........................... 228 Myrmecia (/xvp/xrjg an ant), warts on the palms of the hand, or soles of the feet. oOS GLOSSARIAL INDEX. PAGE Naevus, a mark ; they are hairy, 287 ; vascular, 287 ; or pigmentary, lS(j Nails, diseases of........................................... 230 " parasitic............................................ 230 Neoplasma (veos new, TrXda/xa formation), a new formation. Ngerengere, the leprosy of New Zealand........................ 164 Neurosis, nerve disorder..................................... 233 Nigrities, Nigredo (niger black), darkness of the skin. Noli me tangere (touch me not), lupus exedens. Noma (vopLrj, from vipun to spread), a general term for sloughing ulcers. Norwegian scabies.......................................... 201 Nosophyta (vdcro? disease, (pvrbv a plant), vegetable parasitic diseases, 207 Occupation and disease..................................... 26 CEstrus.................................................... 191 Ointments, see Formulary. Onychia (owl; the nail), inflammation of the nail................. 230 Onychomycosis (ow£ a nail, fxvKrjs a fungus), parasitic disease of the nails.................................................. 230 Ophiasis (ots a serpent), serpentine. A bald place, hi irregular band-like form. Osmidrosis (6ap.r) odor, and i'Spwcris sweating), foetid perspiration. . . . 249 Pachydermia (Tragus thick, 8£pp.a skin), a thickened state of skin. Pachydermatocele (Pachydermia, which see, and KrjXw tumor), hy- pertrophy of the skin forming a tumor..................... 184 Pachylosis (iraxvXos thickish), the same as pachydermia. Papula (a pimple), a solid elevation of the skin of minute size..... 8 Papula. Diagnostic features of different papulae................ 8 Papular diseases............................................ 145 Parasitic diseases, nature of.................................. 190 " animal.................................... 191 " vegetable.................................314, 207 Parasites (see Fungi)........................................ 208 Paratrimma (irapaTplfiu to rub together), intertrigo............... 45 Paronychia (irapa about, 6vv£ the nail). " whitlow........................................ 230 " syphilitic........................................ 153 Pathology, general remarks on................................ 5 Pediculus, the louse........................................ 195 " body............................................ 196 " pubis--------................................... 196 " head............................................ 196 Pellagra (Italian, pelle skin, agra rough), Italian leprosy......... 58 Pemphigus (7repX\>KTaiva a vesicle), a general term for vesiculae and bladders. Phlyctenosis, an eruption of phlyctenae. Phlyzacion (Xv£,di«iov, (f>Xv£0eipidcris, from 6eip a louse), the lousy disease, or morbus pedicularis.....................................195, 237 Phyma ((f>vua a tumor, or cpvoj to spring forth), a small boil. Phytoderma ((pvr6v a plant, 8£pp.a skin), any vegetable parasite that grows on the skin, hence phytodermata, the diseases in which fungi occur............................................ 207 Pian (a raspberry), the same as framboesia...................... 42 Pigment alterations......................................... 244 Pityriasis (iriTipov bran), a branny or scaly disease............... > 166 " pilaris........................................... 167 Plastic inflammation........................................ 79 Plica polonica (plico to knit together), the Polish plait, a disease seen in Poland especially, in which the hair is much matted together, 230 Podelkoma, a synonym for the fungus foot of India.............. 228 Pomphi, wheals, see next. Pompholyx (7rou(p6Xv£ a water bubble), the same disease as pemphigus. Porrigo, a term applied to so many different diseases that it should be at once discarded to avoid endless confusion. Porrigo scutulata, an old term for tinea tonsurans. Prurigo and Pruritus (prurio to itch). The first is a particularly itchy and rashy disease ; the second the sensation of itching. . . 234 Psora (\]/u)pd the itch), scabies. The Greeks use the term to eczema. Psoriasis, literally an itchy disease. Some apply the term to lepra vulgaris ; Mr. Wilson to the scaly stage of chronic eczema. . . 123, 129 rsvdracia (ij/v8priKiov, xj/v8pa£ a blister on the tongue tip, from ijrv8petv to lie, or i(/vxpa, i)8paKia cold blisters). An inflammatory pus- tule, less dee}) and red than phlyzacious pustules. Pterygium (7rnfpu£a wing, unguis a nail), epidermis growing over the nail. Pulex irritans.............................................. 191 " penetrans............................................ 192 Purpura (pnrrpurtus purple), the purple eruption caused by haemor- rhage into the skin..................................... 242 310 GLOSSARIAL INDEX. PAGE Pustula or Pustule, an elevation of skin produced by a collection of pus 11 Pustular Diseases.......................................... 91 Pyogenic (ttvov pus, yeWecrts creation), pus-producing. Radeseye. This, according to Boeck, is a bad form of syphilis. Rhagades (payds a rent or chink), a scab, fissure, or chap. Rhinoscleroma, from'Pis (genitive pivos) the nose, and 2/vn, a belt), herpes zoster.............................. 113 Zoster (^wa-Trjp a belt), herpes zoster, shingles.................... 113 Zymotic (t,vjxn, leaven), acute contagious diseases, supposed to be due to the action of animal ferments or viruses. the end. r*Z .*$*&-' ®*mmm fe4tE^^»d^;^v. NLM005764310