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67 
Scientific and Medical




Philadelphia, Pa.
  Surgeon  General's Office





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DISEASES OF THE SKIN. 
               BLANCHARD  &  LEA

                          HAVE NOW  READY.



ON   DISEASES   OF   THE  SKIN.

                  BY ERASMUS AVILSON, F.R.S.

Consulting Surgeon to the St. Paneras Infirmary, author of a "Treatise on Human
               Anatomy," " Portraits of Skin Diseases," &c. &c.

         THIRD AMERICAN, PROM THE THIRD LONDON EDITION.

           In one neat octavo vulume, of about 500 pages.

                   INCREASED NUMBER OF PLATES.

Also, to be had with Fifteen beautful Steel Plates, of which Eight are exquisitely
  colored; representing the normal and pathological anatomy of the  skin,
    together with accurately colored  delineations of more than sixty
           varieties of disease, most of them the size of nature.

             ALSO,  THE  PLATES  SOLD SEPARATE, IN  BOARDS.

  The increased size of this edition is sufficient evidence that the author has
not been content with a mere republication, but has endeavored to maintain
the high character of his work as the standard  text-book on this interesting
and difficult class of diseases.  He has thus introduced such new matter as
the experience of the last three or four years has suggested, and has made
such alterations as the progress of scientific investigation has rendered expe-
dient.  The illustrations have also been materially augmented, the number of
plates being increased from  eight to fifteen.


  As a practical guide to the classification, diagnosis, and treatment of the
diseases of the skin, the  book is complete.  A\'e know nothing, considered in
this aspect, better in our language; it is a safe authority on  all the ordinary
matters which, in this range of diseases, engage the practitioner's attention,
and possesses the high quality—unknown, we believe, to every older manual,
of being on a  level with  science's  high-water mark; — a  sound book_of
practice.—London Med; Times.
                BY THE SAME AUTHOR—(Now Ready.)


ON  CONSTITUTIONAL   AND   HEREDITARY  SYPHILIS.

       AND  ON  SYPHILITIC  ERUPTIONS.

  In one small octavo volume, beautifully printed, with four exquisite colored
     plates, presenting more than thirty varieties of syphilitic eruptions.

  Mr. Wilson's extensive experience in the treatment of this class of diseases
has enabled him to present an interesting and highly practical work, embody-
ing some novel views, and illustrated with numerous cases.


  AVe need scarcely say that Mr. AVilson's book on Syphilis commands atten-
tion.  It is illustrated  by some well-finished colored drawings, which  are
excellent representations of syphilitic affections of the integument, and it is
full of cases replete with interest.—Medical  Times. 
•' A
PRACTICAL  TREATISE
ON
DISEASES  OF  THE  SKIN.
                      BY

     J. MOORE.NTJTJGAN, M.D., M.R.I.A.,

       HONORARY FELLOW OP THE SOCIETT OF PHYSICIANS OP SWEDEN;
PHYSICIAN TO JERVIS-STKEET HOSPITAL; AND LECTURER ON PRACTICE OF MEDICINE IN TITE
               DUBLIN SCHOOL OP MEDICINE.
     PHILADELPHIA:
BLANCHARD  & LEA.
1852. 
               N4l9p
                1652
f\\f^\  «^oi  Wo £9, XAtw, \
KING & BAIRD, PRINTERS, 9 SANSOM STREET. 
                       TO





     ROBERT J. GRAVES,  M.D., P.R.S., I.R.I.A.,





             THIS VOLUME IS INSCRIBED,





AS.A  MARK  OF  PROFESSIONAL RESPECT






            AND OF PRIVATE  ESTEEM. 
 
PREFACE.
   In  submitting the  observations  contained  in the  following
 pages  to  the  Profession, the  Author  has  been  influenced
 chiefly by  a  desire  to offer,  as an aid  to the  diagnosis  and
 treatment of an important class of diseases,  the results of an
 experience  acquired  during several  years' special  attention to
 the  study of cutaneous  eruptions.    Of  late years the British
 Medical press has abounded with monographs  on other special
 affections, but few have  been  published on  those of  the  skin;
 he  has, therefore, thought  that  a concise practical  Treatise on
 them might find favour with the Profession.

  As regards the plan adopted in the construction of  the  work,
the only points requiring notice are  the  omission  of the details
of cases which might be cited  to prove the correctness of  the
views propounded, and the slight reference  to  other writers on
the same  subject:  for both  the  only apology he has to offer, is 
X                       PREFACE.

his anxious  desire   to  condense  the inquiry  he  proposed  to
himself, within  as narrow limits as possible, being fully aware
"how great an  evil  a  great book" is to the  physician  busily
engaged in practice.


  17 Merrion Square, East Dublin,
         June 1,  1852. 
CONTENTS.
                       CHAPTER I.
Classification,.................13

                       CHAPTER II.
Exanthemata,..................30

                       CHAPTER III.
Vesiculje,...................G3

                       CHAPTER IV.
Pustule,....................116

                       CHAPTER V.
Papula,....................14^

                       CHAPTER VI.
Squama,....................I68
                      CHAPTER  VII.
Hypertrophic,..................1^9

                      CHAPTER VIII.
Hemorrhagic,.................."" 
xii                    CONTENTS.

                       CHAPTER IX.
                                                        "37
Maculae, .................

                       CHAPTER X.
                                          ...         240
Cancrodes,...............

                       CHAPTER XI.
                                               .  ...  264
Dermatophyte,   ............

                       CHAPTER XII.
                                                        281
The Syphilides,..............•■

                       CHAPTER XIII.
Diseases of the Appendages of the Skin.........304

                       CHAPTER XIV.
 Therapeutics of Diseases of the Skin,.........3™

 Index,....................327 
DISEASES   OF   THE   SKIN.
                  CHAPTER  I.

                    CLASSIFICATION.

   There is no class of diseases which should interest the
practitioner or  student to a greater degree than those of
the skin, and they are especially deserving of study in con-
sequence of the  difficulties  which  attend  their diagnosis,
and the obstinacy with  which they resist  most of the re-
medial measures that have been hitherto proposed for their
treatment.   It  is only by prolonged practical  experience,
acquired after  a careful and properly directed  study of
their  varied characters, and an investigation into their
peculiar pathology, that even a moderate degree of know-
ledge of them can be obtained.  In their early stages they
are often  simple  and uncomplicated in form,  and, conse-
quently,  easy  to be recognized; but when  they become
chronic they are  generally so changed and altered, that it
is  often very difficult to discover to what  special class  or
order the peculiar form  of disease  under  observation may
belong.
  The skirt, which covers the entire of the  external  sur-
face of the body, has many uses in the animal economy ;
and therefore  a diseased  condition of it is  attended,  not
alone with vast inconvenience to the person affected,  but
is  also usually accompanied  by a greater  or less  amount
of derangement of the  health generally.   It is the organ
or medium of touch ; serves for the defence of the muscles,
bones, blood-vessels,  and  nerves, placed  beneath it; is,
                        2 
14
CLASSIFICATION.
moreover, the organ of absorption and excretion ;  and, as
some  recent physiological  writers  have  well  observed,
agrees, in many of its functions  and properties, with  the
mucous  membrane of which it is manifestly  a continua-
tion,—the mucous membrane protecting the internal parts
of the body, while the skin protects those that are exter-
nal: there  is  consequently a remarkable agreement be-
tween them.  In deranged conditions of the skin,  the mu-
cous membrane becomes  more or less engaged;  and, in
diseases  which  affect the  mucous  membrane, the functions
of the skin, as  regards absorption and excretion,  are also
affected to a greater or less  degree.
   Owing  to the  great obscurity  which so long enveloped
the study of this class of diseases, and the late period in
the history of medicine at which  any attempt was  made to
classify them at all regularly, a great deal is left for the
inquirer, even of the present day, to clear- up.   Yet wre
have abundant  evidence,  in the writings of the Jewish, the
Egyptian, the Arabian, the Greek and the Roman  legis-
lators and physicians, of their existence from the remotest
antiquity ; and that they were very numerous, often occur-
ring as scourges of mankind, is easily proved by a reference
to the Leprosy of the Jews, and the Elephantiasis of the
Greeks and of  the Arabians.   Of late, much has  been ex-
pected from the employment of the microscope in discovering
the exact nature of diseases of the skin, but in this expec-
tation  we have, as yet, been more  or less disappointed.
It is  true, that by its aid much  valuable information  has
been gained, as to the normal structure of the  skin, yet
but little  addition has been hitherto made thereby to our
knowledge of its  diseased  conditions, more  particularly
with reference  to their diagnosis and  treatment, as  based
on minute anatomy.   There is one important fact, however,
which has been attained  by the use  of the microscope in
the  investigation of  the nature  of  diseases of the skin,
namely, the discovery that, in certain affections, a vegetable
production—a  cryptogamic  plant—is present on the cuta-
neous surface,  and is evidently intimately connected with
their true pathology.   A difference of opinion exists as to
whether  these vegetable  growths  are the cause  or  the con-
sequence of the disease  in which they have been found to 
CLASSIFICATION.
15
occur; but there can be no doubt now that all, or at  least
nearly all, dermatologists admit the truth of the discovery,
and conseduently believe in the existence of these vegetable
growths, a new  classification, containing a group or order,
of which the presence of these fungi will form the essential
character, must  be constructed.
   An important point of view in which diseases of the skin
must be regarded, and one that adds much to their interest,
is  the effect they produce  upon the  system generally.   We
sometimes find that in persons who have laboured even for
a  long time under these  affections, but little constitutional
derangement is,  in many  cases, caused  by them—so little,
indeed, that it has often been doubted whether the existence
of an  affection  of the  skin, in a  chronic  form, tends to
shorten life, or  should be taken into account in coming to
a conclusion as to eligibility, in a medical examination, for
assurance.  For my own part I believe that as long as the
individual  remains unaffected  with any acute  or inflam-
matory affection, the existence of a skin disease will not, in
any  respect,  diminish the average chances of longevity;
yet I have no doubt but that a person labouring under any
general cutaneous affection, the existence of which unques-
tionably deranges the functions  of this extensive membrane,
must be  more or less liable to  have the symptoms of an
ordinary acute disease, such as fever or any of the internal
inflammations, aggravated, and  the treatment  rendered
more difficult and  complicated by its  presence.  Thus,
although a chronic affection of the skin may not directly
tend to shorten life,  yet it may do so indirectly.   As, how-
ever,  these various  points will be' more fully considered in
speaking of each eruption individually I shall not dwell on
them  at  present, but proceed to describe the classification
of diseases of the skin which I propose to adopt.
   No subject in the study of medicine  has  created more
difficulty, or for a longer  period tended to  retard its ad-
vancement, than  that  of nosological  arrangements.  It
was at one time believed to be impossible to understand
the nature of diseases or their proper  treatment, without
an intimate  knowledge having been previously acquired
of their classification,  and we  therefore find that all the
writers on medicine of  the last, and of the commencement 
16
CLASSIFICATION.
of the present century, sedulously devoted themselves to
devise new systems, each more complicated than the other.
As regards diseases generally, it is  now agreed by all that
the less complicated and more simple the classification under
which they are arranged, for the purposes  of description or
of teaching, the more advantageous is it for the acquirement
of a knowledge of them ;  and few, therefore,  take  the
trouble of making themselves acquainted with the laboured
systems of  Cullen, Sauvages, Mason Good, or the  many
nosologists of their day.  Simplicity, I  need scarcely say,
is of equal advantage in classifying any special set of  dis-
eases, as those of  the skin ; yet even in  our own time it
seems to me to be strangely overlooked  by dermatologists ;
writer after writer,  impelled, as it were, by an ambition to
devise something  novel,  propounds  a  new  classification,
careless  how complicated  and difficult of being compre-
hended it may be,  provided only it differs  from those which
preceded.
  As in the arrangement of objects of natural  history, so
in that of diseases, a classification may be either artificial
or natural; the former being based on external appearances,
or those which  come directly under the cognizance of   our
senses, without any respect to intimate nature,  structure,
or properties;  while  the  latter has especial  regard to
natural qualities, as  a bond  of  affinity.   In addition to
these two, a third has been  adopted by some  writers on
diseases of the skin, which may be called a local or regional
arrangement—that is,  one in which they are  placed in
groups, dependent on the part of the body upon which they
are seated ;  but, of  course, in this  system, regard must
also be  had to the individual character  and form of  the
various eruptions.
   Of the many systems of classification of diseases of  the
skin  which have  been, from time to time,  proposed,  two
especially of those of the earlier writers are worthy of no-
tice, not alone as being the first which had any pretensions
to accuracy or completeness, but as forming, to a certain
extent, the basis of most of  those which have been since
propounded,—I allude to the artificial system of Willan,
and the natural one of Alibert.  Although Willan adopted,
as  the  ground work of his classification, an arrangement 
CLASSIFICATION.
17
originally proposed by Plenck—following out the idea of
Riolanus put forth nearly a century previously—of placing
diseases of the skin in groups, according to their form and
appearances, yet from  the accuracy and appropriateness of
his nomenclature, which is  that  now almost  universally
employed,  and  the clearness with which he defined the
leading features of his general divisions or orders, it is cor-
rectly regarded as being the first important step made to
the correct understanding of diseases of the skin.   Alibert,
in the first instance, following Turner an Englishman, who
was  himself  preceded by Mercurialis, adopted a  regional
classification,  dividing all eruptions  into two classes, as
they were situated on the head or on the trunk of the body ;
but this  he soon abandoned  for a natural  system, which,
though grandly conceived, did not survive its author, being
found too  complicated and  difficult  of application  when
attempted to be reduced to practice.
   In Willan's system,  cutaneous diseases are divided into
eight orders,  characterized by  the form of the eruption,
viz.:
         Papulae.                 Vesiculae.
         Squamae.                 Pustulae.
         Exanthemata.            Tuberculae.
         Bullae.                  Maculae.
   The distinctive features of the eruptions, by which  these
orders are characterized, he defined as follows : and here I
may again remark  that  his  nomenclature and  definitions
are still in use, and generally recognized as correct :—
   1. Papula (Pimple).—A  very  small  and acuminated
elevation  of  the cuticle, with an  inflamed base, not   con-
taining a fluid, nor tending to suppuration.
   2. Squama (Scale).—A lamina of morbid cuticle, hard,
thickened, whitish, and opaque.
   3. Exanthema (Rash).—Red  patches on the  skin,  vari-
ously figured, in general confluent, and diffused irregularly
over the body, leaving interstices of a natural colour.
   4. Bulla (Bleb).—A large portion of the cuticle detached
from the skin by the interposition  of a transparent, watery

   5.' Vesicula (Vesicle).—A  small, orbicular elevation of
                         2* 
18
CLASSIFICATION.
the cuticle,  containing  lymph, which  is  sometimes clear
and  colourless, but  often opaque and  whitish, or pearl-
coloured.
   6. Pustula (Pustule).—An elevation of the cuticle, with
an inflamed base, containing  pus.
   7. Tubercula  (Tubercle).—A small,  hard, superficial
tumour, circumscribed and permanent, or  proceeding  very
slowly to suppuration.
   8. Macula (Stain).—A permanent discoloration of some
portion of the skin, often with a change of its texture, but
not connected with any disorder of the constitution.
   Alibert, in his natural arrangement, considers cutaneous
diseases to resemble  a tree, which "he terms Varbre des der-
matoses, and the branches of which  constitute the various
divisions or  groups, which are subdivided into genera.   His
primary groups, which are twelve in number, he designates
as follows:—
Dermatoses  Eczemateuses.   Dermatoses Veroleuses.
            Exanthema-                 Strumeuses.
              teuses.                    Scabieuses.
            Teigneuses.                  Hemateuses.
            Dartreuses.                  Dyschroma-
            Cancereuses.                     teuses.
            Lepreuses.                   Heteromorphes.

   Biett, the immediate  and  most celebrated pupil of Ali-
bert, soon perceiving the difficulties which the complicated
system of his  master, though  based on the natural affinities
of the various eruptions of  the skin, threw in the way of
their successful diagnosis, forsook it for that of Willan, which
he modified and so far improved that all the artificial sys-
tems of classification which  have been proposed since  his
time include the changes made  by him.
   Viewed abstractedly, it is manifest that  a  classification
of diseases of the skin which, as a  natural  system is sup-
posed  to do, takes into account not merely the  form but
the essential nature and pathological characters of a cuta-
neous  eruption,  should  possess many advantages,  both
practical  and  theoretical, over an  artificial  arrangement
which  takes cognizance merely of the  alterations of the
skin which  cause the eruption, or, in other  words, regards 
CLASSIFICATION.
19
solely the apparent changes in the cutaneous structure of
the part affected.   Consequently, we find that most modern
writers on the subject have bestowed their attention on the
construction of a perfect natural system, but hitherto, in
my opinion, without  success ; amongst them all there are,
I think, two only at all deserving of notice, that of Eras-
mus Wilson in England, and of Cazenave in France.
  Wilson  adopts,  as the  basis of his arrangement, the
anatomy and physiology of the skin, a groundwork which,
owing to the additions recently made  to our knowledge of
this structure by microscopic investigation, and the degree
of certainty which extended observation has stamped upon
it, has been well employed by him, and renders his system
of classification justly entitled to be designated a natural
one.  He constitutes four primary divisions of the subject,
viz.:—
       1.  Diseases of the Derma.
       2.  Diseases of the Sudoriparous Glands.
       3.  Diseases of the Sebiparous Glands.
       4.  Diseases of the Hairs and Hair Follicles.

   Of the first, five  secondary divisions are made :  1. In-
flammation of the  Derma;  2. Hypertrophy of the Papillse
of the Derma ; 3. Disorders of the  Vascular Tissue of the
Derma , 4. Disorders of the Sensibility of the  Derma ;  5.
Disorders of the Chromatogenous Functions of the Derma.
The first of these  subdivisions constitutes six groups, viz.:
a. Congestive Inflammation, divided into  two sub-groups;
the first  including those affections, in which  both the mu-
cous membranes and the  Derma  are  inflamed, and which
are attended with  constitutional symptoms  of a specific
kind; and the second, those in which the derma alone is
engaged, and in which  there are no specific constitutional
symptoms;  b. Effusive Inflammation; c. Suppurative In-
flammation ; d. Depositive Inflammatton ; e.Squamous In-
flammation ;/. Inflammation from the presence of Acari.
   Of the  second  primary division, three secondary are
constituted, as the diseases are attended with,  1. Augmen-
tation ; 2. Diminution ; 3. Alteration of Secretion.
   Of the  third, five  secondary divisions  are made,  as the
disease of the sebiparous glands are dependent on, 1. Aug- 
20
CLASSIFICATION
mentation ; 2. Diminution ; 3. Alteration ; 4. Retention,
of Secretion;  and 5. In which the Crlands and adjacent
Tissues are inflamed.
  And  the fourth constitutes six secondary divisions : 1.
Augmented Formation; 2. Diminished formation ; 3. Ab-
normal Direction of the Hair; 4. Alteration of Colour; 5.
Diseases of the Hairs ; and, 6. Diseases of the Hair Follicles.
  M. Cazenave,  adopting  likewise an anatomical basis for
his natural system, arranges diseases of the skin in  eight
groups:—
  1. Inflammations.        5. Hemorrhages.
  2. Lesions of  Secretion.  6. Lesions of Sensibility.
  3. Hypertrophies.        7. Foreign Bodies.
  4. Deteriorations.        8. Diseases of  the Appen-
                               dages.

  The first group contains  four  Orders: 1. Non-Specific
Eruptions,  which may exist  in an acute or chronic state;
2. Non-specific  Eruptions, existing  always  in a chronic
state;  3. Acute  Specific  Eruptions;  4. Chronic Specific
Eruptions.
  The second  group is divided into three Orders: 1. Le-
sions of the Follicular Secretions; 2. Lesions of the  Epi-
dermic Secretions; 3.  Lesions of the Colouring Secretion.
  The third group, which constitutes  but a single Order,
is defined to consist in an  abnormal development of the
parts affected.
  The fourth  group contains those diseases which  have a
tendency to destroy the parts attacked.
  The  fifth group  is  characterized  by the presence of
blood, more or less altered, without its proper vessels.
  The sixth group is divided  into two orders: 1. General
or Local Hyperaesthesia ;  2. Anaesthesia.
  In  the  seventh group  are  placed  those  diseases which
seem  to depend on the presence of  parasitical  insects or
animalcules.
  The eighth  consists of  two  orders :  1. Diseases of the
Hair; 2. Diseases of the Nails.
  Both these natural systems, the most perfect that have
yet been proposed, present in some respects, great advan-
tages over  artificial  classifications, yet, I think,  for many
reasons, are not to be preferred.  Could we, for example 
CLASSIFICATION.
21
 predicate  that  the various eruptive diseases, placed by
 Wilson or Cazenave in  the group of inflammations, were
 invariably characterized by inflammatory action, we should
 receive an  important aid, not alone in diagnosis, but in
 treatment.   But such is not the case in the classification
 of  either.    Both place  scaly diseases of the skin in the
 same natural group, though in a different subdivision, with
 the eruptive fevers;  yet can any two classes of diseases be
 more different in their nature ?  The former characterized
 by a chronic inflammation! of so low a form that it is very
 doubtful whether it should be designated as inflammation
 at  all;  while the  latter  are  especially marked  by high
 inflammatory action: the  former tedious and slow in their
 progress, often  lasting  for  years; the  latter, acute  and
 rapid, running their course  in a few days: the  former re-
 quiring a prolonged constitutional treatment, and the latter
 demanding immediate and active remedies.   Thus  an erro-
 neous impression, acquired from a supposed natural affinity
 between two eruptive diseases, may lead to error, both in
 diagnosis and treatment.
   Another  important objection to the employment of  a
 natural system  of classification in the study of diseases of
 the skin is,  that, being more  complicated, and not so easy
 of comprehension,  it is more difficult to be  borne in mind
 than an artificial arrangement, and  thus great obstacles
 are, by its  adoption, thrown  in the way of  the student at
 the very threshold  of his inquiry.  No artificial classifica-
 tion of diseases of the skin can  possibly be perfect, for
 different persons will, of course,  form different ideas of
 the external characteristics and features of individual erup-
 tions ; yet it is an arrangement which seems to me to be
 better adapted for  attaining a knowledge of the subject:
 and this, after all, is the only important use of any system
 of classification.   It is especially one more easy to be re-
 membered.   It is one which aids us  considerably at the bed-
 side, for it  requires  a less complex  process of reasoning
than a natural  classification, to discover by its  agency
what may be the disease  in any special case.   It is, there-
fore, this which  I purpose to adopt.
  A regional classification of eruptive  diseases, although
 it is not adapted for a general inquiry  into affections of 
22
CLASSIFICATION.
the skin, possesses much value in their individual  study,
as they  often present great differences in character and
even in form, and frequently require peculiar modifications
in treatment, dependent on  the  region on which they may
occur.   I  have thus adopted it in  a small work which I
published a few years since on  Eruptive  Diseases  of the
Scalp, and also in an Essay on those which affect the face,
which appeared  in the eleventh volume of the New  Series
of the Dublin Quarterly Journal of Medical Science.  Were
I to propose a regional system of classification, I would sug-
gest .that cutaneous eruptions should be divided into three
groups :   1. Those which  occur  on parts of the body con-
stantly exposed  to  the  air; 2. Those which appear on
parts that are protected from the atmosphere by clothing;
and, 3.  Those which affect the hairy scalp.  The first group
should be subdivided into  those  which occur on the face
(and neck in females), and on the hands ; for as the  latter,
especially in several  trades  and occupations, are exposed
to various matters which cause irritation, and as the skin
there differs  anatomically, in some respects, from that on
the face, eruptive diseases which affect them often present
different appearances, as they are seated on either.   Vesi-
cular  eruptions, in especial,  present  a peculiar character
when they occur upon parts  of the body covered with hair,
—as, for example, on the scalp.   If a blister be applied to
the surface of the scalp, deprived  of  the hair, the blister,
in common language, is  said  not to rise; the epidermis
upon this part of the body being not only somewhat thicker
than elsewhere, except on the soles of the feet and  palms
of the hands, but being  bound down by the numerous in-
volutions which constitute the hair follicles.   When,  there-
fore, a vescular eruption occurs upon the scalp, there is no
apparent vesicle ; and this, I believe, will  account for that
great difference of opinion which exists amongst writers as
to the, nomenclature  of certain  eruptive diseases of the
scalp, I allude especially to  the forms of Herpes.
  The chief improvements which have been made on Wil-
lan's original classification are contained in the systems of
Biett, of Cazenave and Schedel in their joint work, and of
Dr. Hughes Bennett of Edinburgh. Dr. Bennett's modifica-
tion of Biett's arrangement has been published in the Edin- 
CLASSIFICATION.
23
burgh Monthly Jourrnal of Medical Science for April, 1850,
and is in many respects, deserving  of commendation.
  The great difficulty in  devising  an artificial system of
classification  of  cutaneous diseases  depends  upon  the
changes which, in the progress of the disease, all eruptions
undergo, with respect to their characteristic form and appear-
ance.  These changes are often so great that it is sometimes
almost impossible  to  diagnose to what  order  a special
eruption  may belong in its advanced stage, and it is there-
fore  made to occupy a  different place in different  systems.
For example, observers differ as to whether scabies, common
itch, is a vesicular, a pustular, or a papular eruption.   It
certainly changes rapidly, in most  cases, from vesicular to
pustular, or the vesicles become mixed up with pustules ;
but,  in my opinion, it is  always, in its primary  stage, a
vesicular eruption.   In most diseases of the skin, we are,
however, by careful observation, able  to discover the ele-
mentary form  of  the  eruption  in  the early stage of  the
disease:  and from experience we shall always be  able to-
diagnose, even  in  its most extreme  changes, what the  pri-
mary form was.  This, of course, can only be learned  by
prolonged practical experience.
  In proceeding to describe the system of classification of
diseases  of  the skin which I intend  to adopt,  I  wish, in
limine, to disclaim  any pretensions to originality.   My
chief object  is to  endeavour to simplify a subject which
has often not received from the student and practitioner
the attention it merits, owing to the difficulties with which
complicated  arrangements  and ever-changing nomencla-
ture have invested it.  I shall therefore take advantage
of the labours of those who have preceded me, and endea-
vour  to reduce the grouping together of cutaneous erup-
tions to as few subdivisions as attention  to  accuracy will
admit.
  Mr. Plumbe was, I believe, the first modern  writer to
omit those affections which are correctly termed  Eruptive
Fevers from the catalogue of diseases of the ^kin.   Fabre,
in his recently  published  Bibliothlque du Medecin-prati-
cien, has followed  his example, as  also has  Dr.  Hughes
Bennett in his proposed  modification  of Biett's  system.
On this subject Mr. Erasmus Wilson remarks : It may be 
24
CLASSIFICATION.
said that the diseases comprised in the first sub-group [those
characterized by inflammation of the  derma and mucous
membranes, with constitutional  symptoms of  a specific
kind], viz.: Rubeola, Scarlatina, Variola, &c, though here-
tofore  considered and treated of as diseases of the skin,
are, in reality, diseases of the system, of which  the altera-
tion in the skin is a symptom of comparatively  secondary
importance.  I cheerfully assent to  the  validity of this
argument, but I am  nevertheless unwilling to lose a group
of diseases so rich and important in their illustration of the
pathological changes wrought in and upon the skin by active
inflammation."  Independent of these high authorities I
would,  for my own  part, have no hesitation in  excluding
eruptive fevers from being  described amongst diseases  of
the skin ; to consider them still as such is directly opposed
to the advanced position of modern pathology, and can only
tend to diffuse incorrect ideas as to their essential nature.
  A few  recent  dermatologists have  included amongst
diseases of the skin  some  constitutional affections,  in
which  an  eruption—of a special form always—occurs as
a  concomitant  symptom,  and,  as  regards the peculiar
affection, is but  secondary, and more or  less  unimpor-
tant.   The diseases to which I  allude are not met with
in the  British Islands ; they are the  Frambaesia or yaws
of South  America and of the coast of Africa,  the Rade-
syge of the north of Europe, and the Pellagra of Italy and
of Austria.  These  have, I consider, no better claim to be
classed amongst diseases of the skin than has the Plague,
in consequence of its  being attended with malignant pus-
tules and  boils.   I shall, therefore, omit them  from  my
arrangement.
  I propose to divide cutaneous diseases into ten Groups
or .Orders, as follow :—

  1. Exanthemata.          6. Hypertrophic.
  2. Vesicul2e.              7. Hemorrhagic
  3. Pustule.               8. Macule.
  4. Papula.                9. Cancrodes.
  5. Squamje.               10. Dermatophyte.
Adding two supplementary groups, Syphilides  and  Dis-
eases of  the Appendages of  the Skin. 
CLASSIFICATION.
25
   The diseases contained in the Order Exanthemata-are
characterized  by the  occurrence, on a greater  or less  ex-
tended  surface of the skin, of  a blush of inflammatory
redness, usually  more or less  elevated, which  terminates
in epidermic  desquamation, in the form  of fine  mealy
scales.  The most essential  character of the Order is, that
the redness momentarily disappears on pressure with the
finger.  In one form of eruption, classed  amongst the ex-
anthemata, namely, erysipelas, the  epidermis is very com-
monly raised  in large blebs by serous  effusion;  but this
is evidently caused by the  intensity of the  inflammation
which is present, takes place in the progress of the disease,
and  is not a constant or essential symptom.  In general,
the redness is in large  uncircumscribed patches, or unin-
terruptedly diffused over the surface ;  but in some forms
it occurs  in  well-defined,  regular spots.   The essential
nature of the exanthemata  is, that they are inflammatory,
and  they seem to have  their seat in the vascular rete of
the derma.  This Order  corresponds with the second  sub-
group of the first group  of  the first secondary  division of
Wilson's Natural  System, defined by him as " Inflammation
of the derma, without  constitutional symptoms of a specific
kind."  It contains four genera, erythema, erysipelas,
URTICARIA, ROSEOLA.
   The  Vesicule are  characterized  by  an eruption of
vesicles or blebs, which  consist in an elevation  of the epi-
dermis,  varying  in size,  in  some forms minute (vesicles,)
and  in some of tolerable magnitude (bullae or blebs,) con-
taining  a transparent, serous fluid, which, with the progress
of the disease, becomes opaque, and dries into  thin scales
or hard crusts.  The  fluid by which the elevation  of the
epidermis is caused in the vesiculae is at first transparent
and  albuminous,  but  after  a short  time becomes opac^ie,
and  often puriform.   This  order nearly corresponds with
the second group  of the first secondary division of Wilson,
which he defines as " Effusive Inflammation of the Derma."
It contains five  genera: eczema, herpes, pemphigus,
RUPIA,  scabies.   Wilson places scabies in a distinct  sub-
group, defining it to be " Inflammation of the derma, from
the presence of acari."
   The  third  Order,  Pustule, is characterized  by  the
                         3 
26
classification.
eruption of Pustules,—rounded elevations of the epidermis
containing  pus,  which, bursting,  form  scabs  or  thick
crusts.  The  pustules  may be of small  size,  and closely
aggregated together,  or large  and isolated;  the former
constituting the  Psydracia, the latter, the Phlyzacia, of
Willan; a psydracious pustule being defined by him to be
" a minute pustule, irregularly circumscribed, producing
but a slight elevation of the cuticle, and terminating in a
laminated scab," and a phlyzacious one, "of a larger size,
raised on a hard, circular  base of a vivid red  colour, and
succeeded by a  thick, hard, dark-coloured  scab."   The
epidermic covering of  a pustule is much thicker than that
of a vesicle, consequently it takes a longer  time to maturate,
or, in other words, to burst and form a scab or crust; but
in their advanced stage the diagnosis between the two  is
sometimes not unattended with difficulty.  The eruptions
placed in this order correspond with those classed by Wilson
in the third group of his first secondary division:  " Sup-
purative  Inflammation of  the Derma."  The genera are
three in number:  acne, impetigo, ecthyma.   Wilson,
however, puts acne in  a group, the definition of which that
he gives being, " Inflammation of the glands and adjacent
textures."
   The Papule are characterized by an eruption of minute,
solid elevations,—pimples,—generally  reddish, but  some-
times of the  natural color  of the skin, containing neither
serum nor pus, terminating in the disquamation of fine scales,
and almost invariably attended with intolerable  itching.
In some forms, the top of the pimple is of a reddish brown
or black colour, but this merely depends  on the accidental
presence of a small, dried crust of blood, usually effused
by scratching.  This Order contains two genera : lichen,
prurigo.  It corresponds with the fourth group of Wilson's
first secondary divison, which he  defines:   "Depositive
inflammation  of the derma."
   The eruptive diseases contained in the Order  Squame
are  characterized  by the  secretion of dry, laminated,
whitish  scales on the  cutaneous surface,  usually occurring
in  patches, often of a circular form.  The scales, which
are somewhat elevated above the level  of the skin, readily
fall off, to be  again rapidly renewed; the part which they 
classification.
27
cover is  of a smooth, glistening aspect, reddish, and  dry.
The Order corresponds with  the fifth group of the first
secondary division of Wilson's classification :  " Squamous
inflammation of the derma."   It  contains  two genera :
psoriasis,  pityriasis.
  In the Order Hypertrophie, I include those diseases
which  are  characterized by an hypertrophied condition
of the derma or epidermis, or of both, or of the hair fol-
licles.  The term  has  been used  much  in this sense by
Simon, in his " Anatomical Description of Diseases of the
Skin ;"  and from him I have adopted  it.  In its appli-
cation  it is nearly synonymous with  the tubercule  of
former artificial systems of classification.   The latter term,
although probably not so faulty, when first  employed  to
designate a group of cutaneous diseases, is, I think,  highly
objectionable at present, when it is invariably understood
to designate a peculiar morbid  deposit, and its application
in any other sense must tend to cause confusion.  Wilson,
in His Natural  System, has  a group in which  are  placed
those affections that consist in an " hypertrophied state  of
the  papillae of the derma;" but I propose to extend the
application of the term, and to include in the  Order those
diseases  in which the hypertrophy affects the other cuta-
neous structures.   I shall place in it nine genera:  icthy-
OSIS, MOLLUSCUM,  STEARRH03A, ELEPHANTIASIS, VERRUCE,
CLAVUS,  CALLOSITATES, CONDYLOMATA, NEVI.
  The characteristics  of the seventh  Order, Hemorrha-
GIE, scarcely require to be  defined.   In it  there  is a
morbid alteration of the capillary circulation, accompanied
by a changed  or diseased condition of the blood, in which
this  fluid, escaping from its proper vessels, is extravasated
in rounded spots  or patches  beneath the epidermis, and
also beneath  the  epithelium  of the  mucous  and  serous
membranes.  Bursting through the latter finer structure,
more or less bleeding usually takes place from the surfaces
of both  these  membranes.    It contains  but  one  genus,
PURPURA.
  The Order Macule is characterized by an alteration  in
the  colour of the skin, occurring usually  in large patches,
and  unattended with  any  eruption.   The natural  colour
may be deepened,  diminished, or altered  in hue,  and the 
28
CLASSIFICATION.
affection has its seat evidently in the apparatus of the skin
which secretes  the pigmentary matter.  The Order cor-
responds with  the fifth secondary division of  Wilson:
" Disorders of the Chromatogenous Function of the Derma."
It contains two  genera, vitiligo, which includes albinois-
onus, and ephelis.
   The Order Cancrodes  contains  those  diseases of the
skin in which many of their features  resemble cancerous
affections.  They are characterized by a degree of  semi-
malignancy, usually  attended with foul ulceration  of a
slow and insidious nature, often with severe stinging pain,
and a marked tendency to return after apparent cure, or
after excision, in the  same or in remote parts of the cuta-
neous surface.  It contains two genera : lupus, kelois.
   The tenth Order, Dermatophyte, I have adopted from
Bennett.  It includes those  diseases   of  the skin  which
depend  on, or are  characterized by the presence of,  para-
sitic plants.   It contains two genera :  porrigo, sycosis.
   Of the two supplementary Orders, the first—the Syphil-
IDES—contains those eruptions of the skin which are ordi-
narily termed secondary, being caused by, or consequent
on, the introduction  of  the venereal  virus or poison into
the system; and the second includes diseased conditions of
the hair and  nails.
   This classification, in the  drawing up of which  I have
had chiefly in view an attempt to simplify what is admit-
tedly a difficult  study, may be tabulated as follows :— 
              classification.            29

         order.                    genera.
 1. Exanthemata,  .  .  Erythema, Erysipelas, Urtica-
                          ria, Roseola.
 2. Vesicule,   .  .  .  Eczema, Herpes, Pemphigus,
                          Rupia, Scabies.
 3. Pustule,    .  .  .  Acne, Impetigo, Ecthyma.
 4. Papule,   ....  Lichen, Prurigo.
 5. Squame,   ....  Psoriasis, Pityriasis.
 6. Hypertrophie, .   .  Icthyosis, Molluscum, Stear-
                          rhoea, Elephantiasis, Ver-
                          ruca,  Clavus, Callositates,
                          Condylomata, Naevus.
 7. Hemorrhagie, .   .  Purpura.
 8. Macule,   ....  Vitiligo, Ephelis.
 9. Cancrodes,  .  .  .  Lupus, Kelo'is.
10. Dermatophyte, .  .  Porrigo, Sycosis.

              Supplementary  Groups:
    Syphtlides.
    Diseases  of the Appendages of the Skin.
3* 
30               exanthemata.
                 CHAPTER  II.

                    EXANTHEMATA.

  The term "Exanthemata" was employed by the ancient
writers on medicine to designate every variety of eruption
of the skin ; but in modern days, and more especially since
the time of Willan, it has been restricted to denominate a
peculiar group of cutaneous diseases,—one so well definedby
external appearances, that there is no difficulty in diagnosing
any of its forms during all their stages.  They are charac-
terized by the sudden  appearance, on  a  greater  or less
extended  portion of the skin, of an inflammatory redness
in variously shaped patches,  which momentarily disappear
on pressure, are usually attended with a slight elevation of
the surface, and terminate in exfoliation of the epidermis.
The diseases belonging to this Order are almost invariably
accompanied by more or less inflammatory fever, and they
thus constitute a natural group.   In the treatment of them,
however, we  should be careful not to let this idea of inflam-
mation being one of  their marked  characters, lead us to
take too  exclusive a view as  to the remedial measures indi-
cated ; for the attendant inflammation may be either of a
low asthenic form, as it frequently is, or it may assume a
highly sthenic type.
   In Erysipelas, one of the  diseases included amongst the
Exanthemata, the epidermis is  often  elevated  by serous
effusion into bullae, or even large blisters, which has induced
some writers to describe it as a vesicular eruption;  but
these vesications are not a constant or necessary feature of
erysipelas, and when they do occur are evidently dependent
on the high  degree of  local inflammation which  may be
present.
   The four genera belonging to the Order are : Erythema,
Erysipelas, Urticaria, Roseola. 
erythema.
31
                      erythema.
  Erythema {Inflammatory blush) consists in an eruption
of* superficial,  deep-red  stains  or  patches, more or less
circumscribed,  and slightly elevated, attended with  heat
and tingling, and  terminating either in resolution, or with
slight  furfuraceous desquamation.   It  is  non-contagious,
of a mildly febrile character, and rarely a disease of much
importance; most forms of it terminating in  a few days,
and seldom becoming chronic.
  The erythematous  eruption very frequently appears on
the skin in the course of many acute affections, especially
fevers and inflammatory diseases ; often occurs in dropsies,
when it affects the depending parts of the body or those
exposed to pressure ;  may be produced by irritation of the
cutaneous surface, as by the friction of the clothes or of
the opposed surfaces of the skin, as when it appears in the
axillae or in the groins ; and is likewise caused on the un-
covered parts of the body by exposure to harsh winds, or to
the sun in travelling.  The eruption may  appear on any
part of the cutaneous surface, but some of its forms occur
with great regularity in certain regions  of the  skin.
  Several varieties of erythema have been  noticed by der-
matologists, but all  of them  may, I think, be described
under three  heads :—

                  Erythema simplex.
                      "     papulatum.
                      "     nodosum.

  Erythema simplex, under which I include the E. fugax,
E.  laeve,  E. intertrigo,  E.  marginatum,  and E.  circin-
natum of other writers, is generally a  very mild form  of
eruption of the skin,  requiring but  little attention, unless
when it assumes a chronic character,—as intertrigo, when
neglected, or when the causes  by  which  it is produced
are continued, not unfrequently does.   It  appears  in the
form of uncircumscribed red patches, seldom exceeding the
size of the palm of the hand, and scarcely elevated above
the surrounding skin ; it  generally  occurs in  the  course
of some inflammatory disease, when, owing to  the patches 
32
exanthemata.
suddenly  disappearing, and again as suddenly re-appear-
ing on some other part of the body, it  has been termed
erythema fugax; it also assumes the same character  as
indicative of or connected with derangements of the diges-
tive  organs, or obstructed menstruation.   The usual seat
of this sub-variety is on  the face, the neck, the trunk,  or
the upper extremities; there is no  constitutional disturb-
ance marking its  occurrence, and the only local symptom
is a slight degree of heat in the part attacked.  Thus, then,
it would appear to be a very unimportant disease^ were it
not for a  remark of Hippocrates, the truth of which has
been confirmed by most modern observers, that the occur-
rence of erythema fugax in fevers or acute diseases is an
unfavorable sign.
  This form of erythema, when it occurs in dropsical per-
sons, presents a bright red,  smooth, and shining aspect,
whence it has been termed erythema Iseve.   It usually ap-
pears in rather large patches, which spread rapidly,  and,
if exposed to continued pressure, may end  in ulceration,
and  even  in  mortification when  the  vital powers are very
low.
  The sub-variety, which has  been denominated  inter-
trigo, occurs very commonly amongst children, whose fine
skin  may  have been chafed from any local irritation,  as
from the  surface  not being sufficiently cleansed from dirt
or from the  natural secretions; it also appears in adults,
especially during hot weather, in whom it  is  usually pro-
duced by  the friction of  opposed surfaces of  the skin,  or
by rubbing of  the clothes.   In  its  commencement  it  is
characterized by the ordinary appearances of an erythema-
tous eruption, but  affecting, as it chiefly does, those  parts
of the cutaneous surface  in which  the  sebaceous glands
most  abound, it  is soon  attended with  a   diseased  exu-
dation from both the sebaceous and sudoriparous glands,
and  the  parts  are coated with  moisture of  a  fetid and
acrid  character, which  keeps up  the inflammatory irrita-
tion, and  may even cause troublesome  ulceration.   The
two other sub-varieties of erythema simplex were named
by Willan from  the form which they assume, the  one,
circinnatum, which  occurs in small, round, slightly ele-
vated patches, while the other, marginatum, is more eleva- 
ERYTHEMA.
33
ted at  the  edges  than in the  centre, the  margin  being
thus well-defined,—the patches are generally of a deep-red
bue.  The former occurs, for the most part, during some
inflammatory disease, with the cessation of the acute symp-
toms of which it usually disappears ; and the latter seems
to be a  form which erythema simplex frequently assumes
in the old.
  Erythema papulatum is  of frequent occurrence, espe-
cially in young persons  about the age of puberty, and in
females in whom the menstrual functions  may  have been
obstructed.   It  appears most generally on the  backs  of
the hands and  fingers, but  also occurs on  the  face,  the
neck, and other parts of the  body.   It is characterized by
an  erythematous blush on an uncircumscribed  surface of
the skin,  on which there  are numerous  small, round ele-
vations, about the size of  a pea, of a deeper red hue, the
portions of  the skin between the elevations being always
of  a paler or less bright colour.   The commencement of
an attack of this variety is attended with some fever, head-
ache, and  slight nausea, and there are heat and a disagree-
able sensation of tingling iff the affected parts,  which  are
also slightly sore to the touch.   This form of the eruption
is of  no great  importance, lasting usually  for only a few
days, and  very rarely assuming a chronic character.  Some-
times rather larger  elevations  are intermixed with the
others, or they may all from the commencement assume
the size of a nut or a large marble, when the variety has
been named tuberculatum ; it presents this character most
frequently on the  extremities; the raised spots  are  there
harder to  the touch, attended with more local annoyance,
and the eruption more frequently becomes chronic.
  Erythema nodosum, is  so  called from the appearance
which the eruption presents.   It usually occurs on the an-
terior aspect of  the lower extremities, generally from the
knee to the ankle.   I have seen a few cases in which it was
situated on the back of the arms, and I have also  occasion-
ally seen a few spots on the  anterior surface of  the body.
It appears in distinct rounded or oblong red patches, from
half an inch to even  two  inches in diameter, with a well-
defined border,  circumscribed, and slightly elevated in the
centre,—but the elevation is more apparent to the eye than 
34
EXANTHEMATA.
to the finger when passed over the part.   The  centres of
the patches or knots are of a somewhat brighter colour
than the borders, which have a dark red blush ; the general
redness fades but slightly on pressure, which, however, causes
pain,  and on the pressure being removed the colour imme-
diately re-appears.   This form of erythema is most gener-
ally met with in young girls from  the age of 14 to 19
or 20, rarely appearing in males.  It has  been described
by some as  being connected with a deranged state of  the
menstrual functions, but in  my experience I have rarely
seen it produced by such a cause.   It is attended with more
fever  than  any of the other forms  of erythema, being
generally ushered in with nausea, sometimes even vomiting,
pains  in the back, loins, and head, together with loss of
appetite and slight  shivering.  This state may continue
for from twelve to twenty-four hours.  The patient then feels
a sensation of heat and tingling on the fronts of the legs, and
on  examination the  characteristic eruption  is seen.   The
knots  or patches appear simultaneously over the surface, not
coming out in succession, increase in size and become harder
and more painful for three  or  four days, then deepen in
colour until the eighth or tenth day, when they begin to
fade,  and passing often through  the  green  and yellow
stages of a  bruise, disappear with slight  desquamation of
the epidermis in about a fortnight  or three weeks from the
commencement of the attack.
  The seat of erythema is manifestly in  the vascular struc-
ture of  the derma, the nervous functions being but little
affected; the causes by  which it  is produced have been
already adverted to.   An epidemic of erythema  has been
described  as having occured in Paris  in  1828-29, as  a
complication of a painful affection of the extremities, thence
termed Acrodynia, which raged there at that period. M. Ca-
zenave, who witnessed it in the Hopital St. Louis, describes
its characters as consisting in " an erythematous  circle of
a crimson colour appearing on the  soles  of the feet, and on
the palms of the hands, covering a  space of from a third to
two-thirds of an inch, and disappearing  under the pressure
of the finger ; it presented the peculiarity that the portion of
the skin which surrounded it was generally of a yellowish
colour, swollen and very hard, while the affected patch was 
ERYTHEMA.
35
manifestly depressed and very painful to the touch.   These
spots of erythema also appeared occasionally on the thighs,
the scrotum, and in the axilla."
  The diagnosis of any of the forms of erythema is  in very
few instances attended with much difficulty.  It may be mis-
taken for the milder forms of erysipelas, especially in their
early stage, but the blush of erythema is of a deeper red,
and less livid than that of erysipelas, is not attended with
the same amount of local tumefaction, burning heat, and
pain, and is marked by much less disturbance of the system
generally, und  much  less fever.   That form of erythema
simplex which has been named fugax has sometimes been
mistaken  for urticaria evanescens;  they are both exan-
thematous eruptions ; but in  the latter the eruption disap-
pears and re-appears  with constant rapidity, generally in
the  same places; while erythema fugax, though  nearly
equally evanescent, does not  return to  the same parts ;  it
is, too, unattended with the acute itching and annoying
tingling so characteristic of urticaria, and moreover occurs
in the course of some disease of the general system, while
urticaria  evanescens is an idiopathic affection.  Erythema
papulatum has sometimes  been mistaken for  some of the
eruptive fevers, as for measles or scarlatina;  but its local
character, its appearance upon the hands, and its  papular
elevation, serve to distinguish it from measles,  in which the
eruption is of a crescentic form, of a duller red colour, and
attended  with  a  catarrhal fever.   As  regards scarlatina,
the bright redness of the efflorescence and the  acute inflam-
matory fever, together with the sore throat of  that disease,
should suffice to render the  diagnosis  easy.  Intertrigo
may be confounded with chronic  eczema,  occurring behind
the ears, in the axillae, or  in the  groins ; the latter, how-
ever, is a vesicular eruption in its  primary stage,  and as it
advances is marked by the copious serous discharge, tume-
faction, and deep red fissures, which so remarkably charac-
terize the disease.
  The prognosis in any form  of  erythema is, of  course,
very favourable ; all the varieties  being of a slight  charac-
ter, lasting but for a short time, and the patient recovering
without any detriment to the general health.
   Treatment.—In  the very  common  form of erythema 
86
EXANTHEMATA.
simplex, caused by exposure to the heat of the sun or harsh
winds in travelling, nothing further is required than anoint-
ing the parts affected with some mild oleaginous application,
such as  cold cream or fresh olive oil: a  common domestic
remedy, but not so efficacious as the cream of cow's milk.
When the eruption occurs in the course of any acute disease,
no local application should be used except the warm bath, if
it is not otherwise contra-indicated; and where it is symptom-
atic of any derangement of the digestive organs or of any
othgr part or function of the general system, the constitu-
tional, not the local affection should be treated. In erythema
laeve the parts should be carefully protected from pressure,
gently sponged with the dilute solution of subacetate of lead
warmed, then  well dried, dusted over with flour, and enve-
loped in raw cotton.  When the disease  appears inclined to
spread, I have found lint wet with the lead-wash, and covered
with oiled silk,  the best  application.
  Erythema  intertrigo  is  sometimes very obstinate, espe-
cially in children, when it occurs  behind  the ears, as it very
frequently does.  As a  preventive, and in the early stages,
dusting  the parts with very  finely powdered lapis cala-
minaris is often useful;  but when it becomes at all chronic,
an  ointment  consisting of  two grains of the carbonate of
lead, half  an  ounce of white wax ointment,  and half a
drachm  of glycerine, is better adapted.  With some very
chronic cases, all greasy applications seem to aggravate the
disease, when I  have seen it rapidly get well from the use of
a lotion containing three grains of the sulphate of copper
in an ounce of elder-flower water, applied on lint, kept con-
stantly wet with it.  In adults, intertrigo of the groins  is
occasionally very  troublesome  and sometimes obstinate,
especially when the  irritation is kept up by walking; the
cucumber ointment of the French pharmaceutist has proved
more successful in my hands in these cases than any other
application : in the commencement of the eruption it gen-
erally effects a  cure in a few days, the affected parts having
been each time previously cleansed  with a moist towel, and
then dried;  it should be rather thickly smeared over them
three times a day.   If  the cucumber  ointment cannot be
obtained, an ointment  prepared by rubbing together two
grains of  acetate of zinc dissolved  in  a drachm of rose- 
ERYSIPELAS.                37
water, and an ounce of cold cream, may be substituted for
it.   Erythema papulatum is best treated in young persons
by mild antiphlogistics, especially the saline cathartics, or
emeto-cathartics.  When the accompanying fever is at all
well marked, and the disease occurs in robust constitutions,
the use of a mixture containing two grains of tartar emetic
and two ounces of sulphate of magnesia in a pint of water,
of which a  wine-glassful is taken every second hour until
vomiting or purging be produced, is generally attended with
much benefit.   When it attacks old persons, or assumes the
tuberculated form, tonics, as the compound tincture of bark
in infusion of  quassia or of  calumba, are  indicated; the
strength also should be supported with nourishing diet, and
wine  allowed.   Should this variety of  erythema be asso-
ciated with deficient or obstructed menstruation, the prepa-
rations of iron  will in general be found beneficial, unless
the  derangement  be  accompanied by  plethora or  local
congestions, when of course an antiphlogistic plan of treat-
ment should be adopted.
  Erythema nodosum, like the form last  described, is not
benefited by local  applications, if  we except the general
warm  bath  which may be  used every second or third day.
The  patient should remain quiet in bed, and live low until
the  feverish symptoms abate;  saline antiphlogistics, the
bowels having  been previously freed by a mild mercurial
purge, are of  much service; of  these,  a good  form is  a
mixture consisting of half an ounce of bitartratc of potash,
a drachm of borax, two drachms of white sugar, and twenty
fluid ounces of  water, of which two  ounces may be  taken
every sixth hour.  While the use of the general warm bath,
as above remarked, is  usually productive of much benefit
in this form of erythema, local baths, such as the foot-bath,
generally  aggravate the disease, in  consequence of their
determining an increased afflux of the blood to the affected
parts.

                      ERYSIPELAS.
  Erysipelas (St.  Anthony's Fire) is characterized by a
diffused shining redness  of the skin, attended  with  burn-
ing heat,  pain, tumefaction,  and a tendency to spread,
and  terminating  in resolution with or  without' previous
                         4 
38
EXANTHEMATA.
serous effusion beneath the epidermis, in  suppuration, or
in gangrene.  It may be  conveniently considered  under
two divisions :—

              Erysipelas idiopathicum.
                  "     traumaticum.
   Cazenave arranges the varieties  of it which have been
described into three groups: True erysipelas, in which the
inflammation is confined to the skin; Phlegmonous erysipe-
las, in which the disease extends more or  less deeply into
the sub-cutaneous areolar tissue;  and Gangrenous erysipe-
las, in which the inflamation terminates in mortification.
   Idiopathic erysipelas almost invariably attacks the head
and face, so much so that some writers, amongst others  Dr.
Watson, propose to restrict  the term  to  that disease in
which  this  portion of the cutaneous surface is diffusely in-
flamed ; but the inflammation so frequently spreads from
these  parts to the integuments of the neck and trunk,  and
as in some cases it appears primarily even  on the extremi-
ties, I cannot agree with this proposed restriction.  In  one
case, that of a young man, eighteen years of age, who  was
brought into Jervis-street Hospital in the year 1846, every
part of the cutaneous surface, even to the soles of the feet,
was affected Avith idiopathic erysipelas; it had commenced
on the integuments of one  side of the face after exposure to
cold, and spread so rapidly that, on  the fifth day, the entire
of the body  was engaged  in the disease;  he died  on  the
second day after his admission into the hospital, the seventh
from the appearance of the eruption.
   Idiopathic erysipelas is, in nearly all cases, ushered in
with well-marked febrile symptoms, shivering, pain  in the
back  and  limbs, loss  of appetite, thirst, bad taste in  the
mouth, nausea, and rapid pulse, which, however, is often
very compressible; the urine  is  scanty  and high-coloured,
and the bowels  costive.   In  a few cases, more  especially
in very old  persons, or in broken-down habits,  the local
symptoms are attended with very little constitutional  dis-
turbance.   The erysipelatous inflammation frequently ap-
pears first on the tonsils, when the patient complains of the
symptoms of an ordinary sore throat, but, on examination
they present a darker red hue than is usually present in 
ERYSIPELAS.
39
tonsilitis, and they are also more swollen. Within the next
twenty-four hours diffuse swelling  and redness appear on
some part of the cutaneous surface of the face or head, ac-
compained  by burning heat, pain, and tension, the pain
being much  increased by the slightest touch, resting the in-
flamed part on the pillow even being often intolerable. The
surface pits on pressure with  the finger, which also causes
the redness to fade momentarily; the affected part is bright,
shining, and swollen, but smooth.   With the  progress of
the disease the tumefaction increases much, especially where
the integuments  are loose, as in the eyelids and ears, and
around the  eyes, so that on  the second  or third day the
eyes are usually quite closed by the swelling.
   The local inflammation generally attains its height about
the sixth or seventh day, when, if  vesications have ap-
peared, they burst, and give exit to an acrid, ti'ansparent,
watery discharge, which  occasionally irritates the  sound
skin in the  neighbourhood over  which it may flow.   These
vesications rarely appear before the fifth day of the erup-
tion, and run a very rapid course; they vary in size from a
few lines  to an  inch  or more in diameter.  The constitu-
tional  fever, which increases with the maturation of the
eruption, being most severe on the fifth or sixth day, when
delirium frequently occurs, declines with the diminution of
the local symptoms;  the redness now  begins to fade, the
swelling subsides rapidly,  and the disease  terminates in fa-
vourable cases with desquamation of the  epidermis on the
tenth or twelfth day.
   When the erysipelatous inflammation extends to the sub-
cutaneous tissue  and  deeper seated structures, the disease
is denominated erysipelas phlegmonodes. This form appears
more  frequently  on the  extremities than on the head or
trunk of the body.  The constitutional  symptoms by which
it  is ushered  in, and which  accompany it,  are of a more
severe character, and very frequently assume a typhoid
type.   As regards the local characteristics, the portion of
the integuments affected presents a dull red  or livid colour,
is  intensely painful, hot,  and tense, pits more deeply on
pressure, and is more tumefied. The inflammation here very
seldom terminates in resolution,  suppuration usually occur-
ing in the areolar  tissue, with  death  and sloughing to  a 
40
EXANTHEMATA.
greater or less extent to this structure, occasionally ending
in mortification of the part attacked.
  Erysipelas spreads over the  cutaneous surface often with
great rapidity, yet assuming a  regularly progressive course,
the parts on which it first appeared being those, when the
disease ends in  resolution, which first desquamate.  Thus
it  sometimes occurs  that  the  eruption is fading from the
face and  the swelling disappearing there, while the disease
is  beginning to  show itself on the side of the head or the
neck.  Erysipelas is in an occasional case seen to assume
a singularly erratic course, fading rapidly from the part on
which it appeared, and suddenly attacking another portion
of the skin at some distance, not spreading to it by con-
tiguity.  This has been  made a distinct variety by some
writers under the name of erysipelas erraticum.  Dr. Graves
was the first to notice a singular fact, as regards the mode
of spreading of erysipelas, that when it commences at any
point of the mesial line of the body it is very apt to spread in a
symmetrical manner ;1 that is to say, corresponding portions
of the integuments are simultaneously attacked on both sides.
  In the course of erysipelas, the inflammation sometimes
attacks one or more  of the internal  organs, as  the mem-
branes of the brain, the larynx and trachea, or the gastro-
intestinal mucous membrane.   By some this is considered
to be a metastasis; and on this supposition it has been de-
scribed as a distinct variety of the eruption under the name
of erysipelas metastaticum; but in all  the cases that I have
seen in which any internal part of the body  became thus
affected, the local erysipelatous inflammation still remained
unchanged,  and  therefore it could not be correctly termed
metastatic.
   Traumatic erysipelas has its origin in some local injury
which may or may not have caused breach of the surface;
it  more usually,  however, succeeds   the former;  when  it
spreads from an ulcerated surface it is also said to be trau-
matic.  ^ In  its local  characteristics it corresponds in most
cases with the phlegmonous form of the disease, presenting,
however, more effusion of the liquor sanguinis into the deep-
seated tissues, in consequence, seemingly, of which, vesica-
tions rarely appear on the surface.   The  inflammation is
         ' Clinical Medicine, Second Edition, vol. ii., p. 327. 
ERYSIPELAS.
41
also more  diffuse, spreading rapidly from the wound, and
unless checked by treatment, rarely becoming circumscribed.
The parts affected, too, are more apt to become gangrenous,
a not uncommon result in bad constitutions.  The general
symptoms of traumatic erysipelas most frequently assume a
typhoid type, and are attendant on, not antecedent to, the
local  inflammation.  In  some few rare cases of this form
both  the local and constitutional symptoms are very mild,
and do not  last for a longer period than a week or ten days ;
in general, however, their duration is prolonged to from a
fortnight to three weeks, if death does not take place at  an
early date.
  In idiopathic  erysipelas  death most usually occurs from
the result of inflammation  attacking some internal organ ;
but patients occasionally sink under  this disease with the
ordinary fatal symptoms of asthenic or typhus fever.  The
traumatic form often terminates in gangrene, or,  the veins
becoming inflamed, purulent  deposits  take place in  the
lungs or liver, and the individual dies of phlebitic pneumo-
nia or hepatitis.
  Erysipelas may occur at  any age, even in new-born chil-
dren, in whom it attacks the umbilical region, from whence
spreading rapidly, it almost invariably proves fatal. Gene-
ral experience  seems to prove that it is more frequent in
females thtin in males, and in adult  life than in the very
young or the aged.  The causes of erysipelas are at times
very obscure, yet in many cases  its origin can be distinctly
ascribed either  to  some local action,  as  in the traumatic
form, or when it is produced by some direct irritant, or to
some general constitutional disturbance: indeed the latter
may be said to be always requisite as a predisposing cause.
Thus it is often seen to arise from the same causes as those
which under other circumstances  produce  fever: it follows
exposure to cold or wet, especially when the persons so ex-
posed are deprived of their usual food or stimulants; I saw
several cases of  erysipelas  of the face and head occurring
in car-drivers and others, who from their occupation were
much exposed to the weather, at the time Avhen the tempe-
rance movement first occured in  Ireland, and in Avhom the
disease was evidently traceable  to the Avant of the stimuli
which they  had been previously in the habit of using freely. 
42
EXANTHEMATA.
A very fatal  form of erysipelas is caused by the introduc-
tion of an animal  poison into the system, as by the inocu-
lation  of morbid matter arising from wounds received dur-
ing dissection, from  persons labouring under phlebitis, &c.
Erysipelas  may be produced by a sudden  violent mental
emotion, as  a fit of passion,—such cases are on record,—
in which the local determination of blood probably aids in
the production of this disease.  In young children vaccina-
tion is sometimes the exciting cause of erysipelas, when it
usually presents an  oedematous character:  I Avitnessed a
case lately Avhich thus arose, and in Avhich the inflammation
spread from the vaccine pustule on the left  arm to the fin-
gers, thence proceeded up along the fingers  of the opposite
arm, and ^topped  Avhen it reached the same height on this
arm that it originated from on the other: the child recovered.
   As to  whether erysipelas is contagious or  not, a singular
difference of opinion has always existed and still exists be-
tAveen  the practitioners  of the French and English school;
the former  laying it doAvn as one of  the  characteristic
definitions of the disease that it is non-contagious, and the
latter with almost universal consent asserting that it is mar-
kedly  contagious.   The  simultaneous  occurrence  of  the
disease amongst a number of persons  is attempted to be
explained away by the French writers  on the principle that
such persons were predisposed to it,  or that an epidemic
influence, or  a  peculiar atmospheric condition, reigned at
the time.  It is unquestionable that  at certain seasons or
during certain  years, the contagiousness of erysipelas is
more manifested than at other times, but this  is  equally
true of all  other contagious diseases.  The direct proofs
now accumulated are too numerous and too certain, I think,
for the question  to be  any longer one of  doubt, and no
British surgeon would, I feel confident, undertake an opera-
tion in an hospital in Avhich erysipelas  was  present.   The
form of erysipelas arising from an animal  poison is deci-
dedly  the most contagious ; the medical attendants  and
nurses are in such cases generally infected, and they convey
the disease even to others.   It has been often  remarked
that when puerperal fever—which is manifestly due to the
presence of a morbid poison in the system—prevails  wounds
are very apt  to take on  erysipelatous inflammation,'and the 
                   ERYSIPELAS.                 43

disease spreads rapidly by contagion; and  likewise when
erysipelas occurs epidemically, that puerperal fever is apt
to arise.   The truth of these observations has been several
times confirmed  in  the  Rotunda Lying-in Hospital, and
large surgical hospitals of this city.
   Persons who have had an attack of  erysipelas  are  very
liable to  he again affected Avith it,^a distinguishing feature
between  it and the eruptive fevers.*"
 _ The diagnosis of erysipelas is rarely attended  with any
difficulty.  From  erythema, which, however, some derma-
tologists  regard  as merely a mild form of erysipelas, it is
distinguished by the attendant  constitutional symptoms,
the smoothness of the tumefied surface, the greater degree
of swelling, and  the burning pain and tension.   It differs
from the eruptive fevers in  the  uniform redness which the
inflamed surface exhibits; from  phlebitis, in the absence of
the cord-like feel Avhich the inflamed veins present, and in
the inflammation not spreading in lines over  the track of
the large vessels ; and from  synovites in the inflammation
not being confined to, or taking its origin from, the integu-
ments covering the synovial membranes,—but in many cases
synovitis terminates in true erysipelas.
   The prognosis in  idiopathic  erysipelas  is in general fa-
vourable, unless when  the disease occurs in the  very old,
in broken-down habits of body,  or in  extreme  infancy.
The chief indications  of  danger are,  the attendant fever
assuming a  low typhoid type, or some internal organ be-
coming  affected.   When the erysipelatous  inflammation
attacks the  larynx and glottis, which  may always  be  ap-
prehended when  it  is seated on the integuments covering
these parts, it  usually proves rapidly  fatal, owing to the
tumefaction Avhich ensues, closing up the respiratory tube.
Erysipelas of the phlegmonous character is  ahvays more
dangerous  than Avhen the inflammation is superficial;  and
in the traumatic form, unless the local symptoms are very
mild, the prognosis is ahvays grave.
   With reference to the pathology of erysipelas  it is evi-
dently an  acute  inflammation of all  the structures of the
skin, the vascular rete being chiefly affected.  M. Blandin
has propounded the theory  that the  seat of the inflamma-
tion is in the capillary lymphatics, and M.M. CruAreilhier 
44                EXANTHEMATA.

and  Ribes, that it is situated in the capillary veins of the
integuments.
  The treatment of idiopathic  erysipelas may be conve-
niently  considered  under two  heads,—the constitutional
and  the local.   As regards  the  former,  many different
views have  been  propounded,  the  supposed  indications
depending on the idea formed  as  to the  essential nature
of the disease.  Thus those who  believe it to depend  on
some deranged  condition of the  hepatic  secretion,—the
prevalent opinion among them being that it is caused  by a
deficient secretion of bile and  a consequent  accumulation
of it in the system,—treat all forms of erysipelas, no matter
what may be the age or condition  of the patient, bythe
administration of remedies calculated to promote a copious
evacuation of that fluid by the alimentary canal.  Others,
regarding it as  a highly inflammatory disease, employ de-
pletion,  and other active antiphlogistics ; but  this plan of
treatment, although it may succeed in the robust dwellers
in country districts, is not at all suited  for the inhabitants
of towns or large cities.  With some,  the affection being
viewed as one of  asthenia,  being  attended with or depen-
dent  on diminished vital poAver,  the  use of tonics and
stimulants is relied upon ; while again, others, finding that
the urine is highly acid in the early stages of the disease,
as it is in all febrile affections, recommend an alkaline treat-
ment.
  Seeing that these so opposite plans of treating erysipelas
are reported  by those Avho have proposed or adopted them
as being attended  with almost invariable success, we are
forced to the  conclusion,  that in the ordinary run  of cases
constitutional treatment  is of little importance.  Unques-
tionably cases occur in  Avhich there are  extreme inflamma-
tory action and high fever,  demanding the  use of bleeding
and antiphlogistics; and others in  Avhich the  vital  power is
so low and the accompanying fever assumes from the onset
so marked  a typhoid type,  that the most powerful tonics,
stimulants, and nutrients are clearly indicated.   My own
experience, which,  however, it  is  right to  say, has  been
chiefly acquired  in this large and crowded city, is decidedly
in favour of the tonic and stimulant plan of treatment.   I
ordinarily rely on the use of bark, which  I give from the 
ERYSIPELAS.
45
very commencement of the  disease;—in  the  very old  or
debilitated combining it Avith tincture of serpentaria, as in
the following form :—

       R  Tincturae Cinchonae,.......fl  jiv.
          Tincturae Serpentariae,......fl  3iij.
          Tincturae Croci,.........fl  Jj
          Decocti Cinchonae,........fl  Jxj.  Misce.

            " An ounce to be taken every sixth hour."
  At the same time giving wine and nourishing diet accord-
ing to the circumstances of each case.
  The preparations of iron are by many preferred to those
of bark  in the treatment  of  this  disease; their mode of
action would  appear to  be similar:  the tincture  of the
sesquichloride, in the dose of from twenty  to twenty-five
drops every second or third hour, has been especially re-
commended by Dr. and Mr. Bell,  of Edinburgh, in a paper
lately published by them.1
  I consider the use of purgatives in the early stages of
erysipelas as decidedly objectionable : they tend to increase
the debility, usually  so  important a characteristic feature
of danger, and, determining  to the mucous membrane of
the alimentary canal and to the  abdominal viscera,  their
action prevents the full development of the eruption on the
cutaneous surface,—a circumstance to  be especially avoid-
ed in  the treatment of all inflammatory diseases of the skin,
—and thus gives rise to local congestions and  transference
of the inflammation to some internal organ.
  The use of billiary evacuants  has  been  very  strongly
supported  in an excellent practical essay published  by Dr.
Albert Walsh f the remedy he recommends being tartar
emetic, in rather minute  doses,—one  grain  dissolved  in a
quart of some emollient drink, as  whey or barley water, in
the twenty-four hours;  he continues its use until the erup-
tion begins to fade, when he administers sulphate  of quina
and other tonics.
  Mr. Lawrence is the  chief advocate in the  present day
for bloodletting and active antiphlogistics; but  in his vieAVS,
  1 Monthly Journal of Medical Science, June, 1851.
  2 Dublin Quarterly Journal of Medical Science,  New Series, August, 1850. 
46                EXANTHEMATA.
as regards the constitutional treatment  of  the disease, he
has very few followers.
   If any internal organ be attacked during erysipelas, the
most active derivatives to the surface should be employed.
Thus,  when the membranes  of the  brain are engaged,
sinapisms and  blisters should  be applied to the legs, and
Avarrn stupes to the  head;  active purgatives also are now
indicated, and of these the most valuable is the turpentine
enema.    When the  inflammation  seizes  on the larynx,
leeches, even although great debility be present,  should be
applied beneath the angles of the jaws, and hot stuping to
the throat, with relays of  sponges  assiduously employed;
a blister to the nape of  the neck is also here a valuable
remedy.   The  operation of tracheotomy is  not  applicable
in such  cases, for the erysipelatous inflammation spreads
rapidly  downwards through the respiratory tubes, causing
copious effusion into their sub-mucous areolar tissue.
  When erysipelas affects the scalp, the hair should be im-
mediately cut as close as possible, with the view of keeping
the surface cool, and of permitting local remedies to be more
easily applied.
  In the milder forms of idiopathic erysipelas, the best and
only local  treatment requisite consists in dusting the in-
flamed parts freely  with wheaten flour or finely  powdered
starch, which may  be conveniently applied from an ordi-
nary dredging-box;  the dredging should be repeated several
times  in the twenty-four  hours.   It  allays the burning
pain and irritation, and always proves highly  grateful to
the patient; therapeutically it appears to act by protecting
the surface  from the air, and  by drying  up the  discharge
as fast as it exudes  from any vesications which  may have
formed.  When the vesications are numerous, and the dis-
charge excessive, I have found  the addition of a drachm of
oxide of zinc and twenty grains of finely poAvdered carbon-
ate of lead  to half a pound of starch  of  much advantage.
In  using  this combination  the mixed powders  should be
well shaken each time before the parts are dusted with them,
as, in consequence  of their specific gravity, the zinc and
lead soon sink to the bottom of the vessel in Avhich they are
kept.
  Anointing the inflamed surface  with melted  lard  is by 
ERYSIPELAS.
47
some preferred to the use of dusting powders.  Mr.  Wil-
son speaks highly of his experience of it, having first, he
says, employed it on the recommendation of Mr. Grantham,
whose method is,  "to relax the skin with hot water or steam
fomentations,  and after each fomentation to saturate the
inflamed surface with hot lard, which is afterwards covered
with wool."
  When erysipelas  is spreading  rapidly, although super-
ficially, over  the  cutaneous  surface, the inflammation  still
persisting in  the  parts where it first  appeared, inunction
with mercurial ointment has in my experience  more effect
than any other local application in checking  its progress.
The ordinary mercurial  ointment,  to every ounce  of which
a drachm of glycerine has been added, should  be smeared
thickly over the  inflamed surface, and on the sound skin
for  a considerable distance beyond; it need be applied only
twice in the tAventy-four hours, and if any  symptoms  of
salivation be produced, its employment should  be at  once
stopped.
  Acting as  an  impermeable varnish, and probably pro-
ducing some effect also by the compression it causes, colodion
has been successfully employed  by Spengler and Rapp  as
a local application  in erysipelas; the parts are thickly
coated with it by means of a camel's hair pencil,  and it is
renewed, as  often as may be required in consequence of its
cracking and peeling off when dry.  When the disease
affects one of the extremities, bandaging the limb  has  been
used with very favourable results : this practice originated
with the Continental school;  its  action seems to depend
chiefly on the equable compression exercised on  the  con-
gested capillaries  and cutaneous veins, whereby  they are
emptied of the excess of blood contained in them ; but some
of the good effect produced is also probably due to the pro-
tection from the action of the air thereby given.
  Phlegmonous and traumetic  erysipelas demand  more
active local medication than  Avhen  the  inflammation affects
the superficial layers of the integuments merely.  In these
forms  of the disease many rely on topical  depletion by
leeches, by punctures, or by  deep incisions.  While leeches
may produce a good effect by withdrawing blood from the
inflamed superficial vessels,  the determination caused  to 
48                EXANTHEMATA.
parts on which their suction power is exerted is to a certain
extent  productive  of mischief.   The same objection  does
not hold with regard to  punctures;  their employment has
been highly  advocated, amongst others,  by Sir Richard
Dobson, by Liston, and  by Wilson; they should be made
with a  lancet, all over the inflamed part, at distances of
from a quarter of an inch to an  inch, according to the ex-
tent of  the surface engaged, and penetrate to the depth of
a quarter of an inch.   As soon as they have nearly ceased
to bleed, a  warm bran poultice may be applied.   Mr. Cop-
land Hutchinson strongly recommended free incisions,  and
his practice has been adopted by Lawrence, Guthrie,  and
others; they should  be made  down  to  the  subcutaneous
fascia,  and  be several  inches in  length.  When there is
much deep  seated effusion of  the liquor sanguinis, as is so
frequently  the case in traumatic erysipelas, they are deci-
dedly productive of the best effect,  and they should never
be omitted  when matter has formed.
   Nitrate of silver is used in the treatment of erysipelas
with two intentions, to check the spread of the inflammation
superficially, and to  promote resolution in the parts which
have been attacked.   With the former view a broad line or
cordon is made on the sound skin, at a short distance from
the margin of the inflamed surface, by the application  of a
solid stick  of the nitrate on the part, previously wet with
pure Avater; when the disease is  situated  on  one of  the ex-
tremities, this line is made to surround the limb  completely.
Mr. Higginbottom, who amongst English surgeons is the
chief advocate for the use of this agent, at first recommend-
ed the  employment of  the solid nitrate to  the inflamed
surface; but in his  observations, recently published, and
which  contain  the results of his accumulated  experience,
he states that he prefers a solution containing  a scruple of
the salt to a drachm of distilled water.  He gives the following
direction for its application:  " The affected parts should be
washed Avell  Avith  soap and water,  then with water alone,
to remove  any  particle of soap  remaining, and then wipe
dry with a soft cloth:  the  concentrated solution of the
nitrate  of  silver is then to be applied  two  or  three times
over the whole inflamed surface,  and beyond it  on the  sur-
rounding healthy skin, to the extent of two or three inches." 
URTICARIA.
49
In twelve hours, should the erysipelatous inflammation be
unaffected, it is to be again applied ; when vesications exist,
they  should be opened previously to the  application.  I
prefer to use the nitrate of silver in the form of  ointment,
a drachm  to  the ounce of lard; it thus comes  more com-
pletely into contact with the  inflamed surface, does not dry
up so rapidly, and is more easy of application to some parts
of the body, as to the scalp.
  Sulphate of iron,  both  in solution and in ointment, has
been recommended as a most valuable local  application in
erysipelas by Velpau, but  I have not seen it prove so useful
as nitrate of silver ; the solution which he uses contains one
part of the salt dissolved in fifteen parts of water, and the
ointment consists of one part of the sulphate to three or
four of lard.
  Blisters  are sometimes employed with success to prevent
the spread of erysipelatous inflammation ; they are applied
at the margin of the affected surface:  their effect appears
to depend on a new action being excited in the  parts, and
their use seems to prove especially of service in the erratic
form of the disease.   The only other local remedies requir-
ing notice are, creasote, which, painted over the surface, has
recently proved successful in the hands of some practition-
ers ;  and congelation of the surface by means of pounded
ice and salt mixed in a bladder, Avhich has been  proposed
by -Dr. Arnott: from the use of the latter it maybe appre-
hended that some  internal organ might be attacked.
  Should erysipelas assume a gangrenous tendency, in ad-
dition to the internal administration of the most powerful
tonics, as wine, bark, and quina, the parts ought to be en-
veloped with a charcoal poultice, and  afterwards dressed
with  lint soaked  in a lotion, containing from one to  two
ounces  of  the solution of chlorinated soda or chlorinated
lime to the  pint of distilled water.
                                             •
                      URTICARIA.
  Urticaria (Nettle-rash) may be defined to consist in an
eruption of irregularly-shaped prominent patches, or wheal-
like elevations of the skin, of a yelloAvish-white or reddish-
yellow colour, which are surrounded by a  diffuse  redness,
are  often  evanesent, and are  attended Avith a  burning
                         5 
50
EXANTHEMATA.
sensation, tingling, and extreme itching.   It is non-conta-
gious,  and is usually accompanied by a  greater  or  less
degree of fever ;  and it may be either acute or chronic, in
the former case lasting for a few weeks, in  the  latter for
months or even years.  The name of this disease is derived
from the resemblance which the eruption bears,  both in  ap-
pearance and symptoms, to that occasioned by  the sting of
the common nettle— Urtica urens.  Willan describes several
varieties of  urticaria, and numerous subdivisions of it have
also been made by other dermatologists; but I think they
may all be conveniently classed under three heads:—

                    Urticaria febrilis.
                       "     evanida.
                       "     tuberosa.

  An  attack of Urticaria febrilis is ushered  in with  the
ordinary symptoms of mild fever,—shivering, headache,  hot
skin, thirst, loss of  appetite,  pains in the  limbs, and  in
many cases vomiting.  In from tAvelve to twenty-four hours,
the cutaneous  surface  becomes  covered  with numerous
patches of the  characteristic eruption, the parts on Avhich
it appears having been for a short time previously the spat
of a burning  sensation, attended Avith tingling and itching.
The wheal-like  elevations generally appear simultaneously
on various  portions  of the  body,—on the face, the neck,
over the back, and on the anterior aspect of the arms and
legs;  they often disappear suddenly, and as suddenly re-
appear on some other part of the skin.   They bear much
resemblance to the sting of a nettle, being slightly elevated,
of a bright red  colour, with raised yellowish spots or lines;
in most cases  the itching  which attends  them is very in-
tense, and  accompanied  by a  burning sensation,  and  ad-
ditional patches are  produced on the apparently unaffected
surface by the patient rubbing  or scratching the part.
The eruption runs its course generally in  from  six to eight
hours,  but to be succeeded by a fresh crop on the same or
on different parts of the body—in most cases appearing in
the evening, and  the out-break of  which is attended, as
before, Avith tingling and itching.  Febrile urticaria is thus
prolonged for a week or ten days, the eruption being  less 
URTICARIA.
51
extensive and the constitutional symptoms less marked with
each successive crop; the general febrile symptoms subside
to a certain extent when the rash comes fully out, but are
usually again somewhat aggravated each time the eruption
disappears.   The  epidermis of the parts which  have been
affected  disquamates  in fine mealy scales after the disease
has subsided, but no stain or mark is  left behind.
  When  the eruption does not recede and  again re-appear
as now described, but remains permanently on the surface
on Avhich it  first presents, it assumes somewhat of a more
chronic character, lasting for  three or  four weeks, and  is
termed urticaria perstans.  This sub-variety is attended
with milder  constitutional symptoms, and with  less  local
irritation and itching.   In the variety named eonferta the
local and general symptoms are  precisely  similar to  those
of urticaria febrilis, but in general more severe; the patches
of eruption  are numerous, and  coalescing cover a  much
more  extensive  surface of the skin.  A form of urticaria
has been described under the appellation  of intermittens,
in which the  appearance  of successive crops of the eruption
assumes  a regular intermittent  type,  usually  quotidian,
sometimes, however, more prolonged, being  tertian or  quar-
tan, or the rash may not re-appear until the end of every
seventh,  eighth, or ninth day,—coming  out in the evening,
attaining its  greatest  intensity during  the night, and dis-
appearing almost  entirely  before morning.  Willan  men-
tioned as  a variety  of this disease,  under  the  name
subcutanea, what was manifestly chiefly a nervous irritation,
there being  constant and violent itching of the cutaneous
surface commencing on some spot of one of the extremities,
thence extending  to  the  entire limb,  to  the trunk, and
finally over the Avhole  body, with only an occasional  erup-
tion of urticaria at distant intervals.
   Urticaria evanida is a chronic form of the disease, which
not unfrequently lasts for years, and although unattended
with fever renders the life of  the person who suffers from
it almost intolerable, from  the  unceasing   painful itching
by which it  is characterized.  The  eruption  appears  in
small,  rounded, reddish-yellow elevations,—often two, three,
or more  such, closely  set  together, forming a  wheal like
that caused by the lash of a whip,—with little, if any, sur- 
52
EXANTHEMATA.
rounding redness of  the  skin ; they may appear on any
part of the body, but are usually developed by scratching,
or by friction of the clothes:  in females they are most fre-
quently seated  around the neck, where the  upper part of
the dress rubs the surface, and on the arms where they are
likewise caused by the friction of the sleeves of the dress.
The rash generally begins to appear towards evening, and
is fully developed during the  night, fading away before
morning.   The itching  it occasions  is most intense, caus-
ing absolute suffering, and  persons  even of the utmost
fortitude cannot refrain  from scratching violently the parts
affected, by which an additional eruption is caused.   The
wheals do  not remain longer on  the surface than five or
six hours, but they are renewed by the least local irrita-
tion, and the  disease thus  continues  for months with oc-
casional  intermissions, being always  most  severe during
the summer and autumn.   After  it  has lasted  for some
time the general health  becomes more or less affected, both
from the constant irritation it  occasions and the derange-
ment of the natural functions of the skin.
   Urticaria tuberosa, which is a very rare  variety of the
eruption, occurs rn the form of distinct, rounded elevations,
about the size of a small walnut, hard and firm, extending
evidently into the subcutaneous areolar tissue, of a livid red
colour, with a yellowish raised centre.  The portion of the
integuments affected is stiff, tense,  and painful to the touch
or  on motion.   The  tumours generally appear  on the ex-
tremities, coming out during the night  with  pain, much
itching,  and some fever,  and nearly  disappearing before
morning, leaving the  patient weak, tired, and  sick.   It  is
essentially chronic in its  course, and very obstinate in its
duration, sometimes  extending  to two or three years, or
even  longer, with short  intervals of remission.
   Urticaria is  of more frequent occurence in females than
in  males, which  may be  accounted for  by its seldom at-
tacking any but those whose skin is fine and delicate ; for
the same reason, while it appears not uncommonly in in-
fants and children, it is not a disease of advanced life.  The
causes by which the  febrile form is  produced  are, in most
cases, well  marked, but those  on which  urticaria evanida
and urticaria  tuberosa depend are not  so  manifest.   A 
URTICARIA.
53
marked connection exists  between the appearance of this
eruption on the cutaneous  surface and derangements of the
digestive organs, or rather the irritation caused in  some
persons by certain indigestible articles of food.   Shellfish,
especially mussels, oysters, crabs, cockles, periwinkles, and
shrimps, have been long noted as producing urticaria  in
many individuals, the  eruption appearing in  a few  hours
after any of them may have been eaten.   Similarly  it  has
been seen to arise after the ingestion of pork, veal, or goose,
of salted, spiced, or dried meats or fish, of cheese, of honey,
of many fruits and vegetables,  particularly  gooseberries,
cucumbers,  melons, mushrooms, pickles, &c.  I  know two
persons in both of whom urticaria appears  in half-an-hour
after  they have eaten almonds or nuts if the brown skins
had not been previously removed.  In all these  cases  the
occurrence of the eruption must be due to some individual
idiosyncracy, with the nature of Avhich we are unacquainted.
The use of certain  medicines,  especially of copaiba  or
valerian, sometimes  gives rise  to  this  disease;  in one
instance which I Avitnessed, copaiba was given to a woman
who was at  the time suckling her  infant,  and  urticaria  ap-
peared both on herself and on her child.  Frank mentions
his having seen it  occur from drinking Selters water.  In
the case  of  a boy,  aged 15, who was admitted into Jervis-
street Hospital in the month  of December, 1851, for  acute
pleuritis, a copious eruption of urticaria appeared over the
face, the upper extremities, and the trunk, on  the third day
after his admission ; the feverish symptoms had commenced
to subside, and his system  had been brought under the in-
fluence of mercury the day previously.
   Urticaria has been  often noticed as occuring in connexion
with other febrile diseases, especially with rheumatism, and
Dr. Graves  has pointed out the connexion Avhich exists  be-
tween rheumatism, deranged  conditions of the liver, and
this eruption.1  In children  it frequently appears at  the
periods  of  dentition,  being evidently  associated  with  the
gastric irritation which then occurs.  Many have described
some of  the forms of  this disease as  being caused in  the
female sex by deranged states of the  menstrual  function ;
but my experience is quite  opposed to this view.
         1 Clinical Medicine, Second Edition,  vol. i.  p
                          5* 
54
EXANTHEMATA.
  Urticaria occasionally appears as a complication of other
cutaneous eruptions, more  particularly eczema, impetigo,
prurigo, and lichen.
  The diagnosis of urticaria cannot be  attended with any
difficulty,  its  local  characteristics  are  so well  marked.
From erythema it  is well distinguished by the absence of
the diffuse redness of  the  cutaneous surface, and  by the
intense itching which accompanies it.   Erythema nodosum
might be mistaken for urticaria tuberosa, but the evanescent
character of the latter, even in its most chronic form, suffices
to diagnose it; the former also is marked by the presence
of acute febrile symptoms.   Roseola, the only other of the
exanthemata which might be confounded with febrile  urti-
caria,  is  not  attended  with the intense  itching of this
disease, and  also  differs considerably in the  colour and
appearance of the eruption.   One of the varieties of lichen
has been termed urticatus, in consequence of the troublesome
stinging  by  which  it is  accompanied, owing to which
symptom it has been occasionally mistaken for and described
as a form of  urticaria, but it is a distinctly papular erup-
tion.
  The prognosis in any of the forms of urticaria must be
favourable, as may be  understood from what has been  al-
ready said.  A few  fatal  cases of the  disease, it is true,
have been recorded by some of the older writers, but that
they were instances of this  eruption uncomplicated with an
internal organic affection may well be doubted.  We have,
however, the  testimony of Willan, that a  case fell under
his observation in which death occured from the sudden
retrocession of the eruption about the  fifth day;  but the
patient was a very intemperate man, and had suffered from
great pain in the  stomach  and nausea, which were much
relieved when  the  cutaneous eruption came out, and  deli-
rium and high fever followed its sudden disappearance.
  The seat of urticaria is in the superficial layers of the
derma and the epidermis;  as regards its pathology, it seems
to be chiefly an affection of the nerves of the skin.   From
an analysis of the urine by Dr. Douglass Maclagan of Edin-
burg, he  came to the conclusion that urticaria is intimately
connected  with a  deficiency of  the organic salts  of  the
urine—urea and uric acid, and their probable retention in 
URTICARIA.                 55
the system, and the correctness of this opinion is favoured
by the connexion, already'adverted to, which exists between
this disease and rheumatism.
   Treatment.—The febrile form of urticaria requires the
employment of antiphlogistic purgatives, and diaphoretics,
or, should the fever run very  high  in full  habits, local or
general bleeding may even  be requisite.   The best  pur-
gative is the  sulphate of magnesia given in the acid in-
fusion of roses, with an excess of acid; thus an ounce of
the salt may be dissolved in twelve fluid ounces of the acid
infusion, and  to  it two  fluid drachms of dilute  sulphuric
acid be added ; of this the dose is a sixth part every third
hour  until the bowels are  freely moved :  the purgatives
should be repeated every second day as long as the feverish
symptoms have not subsided.  Nitre whey given at bed-time
forms a good  diaphoretic, or two drachms of the water of
the acetate of ammonia may be added to the whey instead
of the nitre.  Acting  on his view of the pathology of the
disease, Dr. Maclagan has  treated it with colchicum ; and
this medicine is  certainly indicated when the eruption is
complicated with rheumatism.
   When urticaria  is produced by  eating  any particular
article of food, an active and immediate emetic, such as the
sulphate of zinc, should be at once administered,  and its
action followed by the  exhibition of  a mercurial cathartic ;
if the subsequent fever be well marked, bleeding  may be
required, but  only a small quantity of blood should in any
case be withdraAvn, as general symptoms of poisoning,  with
much  depression, not  unfrequently  follow.   The inter-
mittent form  of  the disease requires  to be  treated  con-
stitutionally with tonics and antiperiodics, especially the
preparations of bark, the bowels having been first freely
acted  on by a saline cathartic ; this  variety of  urticaria
may occasionally be cut  short by the administration of an
emetic a few hours previously to the expected re-appearance
of the eruption.
  In  urticaria evanida  a  lowering plan of  treatment is
decidedly contra-indicated, as the disease invariably assumes
a chronic form.   I  have  derived especial benefit in  it from
the use of preparations of iron, and from the administration
of Dover's  powder ; of  the  former, I generally  prescribe 
56
EXANTHEMATA.
the compound iron mixture in doses of two ounces every
morning, or twenty minims of the  tincture of the sesqui-
chloride three times  a day in an ounce of the infusion  of
quassia or calumba, or two ounces twice daily of Bewley's
aqua chalybeata : of the latter, from eight to twelve grains
every night at bed-time.  Under the administration of these
combined remedies, I have seen most obstinate chronic cases
of the disease yield in a few weeks; while administering
them the bowels should be kept  freely open by mild saline
purgatives.   Urticaria tuberosa should be treated similarly;
but in  cases  in  which the disease  has  been of very long
standing, it  will occasionally only yield to the  prolonged
administration of arsenic.   When any of the forms are con-
nected with or complicated by the presence of any other
disease, the treatment ought to be modified accordingly..
  The itching and tingling of urticaria are someAvhat allayed
by the use of the warm bath, but as soon  as the skin is dried
afterwards,  these painful sensations are augmented  in
consequence of the friction of the surface requisite to remove
the moisture.   In febrile urticaria I have employed, as a
local application, with much  effect, the  following  alkaline
spirituous wash:—
    R. Carbonatis Potassae,........   3ss.
        Aquae Florum Sambuci,......flgxiss.
        Spiritus Vini Rectificati,.....fl^ss. Misce.

  Pieces of lint  saturated with the lotion should be laid on
the parts where the itching is most troublesome.  In the
chronic forms of the disease, chloroform  is  an excellent
topical remedy for the same  purpose;  an ointment of  it,
prepared by rubbing together half a drachm of chloroform
and an ounce of cold cream should be smeared rather thickly
over the affected surface.  Lotions  and  ointments, con-
taining prussic  acid, opiates, and other  narcotics,  have
proved successful in the hands of others.
  In urticaria occuring in infants and  children, the state
of the digestive organs demands especial attention, and  in
all cases whether the  teeth are appearing  or not, the gums
should be lanced ; in infants at the breast,  the health of the
nurse is in particular  to be attended to ; the local irritation, 
ROSEOLA.
57
at this early age, may be allayed by sponging the surface
of the body with a warm infusion of chamomile.
   Whenever the sudden retrocession of  the eruption in
urticaria is attended with evidences of derangement of any
internal organ, the hot bath should be used, with friction
over the  surface, and  blisters applied to the  epigastrium
and the nape of the neck.
   As regards the diet in urticaria,  the- chief point  to  be
attended to is the avoidance of the use  of any food  which
from individual  experience, has been found to produce the
eruption.   In the  acute forms of the disease the patient
should live  low; but  when it becomes chronic, the food
should be nourishing, yet not rich or heating.

                        ROSEOLA.
   Roseola (Rose-rash1) is by many dermatologists regarded
as being merely a variety of erythema, erysipelas, or mea-
sles, and its existence  as a distinct eruption not admitted;
but I fully agree with Willan, that its local characteristics
are sufficiently well defined to separate it from any of these
diseases, and to require a  special description.   The  name,
which has been applied to it in consequence  of the peculiar
rose-colour which it usually presents, is  to a certain extent
objectionable, as this  colour varies much in the different
stages and forms of the eruption.   It consists in the appear-
ance of very slightly elevated rose-red patches, of irregular
shape, transient, fading at  times, and again re-appearing ;
non-contagious, and attended with  some degree of  fever.
The various forms of Roseola may be  classed under  two
heads :
                  Roseola idiopathica.
                           symptomatica.

   An  attack of Roseola  idiopathica is usually attended
with slight fever, which, however, in  children is  sometimes
Avell marked and severe;  the febrile  symptoms subsiding
to a great extent when the eruption appears freely on the
skin.  It comes out in numerous reddish-yellow patches,

   'In Scotland erysipelas  is commonly termed "The Rose," which has
caused this eruption to be occasionally confounded with it. 
58
EXANTHEMATA.
which soon assume a roseate hue, and are irregularly dis-
tributed over the cutaneous surface ; generally appearing
first on the face and neck, and spreading quickly thence to
the trunk and the upper and lower extremities ; occasion-
ally the eruption is confined to the face, neck, and trunk,
and at times it occurs on the extremities  only.  The rash
is often very  transient, disappearing  completely  in  from
tAventy-four to forty-eight hours—when the feverish symp-
toms become aggravated, and  re-appearing  again within
the next twelve hours;  it usually runs its course in from
five to  seven, days, terminating with slight epidermic des-
quamation.  When roseola occurs in infants  and children,
it is not unfrequently attended with more or  less tumefac-
tion of the integuments, which  precedes the appearance of
the eruption, being  most marked in those places where the
rash is to come out.
  Two forms of the disease  have been described under the
names sestiva and autumnalis, from their appearing at these
seasons of the year: in  the former, the feverish symptoms
sometimes  run high, and are attended with more or  less
sore throat, which, on inspection, is seen to  be somewhat
swollen and of *a bright rose-red  colour,—the rash, too, is
very generally distributed over  the cutaneous surface ; in
the latter  the  eruption  is of a  duller hue, in smaller-sized
patches, and attended with very slight  fever or sore throat
—this symptom, however, being  often absent.   When the
disease attacks infants, it has by some dermatologists been
described as a distinct form,  and termed roseola infantilis ;
it is in them usually very mild, and disappears in a  feAv
days; but  in  some cases is marked by itching, as would
appear from the annoyance  it seems to give the little pa-
tient ; it is then also more prolonged.
  The  eruption  in idiopathic roseola not unfrequently ap-
pears in the form of rings or circles,  of a bright rosy hue,
surrounding a healthy portion of the skin which is unaltered
in colour;  it is then termed roseola annulata.  This is a
more aggravated form of the disease, setting in with well-
marked symptoms  of fever, a  distinct  shivering fit, fol-
lowed by sickness of the stomach, headache, pains in the
limbs, and hot skin, preceding the appearance of the erup-
tion for from tAventy-four to forty-eight hours ; oedema of 
ROSEOLA.
59
the integuments is also not uncommon in this form, particu-
larly  in  children—in whom the disease usually occurs—
appearing  especially should the eruption suddenly  retro-
cede.   In one case Avhich I attended in 1849, that of a boy
aged six years, the entire body became enormously swollen
on the sudden disappearance of  the rash, so much so that
both eyes  were  closed,  and there  was great  difficulty of
breathing and of swallowing, owing to the tumefaction of
the fauces.  This variety of  roseola may appear on any
part of the cutaneous surface, but is most frequently seen
on the lower  extremities, and  the  trunk of the body.  It
comes  out in  the form  of  numerous small, round, reddish
patches, which, rapidly  spreading  by their  circumference
assume the character of rings, some being quite  circular,
and others irregularly so;  the central portion of healthy
skin, Avhich at first  is  only a few lines in diameter, gra-
dually extends to half-an-inch, or even  two  inches, the
surrounding  rose-red eruption being  from a  quarter to
half-an-inch in width ; sometimes two or three of the rings,
meeting, coalesce, and may thus extend beyond  one of the
joints, or  nearly round  a  limb.   Heat  of  the skin  and
itching generally accompany this form of roseola.
   Mr. Erasmus  AVilson  describes  a variety of  roseola un-
der the name of punctata, in which the eruption,  attended
with fever of a  subacute  type, appears on  the mucous
membrane and skin, " on the latter, in  the  form  of small
red spots around the mouths of the follicles, then becom-
ing diffused  so  as  to cover the greater part of the body,
reaching its height on the  third day; at first of  a bright
raspberry  red colour, afterwards acquiring a  dull roseate
hue, the  dulness  increasing with the progress  of the  de-
cline ;"—the disease lasts for ten days.   He speaks of it as
a rare disease, having seen  only a  few examples ; I never
met  with  it  as an idiopathic  affection, but I  have seen
syphilic roseola present  these characteristics.
   Roseola symptomatica occurs in  the course of, or  as an
accompaniment  to many febrile diseases, but its charac-
ters  are  so similar  to those of the idiopathic form as not
to require  a  distinct  description.   It is  thus Avitnessed in
small-pox,—the eruption of which it  usually precedes by
about  twenty-four  hours,—cow-pock, fevers, acute rheu- 
60
EXANTHEMATA.
matism, epidemic cholera, &c, and as it may attend any of
these diseases, it  has been named  by dermatologists R. va-
riolosa, R. vaccina,  R. miliaria vel  febrilis, R. cholerica,
&c.   When the practice of inoculation  prevailed, roseola
is described as appearing  very regularly on the second  or
third day of the  fever of incubation, and was regarded as
a faA'ourable sign, indicating  that the variolous  eruption
would be mild.  In  cow-pock, it  occurs about the  period
of maturation of the vaccine  pustule, spreading   from it
along  the arm, and often appearing  also on  the trunk; it
is not of very frequent occurrence, is of a very mild  cha-
racter, and fades  away in  two or three days.   Its appear-
ance  during  either fever  or acute rheumatism is  rather a
favourable sign than otherwise;  it  does not require any
special treatment, nor does it interfere with that of either
of these diseases.   The cholera exanthem has been described
by Keir, Babington,  and Rayer, all  of whom  witnessed it
in the epidemic of 1832; it accompanied the fever of re-
action, and its  appearance does not seem to have in any
way influenced  the progress of the disease.
  Roseola  may occur at any age,  but is more frequent in
the young  than in the old.  It  may be caused  by  any
local irritation of the skin, or by  any circumstance acting
on  the system generally,  which  gives rise to determina-
tion of blood to  the cutaneous capillaries; the  latter is
evidently the cause of  the  symptomatic form of the erup-
tion.   In summer it is occasioned  by exposure to a  hot
sun  when  the  digestive organs are deranged, or by the
perspiration  being suddenly checked;  its frequent occur-
rence in autumn is traceable to the gastric irritation which
is at that seasom of  the year so frequently caused by the
too free use  of fruit and  new vegetables.  In children it
commonly appears about the periods of first and second
dentition, and  is manifestly connected with the  derange-
ments of the system Avhich then so  commonly exist;  and
in infants it  is usually occasioned by the nurse's milk dis-
agreeing with the child.
  With regard to diagnosis,  roseola is an  important dis-
ease, as  it is very liable to be mistaken  for either measles
or scarlatina.   From the former it is distinguished by the
colour of the eruption, so  different when it is fully deve- 
ROSEOLA.
61
loped from the dull red hue of measles, by its not assuming
the crescentic or horse-shoe shape, and by the absence of
the catarrhal fever.   From scarlatina, with which, in  con-
sequence of the sore  throat, it is in its early stage apt to
be confounded, the colour  of the  rash,  its  appearing  in
patches or  spots, and  not being generally diffused  over
the surface, the comparatively mild character of the fever
and of the attendant sore  throat, and  the absence of the
burning heat of the skin, are sufficient to diagnose it.   The
distinguishing characteristics betwTeen roseola and erythema
nodosum  are,  the  elevation, the colour, and  the pecu-
liar shape of the latter;  and  the chief diagnostic features
between  it  and urticaria are, the absence of the  intense
itching and of the wheal-like eruption.
  The prognosis in roseola is always favourable, the erup-
tion being attended with but slight annoyance, disappearing
generally in the  course  of ten  days, though  occasionally
prolonged  for three or four Aveeks ;  but in all  cases it is a
simple affection, and one attended with little or no danger, and
in many febrile diseases its occurrence is manifestly salutary.
  The treatment of  the disease  is simple; rest in bed or
even  confinement to  the house, with low diet, the use of
diluent  drinks, and, when  the eruption  is well out,  mild
purgatives, being sufficient in most cases to effect a cure.
Mercurial  seem better  adapted than saline purgatives for
the treatment  of roseola,—with infants and children the
hydrargyrum cum  magnesia appears especially to agree.
Should  the fever run high, and the  eruption  be  slow  in
coming out, the warm bath Avill prove of service ;  it should
be always  used with  children.   When there  is oedema of
the surface, small doses of the spirits of nitric ether and of
the water  of the acetate of ammonia are prescribed  with
benefit.  In chronic  cases, or in weakly habits of body,
should the disease become chronic, vegetable tonics and the
mineral acids are indicated.  If much itching  or  heat  of
surface  attends the eruption, it will be allayed by a weak
alkaline spirituous wash, such as  the following :—

     B. Sodae Biboratis,...........3ss.
       Aquae Florum Sambuci,......fl §xiss.
        Spiritus Rosmarini,........fl 5ss. Misce.
                            6 
62
EXANTHEMATA.
  In most cases, however, no  local application, except the
general warm bath, or sponging the skin with warm water,
will be needed.  Symptomatic roseola  requires no special
treatment apart from  the disease which  it accompanies,
and the employment of any which might repel the eruption
from the  surface should be especially guarded against. 
ECZEMA.                    63
                CHAPTER  III.

                       VESICULE.

  The  term Vesicule, formerly employed to  designate
any cutaneous eruption, in which matter Avas effused beneath
the cuticle, was restricted by Willan to those  forms in
Avhich the effusion is a transparent fluid, contained  in mi-
nute, orbicular, epidermic elevations, corresponding  to his
definition of a vesicle; when these elevations were of larger
size, the disease in which they occurred were placed in a
distinct  class, denominated by him Bullse; but with re-
spect  to their visible phenomena, as they differ only in
magnitude, I shall include both in one class.   The  Order
Vesiculae, then, may be defined to be characterized  by an
eruption of vesicles or blebs,  which consist in an elevation
of the epidermis varying in size, sometimes minute (vesicles),
sometimes of tolerable magnitude (bullae  or blebs), contain-
ing a transparent,  serous fluid, which, with the progress
of the disease, becomes opaque, and dries into thin scales
or crusts.  There are five genera contained in the Order:
Eczema, Herpes, Pemphigus,  Rubia, Scabies.   Of  these
the first two are attended usually with  acute symptoms;
pemphigus and rubia with fever of a low type; and scabies
with local  inflammatory action, 'but very rarely  with con-
stitutional derangement.  In all, the fluid contained in the
vesicles becomes opaque and sero-purulent with the progress
of the disease, and  they are then often diagnosed with dif-
ficulty from pustula eruptions.

                        ECZEMA.

  Eczema  (Scall or Humid  Tetter) is  a most important
and interesting  disease of the skin, being of extremely
frequent occurrence, at times  very difficult of  diagnosis—
particularly in its advanced  stages,  and usually most re-
bellious  to treatment.  It is characterized by  the eruption
of numerous minute transparent vesicles, closely set and 
64
VESICULE.
irregularly  aggregated  on an  uncircumscribed inflamed
surface, and  attended  generally Avith burning pain and in-
tense itching.  It is highly inflammatory, but not conta-
gious.  The vesicles, which are at first perfectly transparent,
become opaque on  the second  or  third day after  their
appearance,—the contained fluid assuming a semi-purulent
character,—and  either  dry up with  a fine  furfuracious
desquamation, or bursting, become covered  with thin, yel-
low crusts, from beneath Avhich an acrid, watery exudation
takes  place.  Eczema  differs  much in appearance, as it
occurs on the  parts of the cutaneous surface  which are
ordinarily covered,  or  exposed, or on which  hair  groAvs,
and therefore must be described more or less with reference
to a regional system of classification.   The forms  of the
disease,  according to  the  course  which  they run,  are
naturally divided into two groups, the acute and chronic:
and as regards external characteristics two varieties are well
marked :
                    Eczema simplex.
                       "   rubrum.

  But it  is also requisite to consider  it specially, as it may
be seated on  the face or on the scalp :—
                     Eczema faciei.
                        "    capitis.
  Eczema  simplex is  attended with  scarcely any fever,
slight nausea and headache occasionally preceding its erup-
tion, which is accompanied by some heat and tingling  of
the surface.   It consists in the appearance of  numerous
minute shining vesicles, not exceeding in size the head of a
small pin, which are closely  aggregated, and irregularly
distributed on apparently healthy skin of the natural colour,
but with a magnifying glass each vesicle may be seen to.be
surrounded by a  narrow red areola  ; in forty-eight hours
the fluid contained  in them becomes opaque, and  on the
third or fourth day they dry up and  are followed by a fine
mealy desquamation  of  the epidermis, and thus the  disease
may run its course in from four to six days.   In most cases
however, a fresh crop of  vesicles  appears as  soon as the
first has  maturated, and  by successive crops its duration 
ECZEMA.
65
may be prolonged for as many weeks; under such circum-
stances, thin yellowish crusts or scabs are formed, and a
serous exudation continues to Aoav from the surface while
the disease  lasts, often in large quantity.   The  heat and
itching are then also troublesome, and if the part be scratched
or irritated,  the  eruption  may become chronic,  or  may
change into the second form.   For a long time after  the
disappearance of  the disease  the epidermis continues to
desquamate, but it leaves no stain on the skin or other trace
of its existence.
   This form of eczema usually appears on the backs of the
hands and arms, sometimes on the scalp, but rarely on the
lower extremities, on the  trunk, or on  the face.
   Eczema rubrum is an acutely  inflammatory disease,  an
attack of it being ushered in generally with sharp fever,
and always with much local pain, heat, and swelling of the
portions of the integuments about to be affected.  Numerous
pellucid, small vesicles are  rapidly developed  on a highly
inflamed, uncircumscribed surface, of  a bright red colour
and tumefied, over which they are irregularly distributed,
but crowded together in patches; the parts feel painfully
tense, and cause a continued tingling rather than itching.
The vesicles, becoming opaque, enlarge somewhat, look fuller,
and, bursting, form yellowish crusts; in a feAV rare cases
the disease terminates in from a  fortnight to three weeks
with the falling off of these  crusts and subsequent epidermic
desquamation.  But in most instances, and invariably when
the parts  have been torn by scratching or  otherwise irri-
tated, a copious discharge  of an  acrid, thin, serous fluid,
continues  to flow from  the inflamed surface,  apparently
without the  formation of  new vesicles; the inflammation
spreads to the  adjoining portions of  the skin, often seem-
ingly caused by this discharge flowing over them ; bright
red cracks and fissures form in the integuments, which are
excoriated, thickened, much  swollen, and  attended  with
intense pain and itching, and blood flows freely should they
be scratched.  The  serous exudation  is usually in  very
large quantity, so great  as at times to require to be con-
tinually wiped away, that  from even  a limited surface
wetting completely a large handkerchief in a few moments ;
when it is not so  copious it dries quickly into fine  lamellar
                            6* 
66
VESICULE.
scales, a constant desquamation of Avhich takes place.  The
aspect of this form of the disease, when fully developed, is
highly characteristic :  the shining  crimson or  bright red
surface, covered in parts with the ichorus discharge, and in
parts with the thin film of desquamating epidermic secretion,
the deeper-coloured fissures and cracks, from which blood
occasionally flows, and the tensely tumefied appearance of
the whole.   Eczema rubrum, when it presents the aggrava-
ted characters noAY described, seldom gets well in  a shorter
space of time than  two or three months, and occasionally,
becoming chronic, lasts for years.
  In some cases the local inflammation is  still more acute,
the discharge becomes sero-purulent or purulent, concreting
into thick yellowish scabs, and scattered pustules form on
the surface; it is then termed eczema impetiginodes,  from
the  resemblance  which  it  presents  to  impetigo.    This
variety of the eruption is generally met with in infants and
children, is  attended with well marked febrile  symptoms,
and much local  pain and itching, and lasts for from three to
six  weeks, or occasionally, becoming chronic, for  as many
months ; its duration being kept up by the successive erup-
tion of semi-purulent vesicles.
  When  any of the forms of eczema become chronic  they
are usually described as a distinct variety, under  the name
of eczema chronicum; the disease then loses its  vesicular
character, the integuments  which are swollen, thickened,
and elevated above the surrounding portion of the skin that
may remain unaffected, assume a permanently dark crimson
hue, with numerous deep  fissures which discharge a  bloody
ichor, and, taking on an inflammatory action from the  least
constitutional excitement or local irritation, are painful to
the  touch, tense,  and attended with an acrid watery dis-
charge and extreme itching.  The  constitution also,  after
a time, becomes affected, the digestive organs being  deranged
and general debility ensuing.
  Eczema rubrum may be seated  on any part of  the body,
but generally attacks a large extent of the cutaneous sur-
face, spreading rapidly from the place where it first appears.
It thus occurs  on the face, the scalp, the  trunk,  the arms
and hands, and the  thighs, rarely extending to  the  legs or
feet except in  very extreme  cases.   It  also  not  unfre- 
ECZEMA.
67
quently is local, appearing  merely on the  scalp, the  face,
the fingers, the backs of the hands, the  ears, around the
nipples in females, or in a single patch on the lower extremi-
ties, or in the pudental region,  being in all  these  cases
very obstinate to treatment, and apt to  become chronic.
Each of these local forms of the disease has been constituted
by some dermatologists into a distinct variety,—an unne-
cessary refinement, as, Avith  the exception of the first two,
they present  no essential differences, whether as regards
diagnosis or treatment.
  The outbreak of Eczema faciei is preceded in young per-
sons by a sharp attack of fever, attended with burning heat
and soreness of the part about to be  affected,  Avhich lasts
for two or three days:  in adults these symptoms are very
trifling.  Numerous minute vesicles then appear, closely
crowded together, on a highly inflamed patch  of  the cuti-
cular  surface, characterized by  acute burning  pain and
intense itching.  These vesicles do not maturate, but burst
usually on the day or day but one  after their first appear-
ance, giving  exit to an abundant  irritating serous  fluid,
which  dries into soft thin scales.  In some few instances
the disease does not proceed beyond this stage, the cuticle
of the  part affected gradually exfoliates, and recovery takes
place : but more generally the inflammation of the surface
goes  on increasing, fresh  crops of vesicles continuously
appear,  the  discharge  becomes  more copious  and of a
more acrid  character, exciting irritation of those portions
of the neighbouring healthy skin flver which it may flow,
and  the itching and  painful  tingling are most intense,
scarcely alloAving the patient a moment's rest, night or day.
The skin which is the seat of the eruption becomes swollen
as the disease advances, the epidermis exfoliates Avith the
soft scabs, or is torn off by scratching, and deep bright red
cracks appear all over the  surface, from which a sanious
often bloody  discharge exudes.   The sufferings  caused
by  eczema, Avhen  it reaches  this stage,  can  scarcely  be
described;  suffice it to say, that  they totally incapacitate
adults  affected Avith the  disease from  folloAving any  trade
or employment.
  Whether eczema rubrum  attacks  young or old persons,
when it assumes a chronic character, it is the most in tract- 
68
V E S I C U L E.
able of the eruptions  which appear on  the  face.  It not
unfrequently lasts for  years (in one case, regarding which
I was  lately consulted, it had been of upwards of twenty
five years' duration),  and is  rarely  cured under several
months' treatment.
  The most usual part of the face on which it appears in
infants and young children is the forehead, to  which  it
ordinarily spreads from the scalp, and, unlike most of the
other eruptive diseases, is much more obstinate there than
on  its primary situation.  This seems to depend on the
greater delicacy of the skin of the face  permitting those
cracks and fissures, to which the  rebellious nature of the
disease appears to be chiefly due, to form more easily.   In
adults, it  occurs  with  greater frequency on  the  nose  and
lips, but in many  cases spreads also to the  forehead and
cheeks.
  Eczema capitis soon loses its vesicular character, and in
its various stages presents so much diversity of appearance
that its diagnosis is not always unattended with difficulty.
The eruption  is preceded by heat, tingling,  and  itching,
which  are rapidly followed by the appearance of minute
vesicles, crowded together in  irregular-shaped patches, or
scattered over a large surface.   The  interspaces between
the vesicles  and the whole of the scalp on which they are
seated are red and inflamed ; in most cases the vesicles are
so minute as to be scarcely recognizable,  or at least are not
seen by the physician until they have burst and given exit
to a copious exudation  9? a serous  fluid, by which the roots
of the hair are accreted  together.  In the acute forms of
the disease this serous  exudation continues for a long time,
and is a  most troublesome symptom ; but in the chronic
forms—and some cases assume a chronic character almost
from  the first—it rapidly dries  into  furfuraceous scales,
which  are pushed forward by the  hair as it grows.
  ' The vesicles of eczema capitis usually appear first behind
the ear close to the edge of the hairy scalp, from whence
the disease  spreads rapidly, very generally  attacking the
ear itself; in  some cases the entire of  the  scalp will be
covered  Avith  the eruption  in a week  or ten days, but in
others the disease spreads very sloAA'ly. 
ECZEMA.
69
  With the progress of  the  affection, the appearance of
the diseased surface varies much;  sometimes it is scarcely,
if at all, elevated above the healthy parts, and the eruption
is only to  be recognized  by  the  Avatery exudation which
keeps the hairs in a constantly moist state.  In other cases
the scalp is raw or excoriated, and secretes a thin, whitish
pus, which dries  into greyish brown  scabs,  presenting
cracks or fissures, through which  the inflamed surface is
seen.   In a third form of the disease the serous exudation
dries  rapidly  into  extremely  thin membranaceous  scales,
which  are  readily removable  by the slightest friction, but
cause much itching.  And a fourth variety is characterized
by a repeated eruption of minute  patches of vesicles—the
patches rarely exceeding the size of a small bean—all over
the scalp, which pass through  the  stages of eczema  as wit-
nessed on other  parts of the cutaneous surface,  and disap-
pear in seven or eight days, but to be rapidly succeeded by
a fresh outbreak of the disease.
  The  hair  in  eczema, no matter how long the  disease
may have existed, remains unaltered.   When in the acute
forms, attended with much inflammation, ulceration  of tfie
scalp occurs, the hair, of course, falls off, but in the  pro-
gress of cure it grows again in a perfectly healthy state,
except that in individuals  past the age of puberty the new
growth of hair is often grey.
  Eczema  occurs at all ages,  from the infant at the breast
to the very aged;  in new-born children it not uncommonly
appears on the umbilical region,—eczema umbilicale,—
evidently arising from the local inflammation attendant on
the separation of the remains  of the funis, or from  a want
of due attention to cleanliness.  The causes  of  the  disease
are often sufficiently apparent, but equally often it is not
to be accounted for; thus, as regards the head  and face,
the eruption occurs on  the scrofulous  and non-scrofulous
child, on the  healthy and the  delicate, on the ill-fed, ill-
housed, deficiently-clothed  children of  the poor, and  the
highly-nurtured, well-housed,  warmly-clad children  of the
rich ; in short, frequently the  only cause that can be plaus-
ibly assigned  for  its outbreak is  that scarcely understood
one, constitutional.   It certainly affects females more fre-
quently than  males, for the same  reason that those of all 
70                  VESICULE.
ages, whose  skin  is fine and  delicate, are more liable  to
the disease than those in whom the skin is coarse and hard;
in many families, too, a peculiar predisposition to  diseases
of the skin exists, and this predisposition, which appears to
be hereditary, is well marked, as regards  the causation of
eczema.
   Exposure  to the direct  rays of the sun often produces
the disease in summer, so commonly that Bateman made a
distinct variety of eczema when so caused, naming it eczema
solare; a  numerous  class of causes, amongst  which this
must be included  as  one, is the action of local irritants, as
of blisters, of Burgundy pitch plasters, of croton oil and
turpentine liniments, &c.; thus, too, in washer-women, the
eruption is produced by the irritation of  the alkali of the
soda or soap which they use, and in house-scourers and char-
women, of the potash,—in both cases the disease is termed
washer-women s itch ; in grocers and makers of confection-
ary, of the sugar—in them  it is named grocers7 itch ; in
glove and clothes-cleaners it is a very usual disease arising
from the irritation of the oil of  turpentine or resin which
they employ;  and in the higher  walks of life a not unfre-
quent cause  of the eruption is the too frequent use of stimu-
lating soaps and  cosmetic washes to the face and hands,
and also  the habit  of washing  the face, when  heated, in
cold water, or of not drying it sufficiently after it has been
washed.   Sitting in close, heated rooms, engaged in any
occupation in which  the face is constantly kept stooped, as
in that of writing, is also a common cause of eczema faciei.
An eruption of eczema is of  very frequent occurrence on
the legs of old  persons in whom  the small superficial veins
are in a varicose  condition,  and in them, if irritated, it is
apt to degenerate into troublesome ulceration.
   The constitutional irritation  caused  by the action of
mercury on  the system produces  in some  cases—now more
rare than formerly, when the employment of the preparation
of this metal was so much  abused—a very grave form of
eczema; it  is  usually termed eczema mercuriale, but was
described as a distinct affection, under the name of  Hydrar-
gyria, by the late Mr. Alley of this city,  in an original
and highly valuable essay  on  the  disease,  published by
him in the year 1810.   In  the majority of cases  it seems 
ECZEMA.
71
to have  occurred when  only a very small quantity of a
mercurial  preparation  had  been  taken.   In its milder
forms  it resembles  the  acute stage of eczema   rubrum,
arising from other causes; but it more frequently assumes
a much more  severe  character when it  is ushered  in  by
fever, difficult respiration, dry cough, and tightness across
the chest, with a general smarting and burning feel of the
skin over  the whole  body.   These symptoms  are soon
followed by an eruption of minute vesicles, which  break
and  discharge  a very fetid  fluid.  As the disease  in-
creases in severity  the  eruption extends over  the face
and  the whole of the body, which become covered  with
incrustations; the fever  assumes a typhoid type, the diffi-
culty of breathing increases and is accompanied by bloody
expectoration, spots of purpura appear, and death ensues,
preceded by delirium or  convulsions.  On the first appear-
ance of this eruption the use of mercury ought  to be im-
mediately  relinquished,  and the accompanying  symptoms
treated by the means appropriate for the individual case.
   The diagnosis of eczema in its advanced stages, and in
some of its local forms, is  not unattended with  difficulty.
Eczema simplex  may at  its  origin be mistaken for herpes,
but the vesicles in the latter are larger, more distinct from
each other, and occur in patches  always well defined, and
often of small extent.  When it appears on the fingers the
serious mistake of confounding it with scabies is not unfre-
quently made, and thus  much mental annoyance may be
caused  not alone to individuals but to families,  owing to
the dread  and anxiety with which that eruption  is viewed
by all; even  at  their commencement they are,  however,
readily to be  distinguished, the vesicles  in itch  being
solitary, large, and conical, and becoming rapidly purulent;
the tingling, burning heat of eczema is also very different
from the intense itching of scabies, and by careful exami-
nation the itch insect, the existence of which is an unfailing
diagnostic sign, may be discovered in the latter.  In fevers
and other diseases, in which profuse SAveating  occurs, a
vesicular  eruption, which, from the cause by  which it is
produced, is termed  sudamina, appears  not unfrequently
on the cutaneous surface, and might be mistaken for. eczema
simplex;  but in it the vesicles, though of a small size, are
few in number, perfectly distinct,  and separated from each 
72
VESICULE.
other, and, drying up in a feAV days, disappear without any
serous exudation or local irritation.
  Eczema impetiginodes, as its name indicates, very closely
resembles impetigo ; in both there is a purulent  discharge,
but the crusts or scabs which form on the affected part are
always of a greenish hue, and the discharge purulent in the
latter,  while they are yellowish or yellowish-brown, and
the discharge sero-purulent in the former.  The chronic
forms of the disease are liable to be mistaken  for chronic
lichen, especially for lichen agrius when seated  on the
hands, a serous exudation being  then usually present; but
the latter eruption  never loses  its papular  character, the
portion of the integuments which is affected being  raised
unevenly, rough, and not marked by the cracks and fissures
so characteristic of chronic eczema;  and the  serous exuda-
tion is small in  quantity, is evidently caused by the local
irritation to which the eruption gives rise, and only  occurs
occasionally.  With psoriasis, too, chronic eczema may be
confounded by the  superficial observer, in consequence of
the epidermic desquamation  by Avhich it is  attended, but
the formation of true scales never takes place in the latter,
nor the copious serous exudation in the former.   The diag-
nostic  marks  between intertrigo and eczema  have been
noticed  when describing  that  eruption.  Eczema faciei is
distinguished from  herpes, in addition to the difference in
the character  of  the eruptions  already mentioned, by the
latter affecting the mouth or lips alone, while the former is
not confined to any special locality.
  Eczema  capitis may be confounded  with impetigo or
herpes of  the scalp ; it is diagnosed  from  either by the
copious serous exudation, which dries rapidly into yellowish,
not greenish crusts, by the rapid and  excessive formation
of  soft  furfuraceous scales, and by  the hair  not being
affected.   For porrigo capitis it can scarcely be mistaken,
but the characteristic differences  between the two eruptions
will be more easily  understood by deferring the mention of
them until  describing that disease.
  In eczema the prognosis varies as regards the duration
of the disease with the  different forms, but in very few
instances can the affection be said to be dangerous to  life;
yet some do occur; these are cases  of debilitated old per- 
ECZEMA.
73
sons in whom it becomes complicated Avita pemphigus, and
whenever such a complication takes place the prognosis
should be most grave.   Eczema  simplex,  when submitted
to treatment at an early stage of the eruption, very seldom
becomes  chronic, but it is very apt  to return  on exposure
to any local cause, and  especially Avhen it has been origi-
nally produced by the direct action  of irritant substances.
Eczema rubrum is always an obstinate and severe affection
of the skin,  and most rebellious to treatment, years some-
times elapsing before it can be subdued;  in such cases the
general health sympathizes more or H?ss, from the continued
annoyance caused  by the local irritation, the individual
affected  being  not unfrequently altogether  incapacitated
from mental or other occupation.   When the disease affects
the scalp or face, it is also one of the most obstinate of the
eruptions which appear on these parts.   The occurrence of
a general attack of eczema in the course  of  some  chronic
constitutional affection, particularly  of the nervous system,
is often not incorrectly regarded as a favorable sign.
   With reference to the  precise  anatomical seat of eczema,
dermatologists  are not agreed:  Cazenave adopts  Biett's
view, that it is an  inflammatory affection of the  sudori-
parous glands, but it is evident that  other structures of the
derma are also  equally engaged.
   Treatment.—Eczema  is   essentially  an  inflammatory
eruption, even in its  most  chronic  stages,  and this fact
should ahvays  influence our choice  of remedies, whether
topical  or constitutional, for its treatment.  In  eczema
simplex  occurring  in adults, mild   saline antiphlogistics
Avith alkalies, as in the following form, are prescribed with
advantage at its commencement:—

   R. Sodae et Potassae Tartratis, .  . .    ^j.
      Solutionis Alkalinae (Brandish),  fl 31V-
      Aquae destillatae,........fl  Jxixss. Misce.

     " A wine-glassful to be taken three times a day."

For children, gentle mercurial purgatives are  better adapt-
ed,  combined with antimonials  such as  James' powder if
the febrile symptoms are well marked.   In the mild  forms 
74                   VESICULE.
of the disease  the  best local treatment in the acute stage
is the use of the general tepid bath, or of warm water spong-
ing, the parts being thoroughly but gently dried afterwards.
When the  local affection is more severe,  the weak  lead-
wash—a drachm of the solution  of subacetate  of lead to
twelve fluid ounces  of  rose or elder-flower water—applied
on old  linen wet well with it, is  an  excellent application:
if the eruption  is seated on any part of the extremities, it
is best and most efficiently applied by means  of bandages
evenly put on,  and kept constantly moist with the wash.
In some cases of eczema moisture appears to disagree sin-
gularly, always aggravating the  local symptoms;  under
such  circumstances an ointment  containing four grains of
the carbonate of lead or of the acetate of zinc, to an ounce
of cold cream,  may be used, and if there is much tingling
or itching in the part, two minims of prussic acid should be
added to the latter, or six  minims  of chloroform to  the
former ointment.   If simple  eczema  occurs, as is not un-
frequently the  case, in children of a scrofulous diathesis, it
is very apt to become chronic; Avhen  it does so, local reme-
dies seem to have little effect on the eruption, but it yields
rapidly to the internal administration of cod-liver oil, and
the daily use of the tepid fresh-water bath.
  In the early stages of eczema rubrum general antiphlo-
gistic treatment, proportionately active  according to  the
inflammatory character of the  constitutional  and  local
symptoms, is requisite;  in  persons  of full habit of body
bleeding from the  arm even may be indicated, and in most
cases topical bleeding by leeches from the neighborhood of
the  affected  parts  is  attended  with  much benefit; active
saline cathartics should be administered and repeated at
short intervals until  the  febrile symptoms  are subdued.
The local heat, swelling, and tingling are best alleviated
by gelatine baths, and at night the application of poultices,
prepared by first steeping the best white bread in boiling
water, squeezing it out as dry as possible, and then moist-
ening the  pulp with the weak lead-Avash  above mentioned.
   When this form  of eczema becomes chronic, it is usually
most rebellious to treatment, and requires the employment
of internal specific or alterative medicines  to  produce  a
change in the state  of  the  constitution Avith  which it  is 
ECZEMA.
75
combined, or on which it may depend, and this is requisite
even though the eruption is of  small extent and local.  In
many cases  the preparations of iodine proAre most effica-
cious, but sometimes it is  requisite to combine them with
arsenic, or to give that medicine alone;  in delicate consti-
tutions, or if debility be present, the iodide of potassium is
the best form:  it may be given in some tonic  decoction, as
follows :—

     R. Iodidi Potassii,.........gr. viij.
        Decocti Ulmi (corticis recentis),   fl ^xij.
        Decocti Dulcamarae,  ......fl 5iv. Misce.

  " A wine-glassful to be taken every night at bed time."

When  thus  given it  is not liable to  sicken  the stomach,
and in my experience small doses  of iodine or its prepara-
tions act most efficaciously in the treatment of diseases  of
the skin.  If the use of arsenic be indicated, either from
the obstinacy of the affection or the failure of other  reme-
dies, five minims, very gradually increased to  eight, of  the
liquor potassae  arsenitis,  or of the  liquor arsenici chloridi
of  the last  London Pharmacopoeia, may be added to each
dose of the  above mixture; but whether iodine or arsenic
be administered alone or in combination, their use must be
continued for a long time,  at least for two or three months,
and beneficial results  are  always most  effectually derived
from the system being brought  very gradually under their
influence.  Numerous internal  medicines, as  well as local
applications, haAre been recommended by different writers
for the treatment of  chronic  eczema; of the former  the
most generally employed are the  tincture of cantharides,
antimonials, sulphur, especially in the form of the  sulphu-
rous  mineral  waters, mercurials, and  various  vegetable
tonics ; but my own experience leads me to rely on  either
or  both  of  the powerful  alteratives above recommended;
even in the  most chronic cases I have  seen the sulphurous
waters—so valuable in other diseases  of the skin—prove
injurious, and  mercurials  generally disagree  except with
children, in whom the green iodide of mercury combined
with  the hydrargyrum cum creta often acts  as  a most
valuable alterative. 
76
V E S I C U L E.
  The itching and copious  secretion attendant  on chronic
eczema demand the  employment of local sedatives  and
astringents.  The  compound  lead-cerate of the  London
Pharmacopoeia, to  every ounce  of  which tAVO drachms of
glycerine and eight minims of chloroform have been added,
constitutes a most useful ointment, no matter on what part
of the surface  the  eruption  may be seated;  or the carbo-
nate of lead or acetate of zinc ointment already described
may be substituted for it should  there be much tendency to
local inflammatory action.  Tannic  acid, in the proportion
of from four to twelve grains to the ounce of cold cream,
with or Avithout the  addition  of  chloroform, is also an ex-
cellent application.   Some recommend  highly stimulating
compounds for the local treatment of chronic eczema, such
as anthrakokali  or  fuligokali (forms of  carburet of potas-
sium, which,  when introduced into the practice of medicine
a few years since, Avere highly vaunted  for their remedial
powers, but have now fallen  into disuse), tar,  pitch,  sul-
phurous preparations, &c.  By distilling tar with water, a
mixture of impure oil of turpentine, a pyrogenous oil, and
some pyretine  is procured;  this liquid has  been recently
used  and highly praised by some  French dermatologists,
under  the  name of huile  de cade, as  a local application,
inunctions  being made with it  twice daily ; by the  term
huile de cade,  however, most of the French pharmacolo-
gists understand a tarry oil obtained by the dry  distillation
of the  wood of  the juniperus oxycedrus.  No matter what
local remedy is employed, it will be found of advantage to
sponge the affected parts  carefully with a weak alkaline
Avash—ten grains of the carbonate of soda to a pint of dis-
tilled water, each time previously to its fresh application.
   When eczema occurs on the face  or hands, the treatment
as above described for its different  forms is  equally appli-
cable,  but in either situation, in  consequence of the expo-
sure to atmospheric  vicissitudes and to various local irri-
tants,  it is usually more obstinate, and when  the disease is
general over the body the face is for the same reasons the
last part to get well.  The  use  of  soap in washing should
be interdicted, the weak carbonate of soda lotion warmed to
blood heat being substituted for it, and especial care should
be taken not to expose the surface  to the  action of harsh 
ECZEMA.
77
winds, the  sun, the heat of the fire, or any cause which
might produce determination of blood to the affected parts.
   In eczema capitis the hair should be cut close to the
scalp with a sharp pair of scissors,—not shaved off,—and
kept as short as possible while the disease lasts, and for a
short time  after it is apparently cured.  The crusts  and
scabs should  be removed by poulticing  with linseed meal,
and sponging with the weak  carbonate of  soda solution
mixed with  an  equal quantity of new  milk,  the  surface
being carefully dried afterwards.  When the scalp is thus
cleaned,  in the milder and less inflammatory forms of the
eruption an alkaline ointment,  containing twelve grains of
the bicarbonate  of soda to the ounce of cold cream, may be
applied morning and evening, the surface having been pre-
viously  sponged as above directed;  but if there be  any
tendency to inflammatory action, the carbonate of lead or
the tannic acid ointment, and the subacetate  of lead-wash,
prove more beneficial.  The scalp should be kept cool, very
lightly covered or  exposed to  the air when  in the house.
As regards constitutional treatment, in scrofulous habits of
body, either  cod-liver oil or  iodide  of potassium,  with
tonics, should be administered; but the best  alterative for
children  who are not scrofulous is the green iodide of mer-
cury, as before mentioned.
   In all  forms of  eczema, when  the origin of  the  disease
can be traced to any local irritant, this of course should
be  carefully guarded  against, both during the progress of
treatment and when a cure is affected;  in the case of per-
sons engaged in trades, and  others wTho cannot abandon
the occupation by which the eruption was caused, the cu-
taneous  surface should be  protected as  much as possible
by the  use of wash leather gloves.  The diet of persons
affected  with eczema should be regulated according to the
constitutional circumstances, but  in  children much benefit
will be  derived from  placing  them  on a strictly milk  and
farinaceous  diet.   In  both adults and children the bowels
require to be carefully attended  to,  the  use of  mild saline
purgatives, if possible the natural mineral waters, of which
probably the Pullna is the best, being employed  with ex-
cellent effects.  In children the process of teething must
be watched  and the  gums lanced when necessary;  and 
78
VESICULE.
the eruption on the scalp should not be dried up  too sud-
denly if there exists a tendency to disease of the brain or
of any other internal organ.
                        HERPES.
   Herpes (Tetter).—This  term,  though very generally
used  in the nomenclature of  cutaneous  diseases by  the
older  medical writers, had with them no special reference:
it is now employed  to designate an eruption of small glo-
bular vesicles  clustered  together,  and  often regularly
grouped, on inflamed patches of the skin usually of small
extent and distinctly separated. The eruption is preceded
by heat, tingling, and some degree of swelling and redness
in the parts on which it is about to appear, but there is no
antecedent or accompanying fever unless, which is rarely
the case, it is developed simultaneously over an extended
surface, and even then the febrile symptoms are but slight,
It is  described by most English  dermatologists as  being
non-contagious, but an  accumulation  of direct evidence
has convinced me  that one form of the eruption is propa-
gated by  contagion, no matter on  what part of the cuta-
neous surface  it may be situated.  The vesicles, which  on
their first appearance are  globular and transparent, on the
second or third day become somewhat flattened, opaque,
and semi-confluent;  they then burst  and give  exit to a
trifling  serous discharge,  which  concreting  into a soft,
thin, yellowish-brown crust, falls off and leaves a super-
ficial  ulceration that heals rapidly.   The causes of herpes,
Avhen it affects the body generally, cannot be traced with
certainty, but  in  some of its local varieties are often suffi-
ciently manifest.
   The forms  of this eruption present great  variety,  and
have  been differently named with  reference both to their
external phenomena and the  parts on which they may
appear;  this has led to  numerous subdivisions of the dis-
ease in classifying it for the purposes of description, thereby
tending to complicate the inquiry.  I shall describe them
all under  the three following heads:—
                 Herpes phlyctenodes.
                    ,,     zoster.
                    „     circinnatus.
   Herpes phlyctenodes  (Nirles) is occasionally, more par- 
HERPES.
79
ticularly when it occurs in adults,  attended  with slight
fever, foul tongue, loss of appetite, nausea, and thirst, but
the pulse is rarely quickened;  there  is a deep-seated pain
in the part  on which the eruption  is about to appear, and
superficial  heat and tingling.   Small irregularly shaped
patches of the skin  become slightly swollen and red, and
in about twenty-four hours afterwards an eruption of ve-
sicles appears on  them.   The majority of these vesicles are
of small size, but a  few of  them attain  the magnitude of
a pea ; they  are  distinct from each other, rounded, and
contain a transparent serous fluid; they occur  in  groups,
varying in size from one to three or  four inches in length
or breadth,  but rarely  exceeding that of  the palm of the
hand; usually, when of large extent,  constituting but a
single group, which, however, is  often made  up of  three
or more smaller, by  the eruption  spreading over the inter-
mediate  sound skin.   On the second day  after  their
appearance  the fluid in the  vesicles becomes  opaque or
seropurulent, and they burst on the third  or fourth day—
those that  were  closely aggregated  together having pre-
viously become confluent, forming soft crust or brown scabs,
from beneath which a thin sero-purulent matter exudes in
small quantity.  These scabs, falling off on or about the
tenth day, leave small superficial ulcers which heal in  three
or four days,  so that the disease rarely lasts longer than a
fortnight.   But it is sometimes prolonged by the  eruption
of a  distinct patch of  vesicles on the third or  fourth day
after the appearance of the first, and in their  neighbour-
hood; they  unite with  the former,  and  the  entire thus
cover a rather extended surface;  requiring, however, the
same time  for maturation  and healing, the duration  ex-
tends to three or  four  days more.    Should there be any
attendant fever, it abates or disappears  with the outbreak
of the eruption, but  the local symptoms  increase until the
vesicles burst, when  some slight itching only remains
   The local pain, which is often severe previously to the
appearance  of the  eruption,  is usually  much alleviated
then, but sometimes returns  with greater intensity after
the surface  is  healed, and, presenting somewhat of a neu-
ralgic character,  lasts with  great obstinacy frequently for
months.  Occasionally in old persons or in bad constitutions,
an herpetic  eruption terminates in troublesome ulceration. 
80                  VESICULE.
   The phlyctenoid form of herpes may  appear on  any
part of the body; its most usual seat is on the trunk, the
neck, aud  the  arms, rarely occurring  on the  lower extre-
mities.   It attacks some special portions of the integuments
with great regularity, and  its occurrence  there requires to
be  separately described: these are, the lips  and the pre-
puce.   Herpes  labialis  is a  slight form  of  the disease,
deserving notice merely in  consequence of the local annoy-
ance which  is occasioned  by its  situation; the  eruption,
which  is  preceded by  a  certain degree of  tumefaction,
dryness of the skin, heat, tingling, and redness, appears
at the angles of the mouth,  or on the upper or lower lip,
more  usually on the latter, being  of small extent, rarely
exceeding the size of a shilling.   The vesicles, which are
minute, closely aggregated, and covering  the entire of the
inflamed surface, are at first globular, transparent, and
shining; within forty-eight  hours  the  contained serum
grows turbid, the vesicles become confluent, forming bullae
of the size of a pea, and on the fourth or fifth day soft
brownish crusts  appear  on their surface, which fall off in
two or three days more, leaving a slight degree of redness
and  swelling  of the part, that  lasts  for about a  week.
Should the  crusts, however, be torn off by scratching, or
irritated from their situation at the commissure or on the
vascular portion of the lips, the surface bleeds, and a hard,
dark  brown scab is formed, which is  sIoav in separation.
Sometimes the herpetic  eruption on the  lips extends com-
pletely  round the mouth,  when  it is  a troublesome  and
obstinate affection; but unless under these circumstances
it runs usually a rapid course, its duration seldom exceeding
a week or ten days.   A variety of herpes, similar  in  all
respects to this, occasionally appears  on the  ears;  it  is
then termed herpes auricularis.
  Herpes prseputialis has  been so named from its appear-
ing on the prepuce, being situated either upon the external
cuticular  surface  or on  the mucous membrane.   The
eruption is preceded by heat and tingling in the part, and
some  degree of soreness, and when it  occurs  on the inter-
nal aspect of the prepuce  there is also more or less tume-
faction ;  the transparent orbicular vesicles soon appear in
a small group, but  distinct from  each other, on  a some- 
HERPES.        "           81
what  circular inflamed patch  of the integument, rarely
exceeding the size of a sixpence ; when  they occur on the
external surface they maturate quickly, becoming  opaque,
and forming brownish crusts, which fall  off on the fifth or
sixth day, leaving the part on which they had been seated
slightly tender and  red; but when the eruption is situated
on the mucous  membrane the vesicles are larger, become
sero-purulent, and  from the confluence of two  or  three
attain  the size of a split pea ; the scabs which  form are
softer, and of a  yellowish colour, and, being  easily rubbed
off, leave a small ulcerated surface, which, from the  swell-
ing of the  surrounding  mucous membrane, occasionally
presents a slightly excavated character, in consequence of
which  it is likely to be mistaken for  a  chancre.   Herpes
praeputialis  sometimes becomes  chronic when  the disease
spreads, by the appearance of successive  crops of the erup-
tion, over the entire of the prepuce, especially  affecting
the part  where  the mucous  membrane and skin meet;
there  is  much thickening from  the  effusion into the sub-
mucous areolar  tissues, caused by the repeated attacks of
inflammation ; the  surface  becomes hard, rugose, fissured
in parts, and in parts covered  with brownish crusts, from
between  and beneath  which  an unhealthy,  fetid, sero-
purulent  discharge  takes place, and as the glans  penis
cannot be uncovered, foul ulceration of it not unfrequently
occurs to  complicate the  original disease.   When  the
eruption  is  of this chronic character,  it often  lasts for
months, and the general health  becomes affected  in conse-
quence of the anxiety and distress of mind it occasions.
   In  females herpes phlyctenodes sometimes appears on
the pudendal region, being situated at  the vaginal orifice
on both  the skin and mucous membrane ; its characters
correspond precisely with those of the disease of the pre-
puce in males, but in consequence of the parts being more
exposed  to  the  irritation  arising from  local discharges
and  from the urine, it  is generally more chronic and re-
bellious to treatment.  By some writers it is made a distinct
variety, and termed herpes pudendalis.
   Herpes zoster  (Shingles ; Ignis sacer)  has  derived its
specific name from  the  peculiar  form which the eruption
assumes, resembling, as it  were, a girdle or  sword-belt. 
82                  VESICULE.
The constitutional  and local symptoms  are  more severe
than, in the variety last described, the former often amount-
ing  to well-marked fever preceding the  outbreak of the
disease, attended with a distinct shivering fit and vomiting.
Locally there are sharp stinging pain, burning heat, red-
ness, and some tumefaction of the integuments in the part
on which  the vesicles are about to appear; these occur of
tolerable magnitude, and closely grouped  together in  three
or four distinct but neighbouring patches, each surrounded
by an inflammatory areola, which gradually spreads, neAV
vesicles appearing  on it, and the entire constitutes a cres-
centic or  oblique demi-zone from  half-an-inch to one or
two  inches in breadth, seated  on one side of the neck or
trunk, often  extending from mesial line to mesial line, by
which it seems to be distinctly bounded, very rarely pass-
ing its limits.  The eruption runs the same  course  as in
herpes phlyctenodes,  but  the vesicles  become more con-
fluent, thus often attaining the magnitude of  bullae, those
which first appear  being  always the largest; and  it is
somewhat more chronic in all  its stages, the scabs being
often particularly slow in separating.
  The local  pain  which precedes the appearance of the
eruption in herpes  zoster  is  not unfrequently very severe,
and  apparently deep-seated, seeming  to shoot through the
chest or abdomen if the disease is  about  to  occur on the
integuments of either of these regions.  This  pain, which
to a great extent  disappears Avhen the vesicles are deve-
loped, usually returns with greater or  less intensity,  espe-
cially in adults  or old  people, when the crusts  fall off,
sometimes lasting even for  years, and  causing great suffer-
ing.   At  times  chronic ulceration succeeds  this form of
herpes in bad constitutions, and this  may terminate even
in gangrene,  and thus prove fatal.
  The usual  seat of herpes zoster is  on the thorax or ab-
domen ;  it also  appears occasionally  on  the  neck;  when
the eruption  commences over the scapula, or in the neigh-
bourhood  of the hip, it  may extend  to the shoulder or
thigh, including either  in  the semicircle which  it forms,
but  it very  rarely originates  on the extremities.   By
Franck and Cazenave the disease is stated to appear more
frequently on the right side of the body, but my experience 
HERPES.
83
agrees with that of Reil and Wilson, that it is situated  on
the left in a  greater number of cases.  It is so extremely
rare for the  demi-zone of herpes to  pass the median line,
that amongst the ancients it was popularly believed, and
the fact  is mentioned by  Pliny, that if the  eruption sur-
rounded  the  body it  should prove necessarily  fatal; yet
cases are recorded by modern writers,—Franck and others,
—in which such took place by the simultaneous development
of the eruption on both sides and their extremities meeting,
yet the patients recovered.
  Herpes circinnatus (Ringworm), like the last described
variety, derives its name  from the shape of the groups in
which the eruption appears,  namely, distinct  rings  or
circles, inclosing healthy skin in the  centre.  Slight prick-
ing  sensation or tingling  accompanies the outbreak of the
disease, but  it is not  attended with  any constitutional
symptoms. At first one or more small, red, circular  patches,
from half-an-inch to an inch in diameter, appear apart from
each  other on some portion of the integuments, on  the
outer border of  which  numerous minute,  globular  trans-
parent vesicles are deAreloped on the second or third day;
the redness then fades from the centre of each circle, which
remains unaffected afterwards  during  the  progress of the
disease, but  the ring  of vesicles  has  an  inflammatory
border both  external and  internal.   The vesicles,  which
are  closely   aggregated, become more or  less  confluent
within forty-eight hours after their  appearance, assume a
pearly aspect, and then bursting, discharge a small quan-
tity  of a serous fluid,  which dries into thin brownish crusts
that fall off on the eighth or ninth day, to be succeeded  by
a fine epidermic desquamation that lasts for  some time.
The disease, however, rarely terminates thus,  but is pro-
longed by the repeated eruption of fresh crops of vesicles
on the outer  inflammatory border, each set running an in-
dependent course, but one similar to the first; spreading
in this manner from the circumference, the rings at times
attain the size of the palm of the hand, which they rarely
exceed.  The  circles may be  few or  many in  number,
rarely, however, more than four or five, and when of larger
size there is usually but  one; they may appear simulta-
neously on the surface or in succession :  in the latter case
the  disease often becomes chronic, lasting for months. 
84
VESICULE.
  Occasionally it occurs that the vesicles instead of burst-
ing and  forming crusts, dry up, and are succeeded by a
secretion of  fine, soft scales, wmich continue to  be  exfo-
liated, not alone from  the circumference, but  from  the
centre of the circles.   This form has  been specially descri-
bed by Cazenave, Avho denominates it herpes squamosus ;
it is always chronic, and very obstinate to  treatment.
  Herpes circinnatus occurs Avith greatest frequency on the
face, neck, and scalp, being, however, occasionally situated
on the  chest, the shoulders,  the  arms, and  the hands.
When it  appears on the  face its most usual  situations  are
the cheeks  and  the forehead ;  as  the circles spread from
their  circumference they often extend from  the  former to
the nose, but do not  pass  the mesial  line,  and from  the
latter into the scalp.   In its milder  forms  ringworm dis-
appears  in  eight or  ten days, but  its duration is  more
usually prolonged for three or four weeks, either by the
spreading of the circles or by the  successive development
of fresh  patches of  the eruption;  occasionally, as above
remarked,  it becomes chronic, and lasts for months, pro-
ducing annoyance more  from  the unsightliness of its  ap-
pearance, when it is situated on any of the exposed regions
of the skin, than from any local uneasiness.
  This form of herpes, when it occurs on the scalp, requires
to be specially described, as it constitutes almost a distinct
variety, which might be termed herpes capitis; it resem-
bles in many of its characteristics the herpes squamosus of
Cazenave, but that distinguished dermatologist, in conse-
quence of the effect its presence exerts on the hair, proposes
to term it herpes tonsurans.  Its occurrence on the scalp
at all is denied by many of the celebrated  English writers
on diseases of the skin, who regard the eruption  about to
be described  as a species of porrigo  ; but prolonged clinical
observation, independent of their corroboration  by so de-
servedly high an authority as M. Cazenave, has tended but
to convince me of the correctness of the views I  propounded
some years since.1
  Herpes capitis usually attacks children from the age of
3 to 12.   It  is very rare in early infancy, and I have never
met with it after the age of puberty, except in one instance,
  1 Dublin Quarterly Journal of Medical Science, New Series, vol. vi. p. 33. 
HERPES.
85
in which it had commenced at the age of 13, and had lasted
for  more than five years before I saw the case.   It is very
rarely witnessed  in its first  stage,—that of vesicle,—as it
then  produces but little  annoyance, and advice is, conse-
quently, not sought for until it becomes more developed.
When seen, however, at its commencement, it presents the
appearance  of a small ring of minute vesicles, not more
than an eighth of an inch in diameter, without any redness
or other marks of inflammation beyond a slight tingling,—
not itching.  These  vesicles are attended  with scarcely
any discharge, soon drying  up and desquamating; but as
they  dry up in the centre  they spread  from the circumfer-
ence, and the diseased spots, in the course of a few days,
attain the size of a shilling.  When we examine them in
this stage,  the centre, the part  where the eruption first
appeared, is thickened, elevated  above the surface  of  the
surrounding scalp, and covered with fine scales, which are
reneAved rapidly on being removed.  As the  disease pro-
ceeds, the  patches extend  from  their periphery, still re-
taining  a perfectly circular shape, and finally, after some
weeks, attain the size of a crown-piece, which  they rarely
exceed, no  matter hoAV chronic the  case may  have been.
Having  attained this size, and ceased to spread, the entire
of the diseased surface is thickened, elevated, and covered
with  fine, soft scales, which  the least touch removes :  this,
the advanced stage of the disease, is usually attended with
itching.   Sometimes  but one patch of herpes  is found on
the scalp, but more generally there are three, four, or more
circles, distinct,  and at some distance from each other.
   As the disease advances,  the hair assumes a very pecu-
liar  appearance,  almost  pathognomonic of this form of
eruption of the scalp.   In the early stage each hair appears
to  be slightly bent on itself, and turned  against the grain,
obstinately refusing to lie smooth ; the roots are also some-
what matted  together  by the scaly crusts of the eruption.
After some time it presents a diseased appearance, being
twisted, broken,  of a whitish colour, and  readily falling
 out; so that bald patches begin to appear, over which are
 scattered small bundles of the altered hair, which has been
 described, not inaptly, as resembling tow.   This condition 
86
VESICULE.
of the hair has induced some writers to describe the affec-
tion as a disease not of the scalp, but of the hair itself.
  The eruption- does not always present the exact charac-
ter  now described.   In the early stage,—when, however,
it is rarely witnessed by the medical practitioner,—its ap-
pearance always agrees with the description given, except
that in  some  cases  there  is more inflammation  than in
others;  but in the  advanced stages  it varies  much, both
as regards the amount of desquamation and the appearance
of the elevated patches : it is this fact which has led  to so
much confusion in the  diagnosis  and  nomenclature of the
disease.   Yet  in the  most chronic or complicated  cases,
the circular form of the eruption, and the peculiar condition
of the hair, render its  diagnosis easy to even the tolerably
experienced eye.
  Herpes capitis does  not cause baldness :  the altered hair
falls off the diseased patches, which, when  the scales dis-
appear in the  progress of cure, are thus left, in a bald state;
but the hair eventually grows on them again, thereby con-
stituting an essential difference  between this affection and
alopecia.   The disease,  unless  when  seen  and properly
treated in its early stages, soon becomes chronic and obsti-
nate,  and loses its inflammatory character.  No constitu-
tional symptoms either precede or accompany herpes of the
scalp.
  In  some very rare  cages the  eruption in herpes circin-
natus assumes a singular arrangement, Avhich, in the opinion
of some dermatologists, entitles it to be  considered as a
distinct variety, receiving the appellation of herpes iris, or
rainbow  ringworm.  A  small, round, inflammatory patch
appears on some part of the cutaneous surface, and around
it, but separated by a narrow band of healthy integument
of the natural colour, is a  red,  slightly  elevated  circle,
which in its turn is again surrounded by two or three other
similar rings of inflamed skin :  on the  centre a few minute
herpetic vesicles are developed in  about twenty-four hours
after  its appearance, as also on each of the rings, but they
are more  numerous  and more closely aggregated on them.
The rings, which are usually four in number, differ in colour,
the inner one being of a darker red than the central patch,
that next to it of a lighter shade, the third darker even than 
HERPES.
87
the first, and the outer ring paler than the second, being of
a yellowish-red hue, fading at its outer border into the
colour of the surrounding skin.  The vesicles run the same
course as in the milder form of herpes phlyctenodes, the
crusts, which are small and thin, falling off on the eighth
or ninth day, to be followed by slight furfuraceous desqua-
mation, which  lasts for a few days  longer.  Herpes iris
seldom occurs except in very young children and in females ;
it  usually appears  on the backs of the fingers or of the
hands, on the temples, and on the prominent parts of the
joints, being sometimes associated with other forms of the
eruption.  It  may  occur singly,  or  several patches may
appear simultaneously on different parts of the body ; the
only local symptoms are some trifling heat and itching, and
it has no tendency to become chronic.
   Causes.—Herpes is a disease almost entirely confined  to
young persons and to those in the prime of life, very rarely
appearing in the old ; among adults it affects females more
commonly than males,  but in children sex seems to have
no influence in the frequency of its occurrence, those of a
sanguine and  lymphatic  temperament, and in whom the
skin is fine and soft, being most liable  to it.  Of the exci-
ting causes of herpes phlyctenodes but little is known;  it
seems to be occasionally developed under the  influence  of
strong mental  emotions, and it is  often connected with
deranged conditions of  the digestive  and biliary organs.
 The season of  the year, too, appears  to have some influence
 on its  occurence, for it is most frequently met with in the
 spring and autumn.  The connexion  of herpes labialis Avith
 febrile states of the system is usually very evident, and
 especially with those Avhich affect the  respiratory organs:
 thus it is an almost invariably accompaniment of  catarrh,
 influenza, bronchitis, and  pneumonia, in all of which  its
 occurrence is a favourable symptom, whence has arisen the
 popular expression  that  the cold  goes  off in this way.   It
 is also occasioned  very frequently in  travelling  by the
 direct  effect of a  harsh cold wind  on the lips, or of the
 sun's rays ; the action of local irritants, too, may produce
 herpes here, as is often  witnessed in its  being  caused  on
 the upper  lip  by the  acrid secretion from the nostrils  in 
88                  VESICULE.
coryza; this discharge, however, more frequently produces
an eruption of eczema.
  Herpes praeputialis occurs only in adults, and most fre-
quently in those in whom the skin of the prepuce is very
sensitive; it is often caused there  by the friction of the
clothes;  and when it appears on the mucous membrane, or
on the glans penis where I have occasionally seen  it,  by
the irritation of the natural sebaceous secretion of the part,
allowed to accumulate from want of attention to cleanliness.
The connexion between the occurence of herpes on the pre-
puce  and stricture of the urethra is  very generally ad-
mitted, but many observers believe it to be only an accidental
coincidence; others, with whom I agree, consider the exist-
ence of stricture to  be  a  cause  of  this eruption,  and the
manner in which it acts may, I think, be easily explained.
In persons affected with stricture, the last drops of  urine
are retained for sometime in the uretha, the shirt is thus
constantly wet, and  the prepuce is irritated by the acrid
moisture to which it is thereby so constantly exposed ;  hence
also, in these cases,  the eruption is usually seated on the
verge of this fold of integument.   In females herpes  of the
pudendum may occur at any age ;  it is' invariably caused
by local irritation.
  Herpes zoster appears  in adults more frequently than
any of the other varieties, occurring also  occasionally  in
old persons, in whom it sometimes becomes chronic, and ter-
minates in troublesome ulceration :  it seems to be generally
occasioned by cold, acting on individuals suffering from
hepatic  derangements.   In the  summer and autumn of
some years it would  appear to be epidemic among children,
and in them it is very frequently produced by sudden sup-
pression of the perspiration.
  Herpes circinnatus is a disease of youth, being very rare
amongst adults, and occurs with equal frequency in both
sexes; it is very  common in schools,  or wherever many
children are congregated together, amongst whom it spreads
rapidly.   The popular idea that ringworm is  contagious is
opposed by most  English dermatologists on the grounds
that no  other form  of  herpes is so, and  that the disease
cannot be  produced by  inoculation.   Now, neither  of
these reasons is sufficient to  counteract, in my mind,  the 
HERPES.
89
amount of direct evidence Avhich an experience of some
years in the treatment of diseases of the skin has afforded
me of the propagation of this form of herpes by contagion,
no matter on what part of the body it may be situated.   I
have elsewhere1 published cases illustrative of the develop-
ment of the  eruption on  the hands of adults  engaged  in
the application of  local remedies to the scalp of children
w7ho were affected  with it, and to these  I could now add
several others ;  and I have seen too many instances of its
direct  communication from child to child of different fami-
lies, when the argument of  similarity of constitution and
of  dietetic arrangements  could not  avail,  to have any
doubt  on the matter; but it must be remembered that, like
all other contagious  diseases, some families  and some
children are more prone to its attacks than others. My own
opinion, too, is  confirmed by that of M.  Cazenave, who, in
his Legons sur  les Maladies de la Peau, and in  his more
recently published  Traite des Maladies  du  Cuir Chevelu2
adduces several cases from his own practice, which exhibit
in a marked degree the contagious nature of herpes circin-
natus.
   Diagnosis.—The characters  of the eruption in herpes
are so Avell defined that, unless when it occurs on the scalp,
it can  scarcely be  confounded  with any other  cutaneous
disease.  It  differs from eczema  in the  vesicles  being
larger, more  globular, and distributed in patches; its erup-
tion is unattended with constitutional symptoms, and in its
advanced stages it  is not accompanied by the copious serous
exudation of" that disease.   When the  vesicles  are very
confluent it may be mistaken  for pemphigus, but  in that
affection the eruption consists of bullae, which do not in any
of their stages present the pearly aspect of herpes, and are
succeeded by hard, dark-brown crusts;  the  bullae of pem-
phigus, moreover, are usually solitary and  scattered over
the cutaneous surface, not distributed in groups.    Herpes
labialis is diagnosed by the  characteristic vesicles,  and  by
their  local  situation.   As  already remarked, the  serious

  i Dublin Quarterly Journal of Medical Science, New Series, vol. viii-

P* ^PariMSSO, p.  197.  See also Annates des Maladies de la Peau et de la
Syphilis, torn. i. p. 37, et seq.
                          8* 
90
VESICULE.
error may be committed of confounding herpes praeputialis
with chancre ; if the eruption is seen on its first appearance
it is readily diagnosed by its vesicular character, but when
the scab is  formed, or ulceration, caused  by irritation, the
diagnosis is often not unattended Avith difficulty.  The ul-
ceration  in  herpes, however, is  always  superficial,  never
deep, and presents a smooth surface without raised edges,
and not coated with a white, filmy membrane, appearances
peculiar  to  chancre;  in  very doubtful cases the question
may with certainty  be decided, by inoculating the integu-
ments of the thigh of the patient with some of the matter
from the diseased surface.  The same remarks as regards
diagnosis, apply equally to  herpes  of  the pudendum  in
females.   Erythema circinnatum, or lichen circumscriptus,
in their advanced stages, present some resemblance to herpes
circinnatus, but neither of  these are vesicular during  any
period of their  presence on the skin, nor do  they spread
from their circumference  in the manner that disease does;
they are, too,  attended with more thickening and elevation
of the integuments on which they are situated.
   Herpes capitis, which corresponds  with the herpes ton-
surans of Cazenave, is, as I have already remarked, described
by many English writers as a variety of porrigo, the yellow,
cup-shaped, favus crusts so characteristic  of which it, how-
ever, never presents.  It is  diagnosed from the other erup-
tive disease of the scalp by its occurring in distinct circular
patches,  the slight  serous discharge from which dries into
fine, soft scales, that are readily detached by the slightest
touch, but  are again very quickly renewed,  and especially
by  the peculiar change, before described,  which it produces
on the hair.
   The prognosis in any form of herpes is favourable, as the
eruption may be said almost never to endanger life, and
is but very rarely productive of any injury to the general
health; it  is also not so liable as  many  other eruptions to
become chronic, unless when it  occurs on the scalp.   The
local neuralgic pain, which not unfrequently is consequent
on herpes phlyctenodes and*herpes zoster, is at times both
severe and obstinate,  often lasting for many months.
   Treatment.—The phlyctenoid form of the disease very
rarely requires  any active  constitutional remedies; in  a 
HERPES.
91
few cases, when it occurs in young persons of a full habit of
body, bleeding from the arm, or the application of leeches
in the  neighbourhood  of the eruption,  is attended  with
benefit, but  neither should  be had  recourse  to  until the
eruption is fully developed:  saline purgatives,—preceded,
if there is any  biliary  derangement, by a mild mercurial,
five  grains of blue pill, or two of calomel combined with a
grain of extract of hyoscyamus,—will, however, in  nearly
all cases sufficiently meet the constitutional symptoms.  In
weakly individuals, tonics  with antacids,—as bark  with
the  carbonate of ammonia,—are indicated.   With refer-
ence to local treatment, all that is requisite  during the
first two or three days after the formation of the vesicles
is to protect them from being  irritated  by rubbing  or
scratching ;  unless there is much tingling and pain of the
part, which  will  be relieved by smearing them  over with
a cerate consisting of two  grains of  acetate of zinc,  an
ounce  of cold  cream,  and  four  minims  of chloroform.
Should  there  be  any tendency to  a copious discharge,
finely powdered lapis calaminaris or starch, will be dusted
over the surface with benefit.  As soon as the brown scabs
form, a spirituous lotion, such as the  following,  should be
substituted for the ointment:
     R. Olei Limonum,.....m. vj.
         Olei Corticis Aurantii, .  .  .   fl 3SS-
         Spiritus Vini rectificati,  .   .   fl 3iv.
         Misturae Camphorae,   .  .    fl 3viij.  Misce.
   The  local  pain  consequent on this form of herpes, or on
herpes  zoster, is as far  as  my experience enables me  to
come to  a conclusion,  but little relieved by  external ap-
plications ; those usually ordered for it  are narcotics and
sedatives, such as preparations of opium, of aconite, of bel-
ladonna, of  arnica, &c.   Regarding it  as being  chiefly
neuralgic, I have prescribed  with much benefit a combi-
nation  of bark Avith hemlock, as thus :—
      R. Tincturae Cinchonae compositae, fl 5ij.
         Succi Conii,   .   .   •'  .  •   A3  vj.
         Infusi Cinchonoe,    .   .  .   fl 3vij. Misce.

      " A table-spoonful to be taken four  times a day." 
92
VESICULE.
   In herpes labialis, if a strong spirituous lotion—I have
 found none  answer so well as Eau de Cologne—be con-
 stantly applied  to the part on which  it is about to appear,
 as indicated by  dryness, heat, swelling, and tingling, before
 the vesicles are  formed, the further progress of the eruption
 may in most cases be arrested.  The only local application
 requisite, where the disease  is fully developed, is some mild
 oleaginous ointment, such as the cucumber cerate ;  should
 it, however, become chronic, an ointment composed of  ten
 grains of calomel to an ounce of simple  cerate will be found
 useful.   Persons who  have  once had an attack of herpes
 praeputialis are fully aware of the premonitory local symp-
 toms  by which  it is ushered in ; the development of  the
 eruption may then be stayed by the continued employment
 of cold water, the colder the better, which  can  be applied
 by plunging the penis several times in the day into ice-cold
 water, and retaining it there for  a minute or two;  when
 the vesicles are formed, no  caustics  or  irritants should be
 employed, as their use is apt to be followed by troublesome
 ulceration ; the  best local application is the black  wash, or
 Turner's cerate,  if there is much discharge when the vesicles
 have burst.
   The same  treatment is adapted for herpes  zoster as  for
 the phlyctenoid  form of the disease.   M. Cazenave, with
 the view of preventing the premature rupture of the vesi-
 cles, recommends that the surface should  be smeared with
 oil, and then dusted with starch.   The  ectrotic  plan of
 treatment, that is to say, opening each of the vesicles with
 a needle, and introducing into them a finely-pointed pencil
 of nitrate of silver, has been recommended in both these
 varieties of the eruption.  If they are situated on an un-
 exposed  part of the body, and not  in  any  way connected
with visceral derangements, it may  be had recourse  to,
but it should be remembered that an indelible mark some-
times  follows the application of caustic to herpes.
   Most cases of ringworm  require  no treatment in the
commencement  except the use of mild mercurial purga-
tives,  and protection of the  eruption from local irritation ;
if, however, there is much heat or  tingling in the part,
poultices prepared  with  bread  and  the  Aveak  lead-Avash
(seepage 77) are productive of much  benefit;  when the 
HERPES.
93
scales have formed, the ointment of cold cream and acetate
of zinc (see page 30) will be found an excellent application.
If the disease becomes chronic, constitutional treatment is
generally required for its removal,  and  preparations  of
iodine, with or without tonics, according to individual cir-
cumstances, are  usually the most  efficacious;  as  regards
local applications, astringent  ointments and alkaline lotions
prove in most cases successful; thus an ointment consisting
of four grains of the dried sulphate  of  iron, an ounce  of
white wax ointment, and a drachm of glycerine, should be
smeared over the eruption three times a day, it having been
previously sponged well each time with a lotion containing
ten grains of the carbonate of potash in twelve fluid ounces
of rose-water; or, in  very chronic  cases, a dilute citrine
ointment, containing  from one to two drachms of brown
citrine ointment to the ounce of prepared lead, may be sub-
stituted for that of the sulphate of iron.   When herpes cir-
cinnatus is inclined to spread rapidly, the progress of the
eruption may be sometimes  stayed by the application  of
strips of blistering plaster around the outer border of the
rings, at a short  distance from the inflamed surface;  their
effect seems to depend on a new action being excited in the
part.   In herpes of the scalp the same  local applications
will be requisite as when  it occurs on other parts of the
body, but the hair  should  be kept cut close with a pair of
scissors during the entire progress of the treatment, and
for at least three or four weeks afterwards ; nor is it suffi-
cient to cut the hair on the diseased part solely, but it must
be removed from the entire scalp, as otherwise the eruption
is apt to appear  in other patches on it.   In herpes capitis
in  children, the  green iodide of mercury,  prescribed  as
recommended for eczema of the scalp, has proved in my
experience the best alterative remedy.  Milk  diet, as  an
important  aid  to treatment, should  be enforced  in this
variety of the eruption.
   Herpes iris is  to be treated on the same principles as the
milder forms of herpes circinnatus. 
94
VESICULE.
                      PEMPHIGUS.

  Pemphigus (Water-blebs).—Willan described three forms
of diseases  of  the  skin which were characterized by the
elevation  of the epidermis into bullae, namely, erysipelas,
pemphigus, and pompholyx;  that  the first of these was
incorrectly classed by him with the others is noAV admitted
by all dermatologists for the reasons given when describing
erysipelas ; and the distinction he made between pemphigus
and  pompholyx,—that the one is attended with constitu-
tional fever and local  inflammation, and the other is not,
—does not sufficiently separate them to constitute distinct
diseases;  the latter  term therefore  is now very generally
abandoned,  and when used is considered as being synony-
mous with the former.   Pemphigus may be defined to con-
sist  in the  development of oval  or rounded elevations of
the epidermis, containing a transparent serous fluid, which
vary in size from that of a pea to that of a large  nut (bulla?),
—at times  they  attain the  size  of an egg,—each being
surrounded  by an inflamed  areola.   The  contained fluid
rapidly  becomes  opaque,  and of  a  yelloAvish  colour,  the
epidermic covering, which is  extremely  thin, then bursts
spontaneously,  or is easily torn, and the eruption results in
the formation of fine foliaceous crusts, or superficial excoria-
tions from  which a slight serous discharge flows.  The
bullae come out generally singly or in crops  of from two
to five or six, each crop disappearing  in a few days with
some trifling epidermic desquamation, but  the  duration of
the  disease is  often indefinitely  prolonged by successive
eruptions.   In  a  few cases all the bullae  appear simulta-
neously, when it runs its course in  about a week.  By some
writers pemphigus has from this circumstance been classified
into Pemphigus simultaneus and Pemphigus successivus ;
others arrange  it  in groups according to the number of the
bullae, and others again with reference to  the  age of the
person on whom the eruption appears.   The division, I
think, least open  to objection, and most convenient for the
purpose of description, is into acute and chronic : —
                  Pemphigus acutus.
                       ,,     chronicus. 
pemphigus.
95
   Acute pemphigus is ushered in with well-marked febrile
symptoms, being preceded by shivering, heat of skin, gene-
ral malaise, and loss of appetite ; as well  remarked by Dr.
Corrigan, there are sometimes two or more shivering fits
so^ distinct that the attack at first sight appears to be inter-
mittent fever.1  The feverish^ symptoms are succeeded on
the second or third day by the appearance of a few or many
bright red spots, scattered generally over the thighs  and
lower part of the abdomen, which are  attended with heat
and itching; these  spots rapidly enlarge,  and a minute,
transparent vesicle is developed in their centre, which in a
few hours extends so as nearly to  cover  the  previously
inflamed patch  of integument, a border  being left  which
forms an  areola to each.   The bullae thus  constituted are
round or oval,  somewhat flattened  at  the   summit,  of a
shining brilliancy, and, being irregularly distributed,  re-
semble the effect which would be produced if boiling water
was dashed on the skin; on the day after their appearance
the contained fluid assumes  a yellowish, opaque aspect, and
within forty-eight hours the bullae usually break, giving
exit to  a thin,  serous discharge, which continues  to  be
secreted  for  a few days longer, the surface thus exposed
being red and excoriated ;  the discharge then accretes into
a thin scab, of a yellowish  colour, and a foliaceous aspect,
which, falling off on the sixth or seventh day from the first
appearance of the eruption, is succeeded by a  slight epi-
dermic desquamation and yellowish stain of the surface ;
the former ceases from the tenth to the fourteenth day, but
the latter often lasts for an indefinite period.  In the acute
form of pemphigus the eruption may occur in a single crop,
but there  are more usually two or three in succession,  an
interval of from twenty-four to forty-eight  hours existing
between  them, and as  each set  of bullae runs  a similar
course, the duration of the disease is then prolonged for
about three weeks.  Two or more bullae being occasionally
developed close to each other become confluent, and thus a
very large vesication  is often formed.    On some of  the
inflammatory patches, on the other hand, no elevation of
the epidermis occurs; when, however, there is more swelling
1 Cyclopaedia of Practical Medicine, vol. Hi..p. 263. 
96
VESICULE.
of the part, and  a serous exudation takes place  from its
surface.
  The feverish symptoms always abate on the development
of the eruption, and the local heat and itching are  much
diminished, but the appearance of each successive crop of
bullae is marked by their return.   In some cases the fluid
contained in the bullae is absorbed when they do not break,
and  the disease terminates with epidermic desquamation,
while in  others superficial  ulceration occurs, and then its
duration is more prolonged, and indelible marks are  often
left on the skin.
  Willan termed the disease Pompholyx benignus, when
the premonitory fever was very mild, and the local inflam-
mation trifling.  He also described  a very rare form  of
the eruption under the name, Pompholyx solitarius; in it
" large vesications arise on some part of the body, one after
another, at nearly equal intervals of time; a disagreeable
tingling is felt for several hours before the vesication arises,
which  is usually  in the night.  It enlarges rapidly, so as
sometimes to  contain on the following day a  tea-cupful of
lymph.   Within forty-eight hours the cuticle breaks, the
lymph is discharged, and a superficial ulceration remains.
Near this another vesication  arises in a day or  two, and
goes through the same process as the first.  A third, fourth,
fifth, and sixth vesication will  sometimes appear  and pro-
ceed in like manner."  This singular variety of pemphigus
seems  to affect women solely; it is  extremely rare, yet
Willan mentions  that he  witnessed three  cases of  it;
Cazenave states that he saw one remarkable instance  ; and
Copland records its occurrence  under his observation in a
man.
  The most usual site of acute pemphigus has been already
indicated, namely, on  the  thighs  and lower  part of  the
abdomen, but  it  may  affect the arms, the backs of  the
hands, the legs, and the thorax; it has been also witnessed
on the mucous membrane of the  mouth and tongue.   It
most usually occurs  in adult life, but infants and children
are  not unfrequently  attacked, and  a variety  has  been
specially described by  some dermatologists under the  de-
nomination of pemphigus infantilis.
   This corresponds  with the form so admirably depicted 
PEMPHIGUS.
97
by the late Dr. Whitley Stokes,1 as  being not  uncommon
in Ireland,  and which he termed Pemphigus gangrosnosus
(popularly known as burnt-holes or eating-hive).   By some
recent writers, however, it has been  regarded as a species of
Rupia, but to any one who has witnessed it in our country
districts, where it  is even in the  present day of not unfre-
quent  occurrence,  its agreement  with the  characteristic
phenomena  of pemphigus must be  sufficiently  evident.2
The eruption generally  appears on a child in  apparently
good health, but occasionally a livid suffusion of the sur-
face of the body precedes its  outbreak ;  one or more bullae
appear on the surface, and increase in size for a few days,
when they burst and discharge  a  thin fluid, having a dis-
agreeable smell;  " before  or after breaking, the vesicles
run together, the sore becomes painful with loss of substance,
and a thin,  fetid, ichorus discharge ;  the edges of the ulcer
are undermined, and it spreads quickly."  The discharge
daily increases in quantity, and becomes more  and more
fetid, the ulcers spreading rapidly,  probably from its acrid-
ity, and  the constitutional fever, which is  evidently caused
by the local irritation, is  extreme; emaciation and great
debility quickly ensue, and the child dies on the tenth or
twelfth  day, death  being  often  preceded by convulsions.
Should recovery take place,  the progress to convalesence
is-very tedious, and relapses  not unfrequently occur, even
when the ulcers are skinned over.  A deep pit, like that
resulting from small-pox,  but much more  extensive, is
always left.   The eruption  appears usually  very gene-
rally  over  the body, sometimes spreading  to the meatus
auditorius, when deafness  follows,  and to the eyes so as to
destroy the sight.
  Pemphigus chronicus is of  more frequent  occurrence
than the acute form of the eruption, and sometimes appears
as an  epidemic ; of this a remark  ableexample  is recorded
by  Dr.  Macbride, who  witnessed it  in the  county  of
Wicklow in 1766.  The disease which corresponds with the
Pompholyx diutinus of  Willan is  not  attended  with any
febrile symptoms, yet the outbreak of the eruption is pre-

  1 Dublin Medical and Physical Essays, vol. i. p.  146 ; Dublin, 1808.
  2 In the  following account of the disease,  Dr. Stokes' faithful and origi-
nal observations are freely made use of.
                           9 
98
VESICULE.
ceded  for some days  by sickness, debility, and muscular
pains.   Red  spots, as in the  acute form, appear scattered
over the skin, but  the  redness is of  a livid colour, and  is
not accompanied by heat or  itching;  on  these spots the
bullae are rapidly developed, each bulla covering completely
the reddened surface, so that to  the naked eye they appear
to have no areola, but Avhen examined with a lens, a narrow
red line will  be seen to surround each.  The vesications,
which generally attain their maximum size in a single night,
are much larger than in the acute form, and rarely become
confluent; they come  out almost invariably in  successive
eruptions, a  second crop sometimes not  appearing until
the  one which preceded it  has completely  disappeared
from  the surface, and thus the disease may be indefinitely
prolonged.
   The bullae  are irregularly  globular,  somewhat flattened
at the summit, and contain a citrine-yellow, semi-transpa-
rent, serous fluid,—in  old persons, or in broken-down con-
stitutions, the fluid is generally sanguinolent in some of the
bullae;  in eight or ten hours  they burst, and are succeeded
by the formation of thin, blackish crusts, beneath which the
surface of the skin is excoriated; when these crusts fall off,
small,  unhealthy ulcers, with a foul ichorous  discharge,
not unfrequently succeed.
   If the disease is not prolonged by  the  development  of
successive crops of bullae, which,  however, is rarely the case,
it may not last longer than for  a month or six weeks, and
the general health is but little affected ;  more usually, how-
ever, a  relapse takes  place,  the eruption  seeming to lie
dormant during the winter, returning  again in  the spring
and summer, and thus, or by fresh sets of  the bullae  con-
tinuing to be developed, its duration is prolonged for months
or even years, very frequently proving fatal.  In the latter
case there  may be seen on the cutaneous surface, at the
same time, recent bullae and black crusts and atonic ulcers,
the result of previous  eruptions.   The  constitution then
sympathizes,  extreme  debility, with  low fever,  ensues on
the loss of rest caused by the local irritation, pain, and foul
discharge;  the appetite fails, and the  patient  dies  quite
worn out.
   In one very chronic  variety of pemphigus which attacks 
P E M H P II I G U S.
99
old persons, the bullae form  with extreme rapidity, no dis-
tinct  interval elapsing between  the development of the
successive  crops;  they become confluent, burst almost as
quickly as  they appear, and spread so as to engage the
cutaneous  surface over the  greater part of the body, the
face in especial being  affected.   The bullae are succeeded
by  epidermic  desquamation in large, yellowish, foliaceous
scales, which partly adhering to and partly peeling  from
the subjacent integument, gives a  singular aspect to the
disease; these  scabs are  aptly compared by Cazenave to
the layers of puff-paste, and he terms the eruption in which
they occur, pemphigus  Chronicus foliaceus.   It is generally
a very fatal form, death being preceded by dropsical effusion
and diarrhoea.
   Chronic  pemphigus may occur on any region of the
body, except those parts on which hair grows;  it is  more
diffused  than when the  disease is  acute,  and  appears
more frequently on the upper extremities, the face and
the thorax.   It not uncommonly is complicated with  other
cutaneous  diseases, especially with purigo or scabies, in
either   of  which cases the  sufferings  it  occasions almost
baffle description.
  The  causes of  pemphigus  are more or less  connected
with  constitutional  derangements; the chronic  form in
particular  rarely  occurring except in persons who  have
been  debilitated by distress, and  by insufficient  or  bad
diet,  or in those  who  suffer  from some chronic  visceral
disease,  of which  it seems  at times to be symptomatic.
Acute pemphigus  is most frequent in children  and young
persons, infants even  not being exempt from  it, appear-
ing rarely in  adults or in the old;  while chronic  pemphi-
gus is  a disease of advanced  life.  The eruption  is  occa-
sionally developed in  children after a continued exposure
to the heat of the sun; but it  much more frequently seems
to depend  on the effects of  moisture, most of those at any
age who are attacked with it being persons who have  lived
in damp situations; this  fact  is well established in the
country  districts of Ireland,  where it is  most prevalent
among the  peasantry who  dwell in mountainous districts,
much rain  falling there, and the hills being constantly en-
veloped in mists.   The  occurrence of the disease as  an 
100
VESICULE.
epidemic has been  already adverted to; some of the  an-
cient  medical writers regarded it as being contagious, and
Willan, by describing a variety of it under the name Pem-
phigus  contagiosus,  tended  to  perpetuate this  erroneous
vieAV, one, too, which was contrary to his own opinion.
  The diagnosis of  pemphigus, whether acute or chronic,
is, in most cases, unattended with difficulty.  Although
the bullae resemble somewhat the vesications  which occa-
sionally accompany  erysipelas, they are never situated on
a diffusely inflamed portion of the  skin, as  occurs in that
disease,  nor  are they attended  with the  consititutional
fever.   The  diagnostic  marks  between  pemphigus and
herpes have been given  in  the  description of that erup-
tion.   Rupia differs  from pemphigus in there being in it
a broad inflammatory areola to each bulla when it  is first
developed,  and in the peculiar appearance of the resulting
scab or crust.   The  foliaceous form of chronic pemphigus
might  be mistaken for psoriasis, but the scales in the lat-
ter aesquamate more freely,  are smaller, of a silvery white-
ness, and are never  preceded by an eruption of  bullae, nor
attended with a serous  discharge.
  Prognosis.—Pemphigus in any of  its forms  is not  un-
attended with danger,  notwithstanding  Willan termed one
variety of it  Pompholyx benignus.   The chief apprehen-
sions in  the acute form are, the  liability to relapse when
it appears  in children,  or about  the age of puberty ; and,
at an earlier age, that  it may assume the characters of the
pemphigus gangraenosus  of  Stokes.  The  chronic form is
always a most dangerous disease, few old  persons recover-
ing from an attack  of  it.  The more  acute the symptoms,
and the more inflammatory the  constitutional  disturbance,
the more favourable the prognosis.
  As regards the pathology of pemphigus,  it is manifestly
an atonic inflammation of  the  superficial layers  of the
derma, which terminates in  serous  effusion: the fluid con-
tained in the bullae is highly albuminous, becoming  nearly
solid when  exposed to heat.
   Treatment.—The acute forms  of this eruption demand
but little medical interference,—the  accompanying fever
being rarely such as to require any active  antiphlogistics;
should it, however,  continue after the bullae are fully de- 
                     PEMPHIGUS.                101

 veloped, or inflammatory  symptoms then appear, a small
 abstraction of blood from the  arm may be requisite: but
 in the majority of cases, rest in bed, diluent drinks, reduced
 diet, and mild saline purgatives will suffice.  The vesica-
 tions should be  as much  as possible protected from local
 irritation, and, aboA^e  all, from  being  prematurely rup-
 tured ; with this view they may be  dusted over with flour
 or starch; as soon as they have burst they may be dressed
 with some simple  ointment, such as the cucumber or ace-
 tate of zinc cerate, or collodion may be applied over them.
 When acute pemphigus presents the characters described
 by Dr. Whitley Stokes, all debilitating plans of treatment
 must be carefully  avoided, good nourishing diet should be
 given in  abundant quantity, the air be at once  changed,
 and powdered bark,  with minute doses of the pulvis cretae
 opiatus and of  the hydrargyrum  cum  creta, administered
 internally.  On the suggestion of Dr. Stokes, an  ointment
 prepared with  lard  and  the leaves of  the common fig-
 wort, Scrophularia nodosa, was used as a local application
 in this  form of pemphigus; he  states  that he derived his
 knowledge of its  beneficial action from an inquiry into
 the  applications which were popularly  employed with suc-
 cess in the country districts of Ireland, in all of which he
 found that the  leaves of this  indigenous plant formed a
 principal  ingredient; at his recommendation it was origi-
 nally introduced into  the  Dublin Pharmacopoeia, from the
 last  edition of which, however, it has been omitted.  It
 was, in fact, but a mild astringent ointment, and  its chief
 efficacy probably depended on the protection from the action
 of the air which  it  afforded; a weak cerate of tannic acid—
 two  grains  to the ounce  of white Avax  ointment—melted,
 and  applied to the surface with a camel's-hair pencil, just
 as it is  again about to become concrete, will be beneficially
 substituted for it.
  In chronic pemphigus the chief indications are  to  allay
both the local  and constitutional irritation, and to  support
 the   strength;  attention  must  also  be  directed   to any
visceral disease  of which it may be symptomatic, or with
which it  may be  complicated.  I have experienced very
great benefit in  its treatment from the free use of  opiates,
                           9* 
102                  V*E S I C U L E.

which  may  be given, combined  with bark, as  in  the  fol-
lowing form:—

R. Liquoris Opii Sedativi,  .  . . . m. x.
   Tincturae Cinchonae Compositae, m. xv.
   Misturae Camphorae,.....fl 5j. Misce; fiat haustus.

        " One such to be taken every sixth hour."

To  allay the  local irritation, the  parts may be  covered
with raw  cotton or dusted with starch, or, if the itching
and pain are very severe, they may be dressed with lint on
which has been spread the compound lead-cerate, to  every
ounce of which a fluid drachm of glycerine has been added.
By some it has been proposed to open the bullae as soon as
they appear, and to apply to the  surface thus exposed a
solution of nitrate of silver, containing a scruple of the  salt
to an ounce of distilled water;  instead of the solution,  Dr.
Graves proposes to employ the  solid nitrate for this pur-
pose, and mentions a case in which  its use was  attended
with complete success j1  the  practice, however, is only ad-
missible when the eruption is  of  small extent,  and  not
connected with constitutional derangement.  In  very ob-
stinate cases arsenical preparations  and iodide of potassium
are occasionally employed with benefit.  Wine and generous
diet should be  allowed in all cases of chronic pemphigus,
and change of air to a drier locality enforced, if possible.
When diarrhoea or dropsical symptoms occur in the course
of the disease, they are to be treated on the ordinary prin-
ciples.

                         RUPIA.

   Rupia is characterized  by the  eruption  of distinctly-
separated  and dispersed, flattened bullae, of the  size of a
small nut, on  an inflamed base, terminating in  elevated,
dark brown crusts, which, falling off, are succeeded by
atonic  ulcers.   The  bullae,  which  in most cases  are  not
preceded by  either  local or constitutional inflammation,

         ' Clinical Medicine, Second Edition, vol. ii. p. 354. 
RUPIA. .
103
contain from the first a  semi-opaque  or  ichorous fluid,
which appears not  to  distend them completely;  this fluid
rapidly becomes  sero-purulent and more  consistent,  and
the epidermic covering of the bullae,  giving  way usually
on  the  second or third day, accretes into a wrinkled scab,
more prominent in  the centre than'at the  circumference.
Three  varieties of  rupia are in  general described by  der-
matologists, but the third of these, rupia escharotica, as has
been already mentioned when describing pemphigus,  is a
form of that eruption, being the pemphigus gangraenosus of
Dr. Whitley Stokes,—two forms, therefore, only  remain to
be considered here:—

                     Rupia simplex.
                       "   prominens.

  In  Rupia simplex  the  bullae  are but few in number,
often  not more  than two or three, and situated remotely
from  each other; the inflammatory areola  is narrow,  and
scarcely raised above the level of  the  surrounding integu-
ment, and the crusts, which are of a dark-brown color, only
slightly elevated  in the centre.   The  resulting  ulceration
is superficial, and scabs cover it in a few days; these scabs,
which are wrinkled  and raised at the edges, fall off and are
renewed several times for from one to two or  three weeks,
when the surface  heals, a livid stain, which does not disap-
pear for some time, remaining on the part.   The duration
of the disease until  the falling off of the scabs is, as  above
remarked, from two to three weeks, unless, as occasionally
occurs, it is  prolonged by  the formation of new bullae at
the time those first  developed are  about  to disappear.   In
some rare cases a slight degree of fever precedes the  ap-
pearance of  the  eruption, and  superficial  redness,  as in
pemphigus, marks the spot on which each  bulla is  about
to form.
  Rupia prominens  is so  named  from  the characteristic
appearance  of the crusts or scabs  which are formed in it.
The bullae  are of larger size than  in rupia  simplex, the
patches of the cutaneous surface on which  they  occur are
previously  swollen  and of a  dark-red colour,  and  the
contained fluid, Avhich is often ichorous or sanguinolent, 
104
VESICULE.
sometimes as dark as chocolate, rapidly thickens and dries
into a hard,  wrinkled, blackish crust,  surrounded  by a
swollen, inflamed border.   From the inner edge of this in-
flamed areola, unhealthy pus is secreted, which, concreting,
forms  additional crusts ;  these, pressing on the original
scabs, already somewhat raised in  the centre and  corrur
gated, force them still more forwards until they eventually
attain such a prominence  that they bear an  extraordinary
resemblance  to the  shell  of  a limpet, or in some  cases,
spreading from their circumference until they cover the
entire  of the inflamed border by which  they were sur-
rounded, to the shell of  an oyster.   These crusts, which
are firmly adherent  and slow in falling  off, in a few days
become somewhat raised at their outer border, and permit
the discharge of unhealthy pus from the excoriated surface
beneath; in the course of a week  or  ten days they may
be readily detached,  or they fall off spontaneously, when an
excavated atonic ulcer, the depth of which is usually pro-
portioned to the thickness of the scab,  is seen to occupy the
site of the original bulla.  These ulcers are extremely indo-
lent, pale, and bleeding on the slightest  touch, and either
become covered anew with the characteristic  crust, which,
however, does not attain the same degree of prominence as
in the first instance,  or, discharging an unhealthy, ichorous
pus, heal slowly, leaving  dark, livid  stains on  the  skin.
Rupia prominens is always a chronic disease, lasting gene-
rally for months, and its  duration  is  often  prolonged by
successive eruptions  of bullae.
  The usual  site of  either form of rupia  is on the lower
extremities, sometimes  on the  abdomen, the  loins, or the
thorax, but, unless when occurring as a syphilitic eruption,
it is very rarely witnessed  on the upper  extremities or the
face.   The disease  may  occur at any age, but it most
usually affects children and old persons, being uncommon
in adults.   The causes  by which it is produced  are suffi-
ciently obscure, but  it  appears to be connected  with a
debilitated  state of  the  constitution, and  especially in
children  with the scrofulous  diathesis.   It is also one of
the sequelae of the eruptive fevers  in  young  persons, and
in the old  it  not uncommonly occurs  at the termination
of some prolonged  illness, such as fever  or dysentery. 
RUPIA.
105
Rupia is sometimes  complicated  with  other cutaneous
diseases, more particularly scabies,  ecthyma, and purpura ;
in the last case the bullae usually contain blood.
   Diagnosis.—Rupia may be confounded with either pem-
phigus or ecthyma.   From the former it is distinguished,
even  in its  vesicular  stage, by the bullae  being  solitary,
never confluent,  and  by the raised  inflammatory border
which surrounds them ; when the scab is formed, its charac-
teristic  prominence serves to render the diagnosis  easy.
Ecthyma is an inflammatory pustular  eruption, and the
resulting  scabs are small and flat, while rupia is distinctly
vesicular at its  origin, and the scabs are large and promi-
nent.  The more serious  mistake may be made of mistaking
idiopathic for syphilitic rupia, which is a much more severe
disease, and one requiring different treatment; the latter is
distinguished by the areola surrounding the bullae being of a
dull, coppery hue ; by the bullae being much more numerous,
often covering nearly the  entire body, and  appearing very
frequently on the face; by there being generally present at
the same time syphilitic sore throat; and by the antecedent
history of the case.
   The prognosis in rupia is always favourable ; it is often
an obstinate, but never a dangerous disease, and rarely in-
jures the general health, unless the resulting ulcers are
very numerous, and attended with much discharge, when a
degree of low, irritative fever is developed by their presence.
   Treatment.—Constitutional  remedies are chiefly  to be
relied on in the  treatment of rupia, and these should be
adapted to the  indications in individual  cases.   Tonics,
especially preparations of bark and of iron, good food, and
nourishing  diet,  are most usually demanded.  When the
disease   becomes  chronic,  hydriodate  of potash  will be
given with benefit in equal parts of the decoctions of elm-
bark, of dulcamara, and  of mezereon; and in the case of
scrofulous children, cod-liver oil should be prescribed.  As
regards  local treatment,  it is generally recommended  to
open  the bullae at the earliest opportunity, so as to pre-
vent, if  possible, the  formation of  the crust;  they  should
then be  covered  with pledgets of lint,  and  slight pressure
made on them, or they may be dusted with starch, or, what
is still preferable, as the chief  object is to exclude the air,
collodion may be applied.  When  the crusts have formed 
106
VESICULE.
they should  be remo\red as quickly  as  possible, having
been previously softened  by the  application of bread and
water,  or  of linseed-meal  poultices;  the ulcers, for  the
first few days, should be treated  with  water-dressing, over
which  oiled silk is placed, but  if they do not show  a dis-
position to heal, stimulating ointments or lotions become
requisite ; of the former, the brown citrine ointment, or one
composed of equal parts of oil of turpentine and of  white
wax ointment, may be used ; or of the latter, if it be found,
as is often the case, that  greasy applications disagree, so-
lutions of  the sulphate of copper or of sulphate of iron,
from six to twelve  grains of  either to the  ounce of dis-
tilled  water, may be employed, lint soaked in  them  being
laid on the ulcerated  surface.   Some of  the French der-
matologists  report that they  have derived excellent re-
sults from ointments of the iodides of mercury,—a drachm
of the  green or twelve  grains of the yellow iodide, to the
ounce  of lard.  By  some practitioners it is recommended
to touch the  ulcer  every second  or  third  day with  the
solid nitrate  of silver, but  the nitrate of copper, allowed
to deliquesce, and then applied  by means of  a camel's-
hair brush, will in very obstinate cases, be found  more
beneficial.  It must not be omitted to mention, that Rayer
states he found the  simple practice of dusting the ulcers
with finely-powdered cream of tartar very successful.

                        SCABIES.

   Scabies (Itch).—No little difficulty has been at all times
experienced in classifying scabies ; by some it is regarded
as being papular, by  others pustular, and  by many mo-
dern dermatologists it  has been made to  constitute a divi-
sion of cutaneous diseases of which it is  the  type,—the
presence of parasitic  animalcules  beneath  the epidermis
being considered by them  as a necessary characteristic of
the eruption.   There  can  be  no  doubt  but that during
the course of  the  disease pimples and pustules constantly
occur on the  skin, mingled with the vesicles, and the ve-
sicles themselves  assume  a purulent aspect in a few days
after  they are developed, yet on careful  observation it
will be found that the  eruption is at first always distinctly 
scabies.                   107
vesicular, and that this character is never  completely lost
in  any stage of the affection.   The occurrence of the  pe-
culiar itch  animalcule is  very constant in scabies, and its
existence easily  demonstrable,  but  as cases do  occur in
Avhich even  the most experienced observers are unable to
detect it, I cannot admit that its presence  is necessary to
and pathognomonic  of the disease.  For  these reasons,
then,  and also because the peculiar vesicle  of scabies is
highly  characteristic, I shall retain it amongst the vesi-
culae.   It has always been  an eruption of much  interest
to  the  physician in consequence of its  great prevalence,
the rapidity with which it  spreads  by contagion, and  the
severity of the local symptoms with  which it is attended.
   The  eruption in scabies,  the development  of which is
unaccompained by  constitutional spmptoms,  is  preceded
by itching and tingling of the  parts on  which it is about
to  appear, usually the  backs of the hands, the angles  be-
tAveen the fingers, and the flexures of their joints; in about
twelve  hours  afterwards  there  may be seen  developed on
them one or more conical  vesicles,  which  rapidly enlarge
until  they not unfrequently attain the size of a small pea,
being more  or less solid at the base,  and transparent at the
apex, which is acuminate.  The majority of these vesicles
soon  become  opaque  and  sero-purulent,  and, bursting,
form yellowish scabs; but in some of them  the serous effu-
sion is absorbed, and they then present a papular  appear-
ance, a thin, epidermic scale forming on the top of each
papule.   In the neighbourhood of  some  of  the vesicles
may be seen,  in  most  cases of itch, a narrow line or  su-
perficial fissure  of a few lines in length,  such as would
be  made  with the point of  a needle—the sillon, which
terminates in  a small,  rounded, elevated point,  of a red-
dish color—the  cuniculus,  or  burrow of the itch  animal-
cule, and from which, with a little care, it  may in general
be extracted.
   This insect—the Acarus scabiei,  or, as it has been also
termed, Sarcoptes hominis, being constituted into a new
genus  by Latreille—was  discovered  and described as ex-
isting in scabies in the  twelfth  century by Avenzoar;  but
although its presence was  evidently knoAvn to the Greek
and Roman  physicians,  little notice of it  occurs afterwards 
108                   VESICULE.
in medical writings until the middle of  the seventeenth
century, when  an Englishman, Mouffet, left  in  a posthu-
mous work  a singularly full  and accurate description of
the animalcule, especially as  regards  its anatomical  cha-
racters, and in which many of the so-called discoveries of
modern days are anticipated.   In  our own times the na-
tural history  of the itch animalcule  has  been  especially
investigated by the French and German  dermatologists,
particularly by Renucci, Raspail, Albin-Gras, Hebra, and
Bourguignon; amongst English writers Mr. Erasmus Wil-
son  gives the  fullest account  of its habits and structure,
and  from his  observations  the following description is
condensed.
  Examined with the naked eye, the acarus scabiei looks
white, shining, and globular in form.   " There is no diffi-
culty in extracting the little animal;  the  cuniculus is seen
without difficulty;  the  end  of the  cuniculus is perceived
to be a little raised, while a greyish speck is seen  beneath
it, as soon as  this little eminence of epiderma is lifted, if
the end of the  needle or pin with which the operation is
performed be  examined,  the  minute,  white,  and  shining
globe will probably be observed attached to the instrument.
If there, be no such object, the point of the needle, placed
again beneath  the raised capsule of epiderma, will pretty
certainly draw it forth.  This  facility of  extracting  the
little creature  is due to its great poAver of clinging to any
object with which it comes  in contact.  When the acarus
is seen running upon the surface of a plate of glass it may
be perceived that its anterior margin presents a dusky tint
of colour, and the examination of this part of the creature
with the microscope brings into view a head not unlike that
of a tortoise, and a pair of  large and  strong legs on each
side of the head.  These organs are encased in a moderately
thick layer of chytine, and have consequently the  reddish-
brown tint of  the cases of certain insects,  or of the bright
part of a thin layer of tortoise shell."1  The general outline
is sub-rotund,  it being a very little longer than broad ; the
ventral surface  is flat,  and upon it may be  seen the
head and eight legs;   the dorsal aspect is arched  and un-

  1 Erasmus Wilson on Diseases of the Skin.  Third Edition, p. 499. 
                     SCABIES.                   109

even, and covered by numerous spines ; and twelve hair-like
filaments, some long  and others  short, project backAvards
from the posterior segment of the animalcule.   Mr. Wilson,
from a comparison of the measurements in ten  specimens   *
found  them to vary  between T^th and ^th of an inch in
length, and 303rd and ^\th in breadth.
   This account refers to the  female acarus, and with it are
generally found some of the ova ; the male insect seems to
have eluded the research of  most investigators ;  M. Bour-
guignon, writing so lately as 1847, says, " that he has neArer
found  male sexual organs in  the acarus, but in every speci-
men he examined has  seen ovaries with the ova, it appearing
that connexion with a male is not requisite for the reproduc-  -
tion of the animalcule."1  Gustav Simon, Physician to the
'Charity Hospital at Berlin, described the male acarus in the
first edition of his Anatomical Description of Diseases of the
 Skin,  published in 1848 ; and in  1851,  it  was also dis-
 covered and  described by M. Lanquetin,  a  pupil of  M.
 Cazenave.  It is much  more minute than the female, and
 being always situated  on the free surface  of the skin, not
 taking up its abode in a cuniculus, accounts for its existence
 being overlooked by so many careful investigators.
   The eruption in scabies is invariably attended with severe
 itching,—whence the name by which the disease is com-
 monly known,—this, causing the sufferer from it to scratch
 and tear the skin with the nails,  increases  the local inflam-
 mation, which already is considerable; fresh vesicles  ap-
 pear,  often thickly set on the surface, and mixed with them
 large  papulae and pustules ;  a bloody serous and seropuru-
 lent  discharge flows from the torn integuments, in  Avhich
 deep  fissures  are  also  formed, and  the eruption  spreads
 rapidly, in severe cases attacking  the lower extremities,
 the abdomen, and the trunk, as well as the  hands and arms,
 but being very rarely,  if ever, witnessed on the face.  The
 sufferings occasioned by the disease are then extreme, sleep-
 less nights are passed often  for weeks together, the itching
 being always much augmented by the warmth of the bed;
 the constitution, consequently, sympathises  more or less,
 and in the  old  or the debilitated, purigo, ecthyma, or
   1 Recherches Entomologiques et  Pathologiques sur la Gale de l'Homme.
 Paris,  1847, p. 8.
                          10 
110                  VESICULE.
    pemphigus, complicates the original eruption, rendering it
    more intractable, and in very aged persons even fatal.
      In some cases of scabies the eruption is apparently alto-
*   gether papular, but on examination with a lens it will  be
    found that a minute vesicle surmounts each papule ; from
    mistaking its true character, Willan and Bateman termed
    this form of scabies papuliformis; when the vesicles are
    perfectly transparent, and with little or no inflamed base,
    they denominated the disease,  scabies  lymphatica; and
    when the pustular character predominated, they constituted
    it a distinct variety, under  the  name scabies  purulenta.
    The occurrence of  the eruption in broken  down  constitu-
    tions is not unfrequent, and its aspects being then influenced
    by the  physical condition of the individuals attacked,  the
    same dermatologists arranged it in a distinct species, which
    they called scabies cachectica.
      Causes.—Scabies occurs at all ages,  in individuals of
    every  rank of life, and in all climates, being  even more
    prevalent in hot countries than in cold, and there it is also
    a more severe disease ;  it is of much more common occur-
    rence  among the poor than amongst the  higher orders, in
    consequence evidently  of the less frequent  ablutions to
    which their bodies are subjected, and the longer period
    during which their  clothes are worn without being changed,
    for the eruption is especially a concomitant of filthy habits.
    That the spread of the disease from individual to individual
    takes place by contagion is undoubted, but that this is the
    only cause some have questioned, believing that it may be
    self-generated  in the system;  however, such  a doctrine is
    now nearly obsolete, and  the sole difference of opinion
    existing on the matter at present may be said  to be as to
    which is the contagious principle in scabies, the acarus, or
    the matter of the eruption.  Mr. Erasmus Wilson  asserts
    his belief, that " the vesicle is a provision of nature to pro-
    tect the derma from the nearer approach of the arator, and
    the vesicle is  formed  with  the  judgment Avhich usually
    marks  nature's  operations—namely,   before  a  defensive
    operation would be too late."   Now  how the approach of
    the insect is to be prevented by the formation of the vesicle,
    I must confess I cannot  understand;  the sillon, or tract
    from the cuniculus, always terminates in^a vesicle, and ob- 
SCABIES.
Ill
servation shows that the development of the vesicle pre-
cedes the appearance of the animalcule ;  I therefore think
that the connexion between them may be more simply ex-
plained by regarding the sillon as  being  the track of the
acarus in making its way from the vesicle—which has been
caused by the irritative inflammation occasioned by its de-
position  from the skin of  another person, no matter how
conveyed, or in the fluid of which it has been hatched—to
the cuniculus or burrow, for the  purpose  of depositing  its
ova.  The belief of those, then,  who think with that der-
matologist is, that scabies, being in all  cases dependent on
and caused by the acarus,  can alone be propagated by the
deposition of this insect, or of its ova on the epidermis, and
that the secretion from the vesicles will not of itself repro-
duce the disease.  Direct experiment, however, proves that
it may  be thus  propagated, but  to  this they answer, that
when it is so, the inoculating matter employed must con-
tain some of the ova; but a similar argument is equally
applicable to their view, namely, that when the disease has
been produced in individuals by the acarus being placed  on
the skin, it cannot be denied that the animalcule conveyed
with it some of the characteristic secretion.
   For my own part, I am of opinion that scabies will be
developed in a person whose skin has been previously free
from the disease by the contact of either the itch-insect or
the secretion from the eruption, but I believe  the latter to
be the most  frequent cause of  the contagion, and  in this
way only can we account  for  the many  cases that occur
in Avhich the disease has been produced  by contact  with
clothes, with gloves, &c,  which have lain by for some
time ; in one instance which I saw,  a  lady was attacked
with scabies on the palm of her hands, and as far as obser-
vation, which I  freely admit is not indisputable evidence
here, enabled me to judge, the contagion  was conveyed  to
her from her servant-man, who was affected  with the disease,
by means of the handles of the  knives Avhich he Avas in the
habit of cleaning.
  From experiments which have been made it appears that
scabies is more quickly developed in the young and in indi-
viduals of a full and robust habit of body than in the old,
or those  who are of a weak constitution ; the  period  of 
112
VESICULE.
incubation in the former being  about four days, while in
the latter it may extend to ten days or a fortnight, or even
longer.
   The diagnosis is, in  some  cases  of scabies, extremely-
difficult,  and in no  other  cutaneous  eruption  is it more
important that  a mistake should not be made, especially as
the plan  of treatment adapted for it is not at all suited for
those diseases  with  which  it is  likely to be confounded;
moreover, an opinion given with regard to  contagion,  if
it prove  to be incorrect, may seriously injure a physician's
character.   When eczema appears on the fingers or hands
it is very often mistaken for scabies; in its early stages
the minuteness and number of the vesicles generally suffice
to render the diagnosis facile, but when it becomes chronic,
the itching with which it is attended not unfrequently may
lead to error.  Eczema, however, never presents the conical-
shaped vesicles of scabies, the  discharge from the parts
affected with it is more watery,—being rarely sero-purulent
except in eczema  impetiginodes,—is accompanied by  a
mealy, epidermic desquamation, and it is rather a sensation
of smarting  and stinging than of true itching that  attends
it.  The papular form of scabies may be mistaken for lichen,
more particularly when the latter affects the backs of the
hands ; but  the complete absence of vesicles  and of a sero-
purulent  discharge in the latter, generally suffices to prevent
the mistake  from.being made; the eruption, too, does not
spread to the flexures between the fingers, the most usual
seat of  itch.   Prurigo,  which, like lichen, is  a papular
eruption, is liable to be confounded with scabies, chiefly in
consequence of the severe itching  with which  it is attended;
but it rarely affects the hands unless when it appears as a
complication of that disease, its usual seat being the trunk
of the body, the shoulders, and the  thighs ;  and the small
black crusts  on the  summits  of the papulae produced by
scratching are  highly characteristic; it is moreover, very
rarely accompanied  by  any discharge.    When  scabies
assumes the  pustular character, and the individual pustules
attain  a large size, it might be mistaken for ecthyma, but
the latter is  characterized by not  being attended Avith itch-
ing, by its mode of development, and by the pustules being 
SCABIES.
113
usually isolated.  In  fine, from all the  cutaneous diseases
now enumerated, scabies is  especially distinguished  by its
contagious nature, and by the presence  of the acarus ; but
it should  be remembered that  it may be complicated with
any of them.
  Prognosis.—As  this eruption can scarcely be said to
prove  dangerous to life, except in the rare instances al-
ready referred to, the prognosis refers only to its probable
duration,  and  this, Avhen effective treatment is adopted, is
always very short; but if scabies be left to itself, uninter-
fered with by  the application of remedies, it may be  indefi-
nitely prolonged, as it never seems to  exhibit a tendency
te wear out, or to undergo a spontaneous cure.
  Treatment.—If  there be any well-established example
of a specific in the whole Materia Medica, it is that  of the
action  of sulphur in the treatment of scabies, and as this
medicine  never fails  to cure the  disease, it is the univer-
sally admitted remedy for it; none other  indeed  would
require to be alluded to, were it  not that the unpleasant
odour of sulphur renders its employment in some instances
inadmissible.   The general  method of using this  substance
for the treatment  of scabies is by the local inunction of
ointments containing it, either  alone  or combined  with
alkalies;  in the latter form  it is generally employed  in the
present day in  France, and found to be  more efficacious
than when used alone; the combination  was first  intro-
duced  by M.  Helmerich, and the ointment, which is called
after him, Pommade d'Helmerich, is composed of two parts
of sulphur, one of  carbonate of potash, and  eight of lard.
The surface of the entire  body, but more particularly of
the affected parts, should be first washed well with a  strong
solution of soft soap, the patient then placed for a quarter
of an hour in an alkaline bath, containing a pound  of the
carbonate of potash to twenty gallons of water, at the  tem-
perature  of 92°, the skin  well dried,  and this  sulphuro-
alkaline  ointment afterwards  thoroughly  rubbed in ; the
disease may thus be effectually cured in two or three days,
a single friction, preceded by the alkaline and saponaceous
bath, being used daily.  Out  of upwards of 700 persons
treated on  a  plan nearly  similar to this at  the Hcipital
St.  Louis, in Paris, M.  Bazin only met with  six unsuccess-
                           10* 
114
VESICULE.
ful cases, all the rest being cured on the third day.1   M.
Hardi, who  succeeded  M. Bazin  in  the charge of the itch
Avards in this Hospital, has introduced a plan of using the
sulphuro-alkaline ointment there, by which the period re-
quired for a complete cure is  reduced to two hours.  His
method is as follows: " On the admission of the patient
the entire surface of the body is rubbed for half-an-hour
Avith soft  soap—savon noir; he is  then placed  in a  bath
for an hour, and the body well rubbed while in it, and at
the end of that time general  frictions made and continued
for half-an-hour with Helmerich's ointment.  The acarus,"
adds M. Hardi, " is thus killed, and  the patient conse-
quently cured."  Of 400 patients  thus  treated, it is said
that 4 only required to return for further advice, and of
these 2 had recontracted the disease.
   A  question arises as to whether it is advisable to cure
thus suddenly a vesicular eruption,  which in some cases is
attended with a rather copious discharge ;  M. Devergie, a
celebrated dermatologist, and one of the senior physicians
to this hospital, thinks it may be dangerous to do so, but I
cannot agree with him, for as scabies is not attended with
any constitutional  disturbance, and is never symptomatic
of  an internal  disease,  the same  causes  do  not operate
against the sudden  cure of it as against that of cutaneous
diseases, the discharge in which is evidently dependent on
some deranged  condition of the system generally.   M.De-
vergie, however, asserts that although the contagious na-
ture of scabies is destroyed by this plan  of  treatment, a
 troublesome  cutaneous  eruption still  remains—one, too,
 attended with  much  annoyance to the  patient, and  often
 difficult of  cure.
   When any insuperable  objection exists  to  the employ-
 ment of sulphur for the cure of scabies, other applications
 may be had recourse to, which, although  more tedious  in
 their action, are equally efficacious ; the use of any of them
 will invariably be  beneficially  preceded by  the employ-
 ment of frictions with soft soap, and of the alkaline  bath.
 Oil of turpentine made into an ointment  with eight times
 its weight  of prepared lard, is a very  certain  application,

 > Journal de Mddecine et de Chirurgie Pratiques, December, 1851, p. 529. 
SCABIES.
115
but its  odour to many persons  more  objectionable  even
than that of sulphur; this may  to a great extent be re-
moved, and its efficacy rather increased, by the addition
of eight minims of  oil of bitter almonds to each ounce of
the  lard  combined with it.   The  ointment of  sulphuric
acid, of the former Dublin Pharmacopoeia, which  is free
from any unpleasant odour, rarely fails to cure the disease ;
stavesacre and white hellebore ointments, also, have been
used with success ; the former is prepared by mixing with
prolonged trituration one part of the powdered seeds of the
Delphinium staphisagria with four times its weight of white
wax ointment and one part  of  glycerine,  and the  latter
by combining two  ounces of the powdered  root with half-
a-pound of prepared lard, and adding  tAventy minims  of
oil of  lemons.   Inunction with simple fatty matters  even,
such as olive oil  or lard, has been found sufficient to cure
scabies, but the duration of  the disease is more prolonged
than when  any of the above-mentioned  remedies  has been
had recourse to.
   A strong objection often existing Ayith some persons  to
 the use of  greasy applications, lotions of the sulphuret  of
potasium, or of chlorinated lime or soda, may  be substitu-
ted for them; of the former twenty grains, and of  either
of the latter a  drachm to  the  ounce  of distilled water,
should be employed.
   With reference  to internal treatment nothing  more is
usually requisite than  the administration of saline or sul-
phurous cathartics, and the use of the former should never
be omitted ; in very obstinate cases the combined  employ-
ment  of  sulphur  as an internal remedy and  an external
 application is  not alone attended with benefit, but often
 absolutely  demanded.   Should the local inflammation run
 high  in  young  persons  of robust  constitution, bleeding
 from the arm even may be indicated, but this is very rarely
 requisite.
   In all cases of scabies  constant  ablutions with soap and
 water constitute an  essential  part  of  the  treatment, and
 the clothes which had been  worn  previously should  be
 laid aside, as from their retaining  the  contagious matter,
 the disease may  be reproduced after a  cure  has been
 effected. 
116
PUSTULE.
                 CHAPTER  IV.

                       PUSTULE.

   The Order Pustule includes those cutaneous diseases
that are  characterized  by the eruption  of  circumscribed,
rounded elevations of the epidermis, which contain pus, and
are situated on an inflamed base—pustules; the pustules
Avhich may  be either psydracious or phlyzacious (see page
26), burst and form scabs or thick crusts, on the falling off
of which a slight, not permanent, depression or stain is left.
Pustular eruptions are non-contagious, attended with  more
or  less  inflammation,  usually of a sub-acute  or chronic
character, and their  duration may be either very short or
much prolonged.   The local inflammatory action by which
a pustule  is produced affects the deeper structures of the
derma as Avell as the epidermis, in  consequence  of  which
the sub-epidermic effusion is  purulent, while in vesicular
eruptions the superficial layer only  of the derma being in-
flamed, the effusion is serous.   In its  early stage a pustule
can scarcely  be  distinguished  from a papule, inasmuch as
the pus on  which its specific character depends does not
usually appear at the apex until the second or third  day;
the purulent secretion then gradually increases, distending
the epidermic covering more and  more, until, finally, it
gives way, when the  matter is  effused on  the cutaneous sur-
face, and  a  scab is formed;  of this  process an excellent
example  is afforded  in  the case of the  pustular eruption
artificially produced by the local application of tartar emetic
in the form of ointment  or solution.  While  undergoing
these changes, the pustule is said, in popular language, to
be ripening.  Some  of the diseases included by Willan
and  Batemen in this order were so classed by them  from
an  incorrect idea of their true  characters ; thus  scabies,
for the reasons given'in the last Chapter, is more properly
placed among the A'esiculae ; variola is one of the eruptive
fevers;  and porrigo is  not  pustular  in  any of its stages. 
ACNE.
117
Acne, included by them in the division which they termed
Tubercula, presents  the aspects of  a true pustule, accord-
ing to the foregoing definition.  The group then compre-
hends three forms of cutaneous eruptions:  Acne, Impetigo,
Ecthyma.

                         ACNE.

  Acne  consists  in  the eruption of psydracious pustules,
with a hardened base, distinct from each other, but usually
aggregated  in  small patches on a circumscribed inflamed
portion  of the  skin; when they maturate, bursting and
giving exit to purulent  matter,  which  dries  into thin,
brownish crusts.   The pus  first appears  as  a minute dot
at the apex of  each pimple, which is somewhat acuminate,
then, gradually increasing in quantity, the pustule becomes
globular,  and  of a straw-yellow  colour,  its  base still
remaining  hard,  red, and painful,  and surrounded with
an inflamed areola.  At times some of the pustules,  taking
on an indolent action, little or no matter forms in  them,
when they present the appearance of hard, inflamed, minute
tumours, about the  size of  a small pea and exquisitely
painful to the touch, and are slow in  disappearing.  The
seat of the inflammatory action in  acne  is chiefly in the
sebaceous glands, and  the  disease is not  unfrequently
produced by obstruction at their orifices causing an accumu-
lation of the natural secretion and consequent  irritation.
By some  modern dermatologists  it has, therefore, been
made to constitute a distinct  class of cutaneous  eruptions,
defined by Cazenave as consisting in " a diseased condition
of the  follicular secretion,"  and by Erasmus Wilson as
" an inflammation of the sebiparous glands and adjacent
tissues, with or without alteration of secretion."  Acne is
a disease  chiefly of youth and of  adult life, occurring with
greatest frequency about the age of puberty, whence its
name,  derived  from the Greek word, ax^, vigour.  The
several varieties of the eruption which have been described
may, I think, be reduced to two forms:—
Acne simplex.
  ,,   rosacea. 
118
PUSTULE.
  Biett was the first to describe a  rather rare cutaneous
eruption as a variety of acne, terming  it acne sebacea, in
which the sebaceous follicles become hypertrophied and their
secretion diseased, and nearly every dermatologist since his
time has adopted his views, and retained the name proposed
by him; as, however, it  does not in any respect resemble
acne, except in being an affection of the sebaceous follicles,
it will be more correctly classed in the group of cutaneous
eruptions which I propose to term Hypertrophiae.
  Acne simplex is a very frequent disease in young persons,
especially in those in whom the cutaneous capillary circula-
tion is  active, appearing  generally in the  spring  and
autumn, and disappearing partially in  summer and  com-
pletely in winter;  it may consist in the  eruption of only a
few scattered pustules on the face, or may occur in small
patches or pretty thickly disseminated  over a large por-
tion of the cutaneous  surface, especially  affecting those
regions  where  the sebacious follicles are most numerous.
The pustules, whether few or many, are developed individu-
ally, and do not coalesce ; each of them appears first as a
small,  red, acuminated elevation,  hard,  and  somewhat
painful, particularly so if the skin where it  occurs is thick;
Avithin twenty-four or thirty-six hours  the pustule, which
has continued  to enlarge, presents at its apex a yellowish
point, which increases for a day or two, when the epidermis
gives way  or is ruptured, and pus, mixed  with the curdy
sebaceous secretion of the follicle which may have  been
involved in the local inflammation, is discharged : although
each pustule  has  an inflamed  base, there  is no  diffuse
surrounding redness of the skin.  Many of the pustules do
not  maturate,  but,  remaining indolent for  a  few days,
terminate  by  resolution, the  lymphy  effusion contained
in them being re-absorbed ;  some slight hardness and red-
ness, however, are left, which gradually disappear.
  In some  persons, who are  characterized for the most part
by  having  a coarse,  greasy skin, the sebacious  and hair
follicles are peculiarly developed, and secrete copiously the
thick curd-like matter  which  naturally exists in them :
individual  follicles  often become obstructed at the orifice,
somewhat  distended, and present a black  point at  their
apex; they then exhibit the  appearance described by  some 
ACNE.
119
dermatologists  as  a distinct variety of acne, under  the
name acne punctata.   The curd-like matter, when pressed
out by  the fingers, forms a round  cast of the follicle in
which it existed, and owing  to its size and shape, and  the
black point at its extremity where it had been  exposed to
the action of the atmosphere, bears much resemblance to a
small maggot,  and which it is commonly  believed to be.
Although this popular notion is, it  need scarcely be said,
erroneous, Dr. Gustav Simon has discovered in  the natural
sebaceous secretion a minute animalcule, from the 0.085th
to the 0.125th of a line (German measurement) in length,
and about the 0.020th of a line in breadth ; it was named by
him  Acarus folliculorum,  but  has  more recently been
shown by Einsicht not to be an  acarus, and is therefore
termed  by the latter Steatozoon folliculorum.
   The  eruption in acne simplex is thus usually composed
of maturating and  non-maturating pustules, and of enlarged
obstructed follicles characterized  by black points,—the
latter are  constantly present on the cutaneous surface in
some individuals;   it  may  consist in  a  single  outbreak
affecting a more or less extended surface, or it may appear
in successive crops, being consequently then of more pro-
longed duration.   No constitutional fever or other disturb-
ance attends the disease, even when it attacks many regions
of the  skin  simultaneously, nor, although some  pustules
may be attended with pain, are the local symptoms trouble-
some, being chiefly annoying in consequence of  their being
situated on the face, and" therefore causing a temporary
disfigurement.   The duration of individual pustules, when
they run an acute  course, is from five to eight or ten days,
but when they are indolent, or  appear in successive crops,
the disease may be prolonged for as many  weeks ;  in  the
latter case the  marks  left on the skin are  slow in  fading
away.   Appearing and disappearing with  the  seasons,
being developed in spring  and  autumn, and receding in
summer and  winter, acne simplex becomes less frequent as
youth changes into puberty,  and  with adult  life  either
ceases  altogether,  or, becoming nearly permanent, is con-
verted into the  next variety to be described.
  The usual seat of the simple form of acne is on  the face,
the neck, the  shoulders,  and the  chest;   it occasionally 
120
PUSTULE.
occurs on the scalp, where it is exquisitely painful, although
the pustules are few in number, and very scattered; but it
is very rare on the extremities.
   Acne rosacea (Gutta  rosacea; Rosy-drop; Carbuncled
face ;  Brandy face) is a disease of more mature life than
the preceding variety; it  has especially attracted the at-
tention of the French dermatologists, by many of whom
it is described as a special disease under the name of Cou-
perose.  The  eruption, which is  invariably seated on  the
face, usually becomes chronic, but in  all its  stages is at-
tended with more local  inflammation  than acne simplex ;
it generally commences in the form of a red  patch on  the
skin, on AYhich  is rapidly developed a cluster of minute
pustules, or rather pimples, hard, and  but  little elevated;
these  enlarge gradually,  but are slow to maturate,  and
their  base becomes harder, often  painful, and much in-
flamed.   Eventually giving  way at their  apex,  a serous
exudation, mixed with blood, oozes forth, which concretes
into  a hard,  dry scab, and from beneath it  a small quan-
tity of a curdy pus escapes in a few days after.   The hard-
 ness at the base of each pustule, however,  still remains,
 and the rosy  or crimson-violet patch of the skin, on Avhich
 a varicose  condition of the superficial veins is sooner or
 later developed, is often persistent on the face for months
 or even years, spreading  gradually over the  nose, cheeks,
 forehead, and  chin, fresh crops  of similar  pustules  con-
 stantly appearing on it.
   When this form of acne is  chronic, it  assumes a  very
 aggravated  character, and from its  unsightly appearance
 causes great  mental annoyance;  the skin of  those parts of
 the face on which it is situated becomes thickened and ele-
 vated, from effusion into  the  subcutaneous  areolar  tissue,
 caused by the repeated  fresh attacks  of inflammation  con-
 sequent on the development of  each successive crop of
 pustules; it  presents a permanent roseate  hue,  which is
 deepened on every exciting  cause,—exposure  of the face
 to heat, indulgence in the pleasures of the table, or mental
  emotions;  and  the surface is hypertrophied,  rugose, and
  seamed with the cicatrices from pustules of  previous  erup-
  tions.
    In its most  chronic  form it  constitutes what has  been 
ACNE.
121
termed acne indurata, but I have seen this variety of the
disease  not unfrequently succeed acne simplex, and even
sometimes  appear as an indurated and tuberculated erup-
tion from the  first; it might, therefore, probably be made
to constitute a distinct form of the eruption, but it has so
many features similar to those of acne rosacea, and so com-
monly occurs apparently as an advanced stage of it, that I
haA'e  thought  it  better to  describe it as such.   Acne in-
durata is characterized by the eruption being much ele-
vated over  the surface of the skin Avhich is of a violaceous-
crimson  hue, and consists in conoidal pustules,  about the
size of a pea, extremely hard and tuberculated, and  pre-
senting minute points of suppuration at their apex.   These
pustules  are not  very painful to the touch; they  do not
scab over,  but whenever they maturate and  burst, they
leave a blueish cicatrix  or pit resembling that of small-pox.
Those that may be  set closely together usually coalesce,
and present then the appearance of boils, but the contained
matter is small in quantity, the aggregated bases extremely
hard  and  minute, and superficial ulcers, coA'ered with a
yellowish, soft scab, form on their  apex.  Acne indurata,
when it  is an advanced stage of acne rosacea,  or when it
occurs as an independent disease, is invariably situated on
the face, affecting especially the alae of the nostrils, and
the most prominent  portions  of the cheeks;  Avhen it is
consequent on acne simplex  it may appear on  any of the
regions of the body mentioned as being liable to be affected
by that form of the eruption.
   Causes.—Acne simplex being, as  already  remarked, a
cutaneous  eruption of  the period  of puberty and  of the
prime of life, appears to be connected with the full develop-
ment of the  capillary circulation of the surface  of the
body, which at these  ages  usually prevails; it is also  pro-
bably for the same reasons most frequently witnessed  in
individuals of the sanguine temperament,  and when  it
occurs in others  it is seemingly dependent on a naturally
enlarged condition  of the  sebaceous  follicles, the  skin
being then usually coarse, sallow, greasy, and shining.   It
is manifestly hereditary, and local heat, or anything which
may determine to the surface, is a frequent exciting cause
of the eruption in those constitutionally predisposed to it. 
122
PUSTULE.
Acne rosacea is frequently connected with the state of the
uterine function in  the  female, in many  cases appearing
for the first time at the turn of life ; it  also occasionally,
but  much  more rarely, attacks the face of young girls
about  the  period of first menstruation;  and when it does
so, they are very liable to frequent returns of the eruption
on the least exciting cause.   It  is also  a constant accom-
paniment of a deranged condition of the  digestive organs,
especially when attended with constipation;  and in many
persons is evidently caused by indulgence in  the pleasures
of the table, particular a too free  use of  rich Avines  or  of
spirituous liquors.   Prolonged  or extreme mental excite-
ment is also a frequent exciting cause of acne rosacea.  An
attack of either form  may be suddenly  produced by the
suppression of  any accustomed  evacuation, such  as that
arising from bleeding  hemorrhoids;  and  they are very
common attendants on pregnancy.
   Diagnosis.—The various forms  of acne are  in general
recognizable without difficulty; the parts  of  the cutaneous
surface which they affect, the conoidal  shape of the pus-
tules with their hardened bases, and the accompanying
altered condition  of the  sebaceous follicles,  being suffi-
ciently characteristic of the disease.  Secondary syphilitic
eruptions may be confounded with acne indurata and acne
rosacea,  from which they are  distinguished by their ap-
pearing on the  extremities, where acne does not occur,  at
the same time that they affect the face and trunk; by their
presenting a tubercular  rather  than a pustular character;
and by the diseased surface being of a dull, coppery colour:
the  sebaceous follicles, too, are unaffected.  The pustules
of  ecthyma differ from  those of' acne in being larger and
flatter, scattered over the  cutaneous  surface generally,
especially that   of the extremities, and in not  having any
hardened base.  Acne indurata in some  cases bears much
resemblance to lupus, but the latter disease presents more
of a tubercular character, and  is always attended with  de-
structive ulceration, either superficial or attacking the deeper
structures; in  acne indurata, also, the rich crimson hue of
the hypertrophied skin, with the varicose condition of the
superficial veins, and the spots of acne punctata scattered
over the surrounding integument, are highly  characteristic. 
ACNE.
123
   Prognosis.—Acne simplex, though  readily  removable
 by treatment, unless when the pustules assume an indolent
 character, is very apt to return annually until after the age
 of 25 or 30, and persons  Avho in their youth suffer from it
 are more liable than others to be affected in after-life with
 either of the.other forms of the disease.  Both acne rosacea
 and  acne  indurata  are  very  obstinate and  rebellious  to
 treatment, in some  cases seeming  for  years to  defy all
 remedial measures.   None  of  the forms tend in  any way
 to shorten life, or to injure the general health.
   Treatment.—-When acne simplex occurs on those parts
 of the body which  are  not  ordinarily exposed, medical in-
 terference is scarcely needed;  in persons of a sanguineous
 temperament and  an  active cutaneous circulation, saline
 cathartics, more  especially  the saline mineral waters,—as
 those of  Cheltenham,  Leamington, Epsom,  and  Scarbo-
 rough, in  England; and of  Seidlitz,  Marienbad, Carls-
 bad,  and Pullna, on the Continent,—will  be  used  with
 benefit; or, should the disease return in a very active form
 every spring, a general bleeding practised just before the
 period of the expected appearance of the eruption, will, in
 strong young persons, of  either sex, sometimes prevent its
 outbreak.   When pustules  of acne simplex  form on the
 face,  the  sooner  they are opened, and the curdy matter
 they  contain pressed out  of them, the  more rapidly they
 disappear.  In persons predisposed to  the disease, the best
 preventive treatment consists  in the use of  carbonate of
 soda—twenty grains to the quart of soft water—instead of
 soap, to wash the face, and in the application of a spirit-
 uous lotion, consisting of  two drachms of oil of lemon and
 half-a-drachm of oil  of rosemary in a pint of rectified spirit,
 immediately after the face is Avashed.  In cases where there
 is much tendency to local inflammatory action, this lotion
 should be reduced in strength, by diluting it with  twice or
 four times the quantity of elder-flower water.  Should the
 eruption accompany or appear to depend on derangement
 of the menstrual function, the treatment  should be directed
to restore it to  a healthy condition, either by the use of
evacuants or of tonics, according to the indications in each
case.   When acne simplex is general over  the regions of
the body  which it  affects,  warm baths every second or 
124
PUSTULE.
third day, accompanied by friction with a flesh-brush, should
there be obstruction of the sebaceous follicles, will be found
of much service;  in chronic cases, when the pustules are in-
dolent, and there is rather deficient than increased cutaneous
capillary circulation, the use of sulphurous baths—more
particulaaly those of the  natural sulphurous waters, as of
Lucan, near this city, of Harrowgate in England, of Moffat
in Scotland, and of Enghien, of Aix-la-Chapelle, of Bareges,
and of the Pyrenees, on the  Continent—usually constitutes
the most efficient plan  of treatment.   If it be impossible to
obtain the natural mineral waters for the baths,  they may
be artificially prepared by dissolving four ounces of sulphu-
ret of potassium in thirty gallons of water.
  No remedial measures  can possibly prove of service in
the treatment of acne  rosacea until the habits  by which
the disease may have  been  occasioned are corrected, and
in every case especial attention must be paid to the avoid-
ance of  all  stimulating articles,  both  of food  and  drink,
which occasion determination of blood  to the face, such
as rich  meats, spices, spirituous and  vinous drinks,  &c,
from  the use of which the eruption is  invariably aug-
mented, if  it  had not been  originally produced  thereby;
heated rooms, exposure of the face to  the fire, continued
stooping of  the head, and mental  excitement  or anxiety,
must be equally guarded against.  When acne rosacea is
seen in  its  early stages, or where  there is  much  inflam-
matory  action present, the application of from four to six
leeches behind the ears twice or three times a week at bed-
time will be found of much service, and at the same time
saline cathartics  should be used daily,  preceded by mild
mercurials, if there be  any biliary  derangement.  The sa-
line cathartic mineral waters are  here, as in  acne simplex,
of  especial service; and of them  all I have found  the
Pullna Avater—which is now very generally imported—the
most  beneficial;  it  may be given in the dose of from one
to two  wine-glassfulls,  mixed with  an equal quantity of
tepid water,  every  morning.  When they cannot  be pro-
cured, one drachm  of  the compound  saline powder, pre-
pared as I have  directed in  my  work on  Medicines,1 dis-
solved in half-a-pint of tepid Avater, may be substituted.
                   I Third Edition,  p. 107. 
ACNE.
125
The tendency to  local inflammation being thus subdued,
slightly stimulating applications may then be used,  such as
ointments of the  ammonio-chloride  or  of  the nitrate  of
mercury, of dried sulphate of iron, of the acetate of copper,
&c.;  the  employment of the first of these will be found
especially beneficial; it may be prepared as follows :—
     R  Hydrargyri Ammonio-chloridi,  . gr. xij.—5SS-
        Cerati Simplicis,........     ^j.
        Glycerinae,...........  fl 3J.
        Olei Amygdalae Amarae, .... m. iij.  Misce.
The ointment should  be smeared thickly over  the  affected
part at night, and washed off in the morning with a weak
spirituous alkaline wash,  containing not more  than twelve
grains  of the carbonate  of soda to the pint of liquid, to
which from  half-an-ounce to an ounce of glycerine should
be added, if the skin be hard and dry and inclined to bleed.
In every stage of acne rosacea the use of  soaps should be
carefully eschewed, as they are all more or less irritating;
the bicarbonate of soda may be substituted for them, and
in the case of men who are compelled to shave, a saturated
solution of it, mixed with an equal part of olive-oil, may be
used.   In chronic cases of the  disease, preparations of
iodine must  be given internally ; two grains  of the iodide
of potassium, dissolved in two ounces  of the  decoction of
fresh elm-bark,  with the addition of a quarter  of a  grain of
iodine when the disease is very obstinate, taken at bedtime,
will be found perhaps the most  efficacious form of adminis-
tering this remedy.
   Should  acne rosacea prove  rebellious to these  plans of
treatment, the more  active local medication  proposed  by
some dermatologists may be tried ;  such as the application
daily to each inflamed follicle  of  a small  pledget of lint
dipped in a concentrated solution of sulphuret of potassium,
as proposed by M.  Duchesne-Duparc,1 the contact  being
continued  for from fifteen to twenty seconds :  of a concen-
trated solution of acetate of lead in white-wine vinegar, as
recommended by  M. Bretonneau ;2  or of a solution of tAvo
grains of the bicyanide of mercury in an ounce of  distilled

        1 Nouvelle Prosopalgie: Paris, 1847, p. 69.
        2 Bulletin de Th6rapeutique, tome xxxi. p. 285.
                           11* 
126
PUSTULE.
water, washed off in a few moments after Avith cold water ;
an application highly spoken of by Dr. Burgess.1
  When acne assumes the indurated character which has
acquired for it that special denomination, it requires active
treatment, both constitutionally  and  locally; blood  may
be removed by cupping from the nape of  the neck to the
extent of from  two to four  ounces  once or twice  a week,
according to the youth and constitution of the patient, and
daily purgation by active saline cathartics had recourse to;
unless, which rarely occurs, the disease appears in an indi-
vidual of a weak constitution, Avhen preparations of iodine
with  iron will  be found more beneficial.   The best local
application is the iodide of sulphur in the form of ointment,
the strength of which  may be gradually increased from
fifteen grains to half-a-drachm to the ounce of lard.  Alka-
line  washes  should  also  be used  as in acne  rosacea, and
change  of air,  with  the internal  use of the sulphurous
mineral waters, will be found of especial benefit.  Blistering
the face has been sometimes had recourse to, and it is said
with  success, in cases of acne indurata which had resisted
all other methods of treatment.
  Most of the lotions  which  are empirically employed  in
acne of  the face consist of corrosive sublimate dissolved  in
bitter almond emulsion, in the proportion of  from one  to
two grains to the ounce;  their use for a short time is not
unfrequently attended  Avith benefit, but if continued  long
they cause the skin to become hard and scaly.

                       IMPETIGO.

  Impetigo  (Crusted  tetter.)—This  term,  like so many
others applied  to  designate  diseases  of the skin, had no
determinate signification previously to the time of Willan.
It is  now  understood  to indicate  a cutaneous  affection,
characterized  by the eruption of  numerous  psydracious
pustules, occurring singly and distinct from each other,  or
in groups  and confluent, with but little surrounding inflam-
mation ; they maturate  rapidly, and  discharge  a  thick
purulent  matter,  which  dries into  a semi-transparent,
greenish-yellow, irregularly shaped, persistent, solid crust.
  'Eruptions of the Face, Head, and Hands: London, 1819, p. 55. 
impetigo.
127
From beneath this crust, when formed, purulent matter
continues to be secreted, often in considerable quantity,
and  the duration of the disease is  thus usually prolonged
for some time ; the crusts are slow in separating, and Avhen
they at length fall off, a red mark or stain is left  on the
integuments, which, however, gradually wears away.  Fresh
pustules are developed in successive crops around the region
of the skin originally affected, and the disease thus spreads,
until it not unfrequently involves  an extended surface of
the body, which becomes covered  with the characteristic,
pellucid, soft,  greenish crust,  and  from beneath   which
purulent matter oozes ; when the eruption has existed for
some time, cracks and  fissures form as in eczema, but they
do not  present the red colour of that disease, nor are they
accompanied by the serous exudation so characteristic of it.
Impetigo is a highly inflammatory eruption, and may run
either an acute or chronic course : it is not contagious.
   M. Gendrin has carefully described the anatomical cha-
racters of impetigo and its seat, having had an opportunity
 of examining it after death,—an opportunity which  occurs
 with extreme rarity, as the  disease  does not prove fatal,
 and as inflammatory cutaneous eruptions generally disap-
 pear in the course of mortal diseases.  The following is the
 account which he gives of the result of his observations:
 "At the parts corresponding to the  eruption,  the skin was
 more adherent to the areolar tissue  than elsewhere, never-
 theless, there existed on the external surface of the derma
 but a slight degree of capillary injection.  The cutaneous
 tissue  Avas more dense  than natural,  and was of a reddish-
 yellow hue, but this morbid colour only extended for a short
 way into  the chorion.  On  the  edges of a section made
 through the  diseased  skin, it could  be observed that the
 small,  reddish, closely aggregated, but only slightly promi-
 nent granulations, which were situated beneath the crusts,
 Avere made up of  minute grains about the size of the head
 of a pin, of a liquid and greenish-yellow, cheesy-like  sub-
 stance; the  surrounding cutaneous  tissue was  red,  and
 matter similar to that Avhich was secreted by the pustules of
 the eruption, and Avhich, by drying, formed the crusts of the
 disease, oozed out  of it when pressed  between  the fingers."1
                  1 Traite des Inflammations, torn. i. 
128
PUbTUL e.
  The various forms of impetigo which have been described
by dermatologists may, I think, be conveniently considered
in two groups, named from the mode of development of the
eruption.   But as it presents certain peculiarities when it
occurs on the scalp, which require  to be specially noticed,
I shall describe it under three heads :—
                    Impetigo figurata.
                             sparsa.
                             capitis.
  Impetigo figurata is so named from the disease appear-
ing in patches of a circular or ovoid shape.   It usually sets
in with feverish  symptoms, which both precede and accom-
pany the eruption, never severe, but generally well marked,
consisting in malaise, headache, loss of appetite, and occa-
sionally slight shivering ;  in children the symptoms amount
only to some heat of the  surface, and general uneasiness ;
but at times there are no premonitory signs noticeable, when
the disease usually assumes rather a chronic character from
the first.   Small,  rounded, slightly-elevated, red patches
appear on the skin  of the face,—where the  disease is of
most frequent occurrence,—of the trunk, the shoulders, the
arms, the hands, or the thighs; and on them  psydracious
pustules, closely set together, and more or less  confluent,
are rapidly developed, their appearance being preceded by
much local heat and itching.   The pustules attain their full
magnitude, which rarely exceeds that of the head of a pin,
in about  forty-eight hours, when they burst and give exit
to the contained  purulent  matter; this,  which is very
liquid, dries quickly into a pale, greenish-yellow or citrine-
coloured, soft crust, of a pellucid aspect, and bearing much
resemblance  to  candied honey, so  much  so that Alibert,
from this characteristic, named the disease melitagra.  The
crust generally covers completely the original red patch ;
it is very friable, and through cracks which  form from the
motion of  the part  on which it may be seated, an ichorous
pus oozes ; this, drying rapidly, adds to the volume of the
first crust, until it often acquires a considerable  thickness,
still, however, retaining  its semi-transparency, and  kept
constantly moist by the discharge  from beneath.  Should
the crusts  be removed or  fall off, the surface on Avhich they 
IMPETIGO.
129
were seated is seen to be raw, inflamed, and secreting pus,
by which they are rapidly renewed.
  The original patches of the eruption, should there be more
than one, may remain distinct from  each other, separated
by healthy integument  during the whole progress of the
disease, but more usually those which are near become con-
fluent, the eruption spreading by the development of isolated
pustules or of successive  crops  on the intervening  sound
skin.   The crusts in  the more acute cases remain attached
to the surface for three or four weeks, during which time
the discharge continues ; they then gradually become drier,
the secretion diminishes in quantity, and, unless successive
crops of pustules appear, the disease  terminates  by their
becoming detached in separate pieces as it were, a reddish-
brown stain being left which is slow in disappearing ; and
from which for some time an epidermic desquamation, ac-
companied occasionally by a slight  serous oozing, takes
place, causing the eruption, as well remarked by Cazenave,
to resemble somewhat eczema.  Until the crusts commence
to dry up and fall off, a constant heat and painful tingling
in the affected parts attend the disease;  these cause children
and  sometimes even adults, to tear the surface with their
nails, and thereby aggravate the malady.
  In  some cases  of  impetigo figurata  the symptoms, both
local and constitutional, are of a much  more severe charac-
ter than those now described.  High fever marks  the out-
break of the eruption, which is characterized by active in-
flammation that extends to the subcutaneous areolar tissue,
and affects a considerable surface of the integument, which
is red and much tumefied.   In  its  commencement  it can
scarcely be distinguished from an attack of erysipelas,—and
was therefore named by Willan and Bateman impetigo ery-
sipelatodes,—but  on  the second day the characteristic psy-
dracious pustules  appear on the inflamed surface, when the
disease runs the  course  above described,  except  that  the
local symptoms are throughout of much  greater severity, the
discharge especially being much more copious,  and so acrid
as to  irritate, and cause the development of  pustules on
those parts of the unaffected skin over  which it may flow ;
there is also more or less fever present to the  end, and its
duration is very prolonged. 
130
PUSTULE.
  Impetigo sparsa differs, as its name indicates, from the
preceding form in the  arrangement of the pustules, Avhich
are developed individually, and scattered or dispersed over
the cutaneous  surface, sometimes pretty  thickly  on the
legs, where it is of most frequent  occurrence ;  but it may
affect any part of the body, in children being often seen on
the ears, the face and the neck.   When the pustules in im-
petigo  sparsa are numerous and  closely  set together, as
usually  happens on the folds of integument in  the neigh-
bourhood  of  the joints, although  they  may not coalesce,
which they very rarely do, the intervening skin is inflamed,
red, and slightly tumid, hot, painful,  and tingling.  The
crusts  which form present the  same appearance as in im-
petigo  figurata,  but they  are distinct on  each  pustule, or
cover the  site of two or three, rarely more, and  are much
thinner, softer  and more easily detached.  The  develop-
ment of the eruption is attended generally with  some fever,
and always with an extreme degree of burning heat, some-
times almost insupportable, which remains, but in a less
degree, until  the crusts are about to fall  off;  then it  re-
turns, if possible, even with greater intensity, and a second
crop of pustules is developed in the neighbourhood of and
in the intervening spaces between the first.  This is in like
manner followed  by a  third or fourth crop, and thus the
disease becomes often very chronic, when the skin is hyper-
trophied, fissured with red cracks caused  by tearing with
the nails, of a crimson  tint, and  discharging  a thin, un-
healthy, bloody  pus, which dries into dark greenish-brown
crusts, that at times envelope an entire limb like the bark
of a tree; when impetigo sparsa assumes this  aggravated
character  it corresponds with the form described by Willan
as  impetigo scabida.   The duration of this variety of the
eruption is always much prolonged—acrid, ichorous matter,
of a heavy,  disagreeable odour,  being secreted from the
surface beneath  the crusts, which are very permanent, and
scattered pustules continuing to be developed in the neigh-
bourhood, often without any apparent fresh attack of local
inflammation ; superficial ulcerations also  form,  and if the
limbs are the parts affected they become more or less oede-
matous.
   Impetigo  of  either of the  forms now  described is very 
IMPETIGO.
131
frequent on the face of  infants and  young  children, and
becoming chronic there  presents  these  characteristics  in
their  most aggravated form;  the  features are completely
changed, and  the eruption covering them, as it were, with
a mask, the disease has been termed impetigo larvalis.
  Impetigo capitis is  the only pustular  disease which ap-
pears exclusively on the scalp.   Its occurrence in children
is  preceded for  a few  days  by  feverish symptoms, fre-
quently attended  with vomiting ;  the surface of  the scalp
is hot and painful, and the part about to be affected pre-
sents  an erythematous blush.   The eruption  makes its ap-
pearance either in  distinct pustules of  a psydracious cha-
racter, scattered over the head, or in groups  thickly set on
an inflamed base.   In the former case  they  are about the
size of small peas both in circumference and elevation, and
are attended with but little surrounding inflammation.  On
the second day of  their  appearance each pustule contains
thick, yelloAv matter at the summit, but  it is soon matured,
when it bursts, and giAres exit to the contained pus, which
rapidly  dries  into  a greenish-yellow  scab.  This form,
which to a certain extent corresponds with impetigo sparsa,
termed  by some dermatologists impetigo granulata, rarely
assumes a  chronic  character,  its continuance, Avhen it has
lasted for any time, being kept up  by an eruption of fresh
pustules on other parts of the scalp.   It not unfrequently
passes into the second form, which is characterized by the
eruption occurring in  groups of pustules.  Their appear-
ance is  attended with more decided symptoms of inflamma-
tion both general and local, and  the heat and itching are
in many cases so severe  that  children  tear the  scalp and
prevent the disease from presenting the  truly pustular cha-
racter of the first stage.   The eruption  usually commences
on the  forehead, involving at  the same time some of the
hairy scalp; the inflamed patches vary in size and form in
different cases; in some extending in their  longest  mea-
surement not  more than from  half-an-inch  to one  or two
inches, while in others the greater part of the scalp is in-
volved from the very  commencement; in nearly  every in-
stance the  skin bordering on the scalp is more or less en-
gaged in the disease, and it often appears at the same  time
on the ears or on some part of  the face.   The pustules are 
132
PUSTULE.
not so large as when they  occur singly;  their  coats are
apparently thinner, and the pus which they contain is not
so consistent, and is of a richer yellow colour. They usually
become confluent before they burst,and the resulting greenish-
yellow—if chronic, greenish-broAvn—scab is consequently
much more  extensive.  When the eruption has continued
for any length of time, large quantities of bright yellow
pus are secreted beneath the greenish crusts, which separate
in cracks to give exit to the  matter, exhibiting beneath the
highly inflamed raw surface of the scalp from which the pus
is secreted.
  In either form of impetigo the hair is unaltered; it is
usually matted together by the purulent secretion and the
scabs,  but it does not fall off or become changed in appear-
ance, even in the most chronic cases.
  Impetigo capitis is not contagious ;  it is met with at all
ages, but most generally in early infancy, lasting for seve-
ral years  if not properly treated ; it very rarely appears
for the first time after the age of 9 or 10, but I have seen
some instances in which the eruption occurred in  advanced
life ; in them  the disease was of the form  first  described.
  In the  chronic  stage  of  the eruption small  abscesses
very frequently  form at the nape of the neck, close to the
roots of the hair;  and some of the  chain of  lymphatic
glands, which lies behind the  sterno-mastoid muscle, be-
come enlarged, swollen, and tender, but they very rarely
suppurate.
  Bateman described a form of cutaneous eruption as a
species of  impetigo, terming  it  impetigo  rodens,  and in
this  he has been followed by Biett and Rayer; but the
disease is evidently a lupoid ulceration of  the  scalp, and
as such will consequently be considered in the group Can-
erodes. Two other forms of the disease have  been charac-
terized by M. Devergie, as impetigo purifluens, and impetigo
pilaris;  the  former is  attended  with  profuse purulent
secretion,  and the latter affects those parts of the skin on
which  the hair grows, the pustules  being frequently devel-
oped around individual hairs, which  thus seem to penetrate
them ; these, however, are merely accidental circumstances,
and  neither  can be  admitted  as sufficient to constitute a
special variety of the eruption.  The impetigo sycosiformis 
IMPETIGO.
133
and  impetigo lupiformis of the same dermatologist are
identical,  the former  with sycosis and  the latter  Avith
impetigo rodens.
   Causes.—Impetigo  is of most frequent occurrence in
infants  and  children;  when  it  affects adults,  appearing
only in  those Avho have a fine transparent skin, being there-
fore  more common in women than in men.   In old persons
it is  usually seated on  the lower extremities, especially the
thighs;  in  them it is  developed  in the form of impetigo
sparsa, and assumes a  very obstinate character.   The con-
stitutional causes of the disease are more or less connected
with the scrofulous diathesis,  and in  children  of  this
temperament it commonly appears about the  periods of
first and second dentition, its eruption being excited then by
the general perturbation of the system thereby occasioned.
Anything Avhich produces cutaneous capillary determination
of blood acts as a  cause of impetigo in those predisposed
to it; thus  its origin may be  determined  by irritants
applied to the surface, such as washing in very hot water—
a frequent  cause in  infants and children—the use of hard
brushes or fine  tooth-combs to the hair, stimulating soaps
and  cosmetics,  and solar  heat or that from a fire—tho
former accounts for the frequently Avitnessed recurrence of
the disease in summer and autumn, and the latter for its
appearance on the lower extremities of old persons.   Pro-
longed constipation and  menstrual irregularities are both
frequent exciting causes of impetigo in females.
  Diagnosis—Impetigo  is  well  characterized  in  all  its
forms by its  truly  pustular character, and by the peculiar
semi-transparent, soft, greenish-yellow, honey-like appear-
ance of its  crusts.   From eczema impetiginodes  it is often
with difficulty diagnosed, and both diseases seem  frequently
in their advanced stages  to be precisely  similar; yet the
copious  ichorus exudation—so well described by the French
term, suintement—and the  epidermic  desquamation, are
present usually in  all forms of  eczema,  and in impetigo
fresh psydracious pustules are  in general  being  constantly
developed in the neighbourhood of the eruption.  From
ecthyma the  disease is diagnosed by the small size of the
pustules, those of ecthyma being phlyzacious, and for the
most part scattered  singly, or  in twos or  threes, over the 
134
PUSTULE.
cutaneous surface, and the scab resulting from them is of a
dull brownish yellow colour : the parts usually affected are
also different in the two eruptions.  When pustules occur
in scabies they are of a large  size, and a conoidal shape,
but that disease is especially distinguished from impetigo
by the itching which accompanies it, burning heat, tingling
and smarting, not itching, being  present in the latter ;  the
detection of the acarus scabiei, of course, renders the diag-
nosis  more  precise, but  it should be remembered that in
some cases both diseases exist together on the  same person.
Sycosis, from its occurrence on the face, has been at times
confounded  Avith impetigo;  but  it invariably affects that
part on which  the  beard grows  and its immediate neigh-
bourhood, is not truly pustular, and the  crusts Avhich form
in it are  hard, dry, and of a brown colour, and, if examined
under a microscope, exhibit  the  characters of a vegetable
parasite.
  As impetigo  is the only pustular eruption which specially
affects the scalp, it can scarcely be  mistaken for any other
eruptive disease that appears on this part of the cutaneous
surface;  the chronic form of eczema is that with Avhich it
is most likely to be confounded;  in it the discharge, which
is either serous or sero-purulent, dries into broAvnish-yellow
scabs, through Avhich the ichorus liquid forces its Avay, or into
furfuraceous scales, while in impetigo the purulent discharge
accretes  into large, greenish-yellow crusts, by Avhich  the
whole  head, and even  sometimes the forehead and part of
the face, is in many cases covered as Avith a mask.
  Prognosis.—The only question here to be considered is
the probable duration  of the disease, as its existence, when
uncomplicated, does not either injure the health or endanger
life.  In children,  although apt to  become  chronic and
obstinate if neglected, it usually yields quickly to judicious
treatment, and when situated on  the scalp -is, in my  experi-
ence, more readily cured than any of the other  eruptions
peculiar to that region, if their relative duration previously
to the  employment  of  remedies be taken into  account.   It
is in general more rebellious in adults, and Avhen  it  affects
the lower extremities in old persons is a most troublesome
and obstinate  disease, the form termed scabida by  Willan
not unfrequently  lasting for years, notwithstanding  the 
IMPETIGO.
135
most careful treatment, at one time showing signs of amend-
ment, but  to break  out with increased severity again and
again. _ In young persons even the eruption is very apt to
return in the summer and autumn months after it has been
apparently cured.  At all ages the obstinacy of  impetigo
is in proportion to its  previous duration.
   Treatment.—The acute stages of impetigo  occurring in
young persons  of robust constitution require rather active
antiphlogistic treatment,—the daily use of saline cathartics,
and local,  or even in  some cases general,  bleeding;  the
local  abstraction of blood should be  by leeches applied in
the neighbourhood of the eruption, or behind the ears when
it is situated on the face or scalp.  When the disease, how-
eA'er,  attacks the  old or debilitated, bleeding is very rarely
admissible,  but should it be requisite in consequence of the
inflammatory symptoms running high with much heat and
tumefaction of the part affected, a few leeches  only should
be  applied, and  the  after-bleeding  from  the bites  not
allowed to continue; tonics are here more generally indi-
cated, and  the use of  preparations of iron, combined  with
vegetable tonics  and saline  purgatives, as somewhat in the
following form, will be found highly beneficial:—
     R. Tincturae Ferri Sesquichloridi,  .  .  fl 5ss.
        Infusi  Quassias,.......fl ixviij.
        Tincturae Calumbae,......fl ?iss.
        Magnesiae Sulphatis,.....5ij.  Misce.
        " A Avine-glassful to be taken every morning."
  In  children  or adults  of the  scrofulous diathesis, cod-
liver  oil is the best  tonic, and if the  eruption is  attended
with  scrofulous enlargement of the  glands  of the  neck,
from  a sixteenth to a  fourth of a grain  of iodine may be
dissolved in each dose of the oil,  which should not  exceed
a dessert-spoonful three times a day for children, or a table-
spoonful for adults; as when given in large doses the local
disease is apt to  be  aggravated, apparently from its over-
stimulating  action on the  system.
  In  the chronic stages  of the eruption, the administra-
tion of more  decidedly alterative medicines  is requisite,
and a mild  mercurial course is often  singularly efficacious, 
136
PUSTULE.
 especially when the  mercury is  combined  with  iodine and
 alkalies.  With this vieAV the green iodide  of mercury may
 be  given  in  the folloAving form for  adults, a proportion-
 ately smaller dose being prescribed for children :—
     R. Iodidi Hydrargyri Viridis, .   .  .  . gr. iv.
        Hydrargyri  cum Creta,.....gr. xij.
        Carbonatis Sodae Siccati,   .   .  .  . gr. xij.
        Pulveris Myrrhae,   .   .   .   .  .  . gr. vj.

   Mucilaginis,  quantum sufficit, ut fiant pilulae duodecim.

          "One to be taken three times daily."

   In the more  obstinate cases, some  practitioners  recom-
 mend  the employment of sulphurous preparations—espe-
 cially in the form of the sulphur-mineral waters ; and others
 have recourse to the  use of  arsenic;—of the  latter,  the
 preparations most suited for this disease are the arseniates
 of  ammonia and of soda, the dose of either is from  the
 twentieth to the tenth of a grain; they may be  given in
 decoction of dulcamara.
  In the  impetigo of  infants and of  very  young children,
 but little constitutional treatment  is necessary :  for infants
 at  the  breast, should  the eruption  exhibit a tendency to
 assume a chronic character, it Avill be advisable to change the
 nurse ; and when the,disease appears at the periods of den-
 tition,  the gums should be freely lanced.  The state of  the
 digestive organs must in all cases be strictly attended to,
 and mild purgatives, combined with alkalies,  administered
 according to circumstances.   The alkaline treatment is at
 this age of especial  service : for children of a full habit of
 body the bicarbonate  of soda may be prescribed in doses
 of from three to five grains, three times daily, in  half-a-
 drachm of syrup of orange-peel and two drachms of orange-
 flower  Avater, and for  those of a  weak or debilitated con-
 stitution, from  one to  three  grains of the bicarbonate of
 ammonia in  the same  menstruum.   Should  diarrhoea, or
 symptoms of any derangement of the  brain accompany
 the eruption of impetigo,  we should  be most careful not
to check'the disease too suddenly, more especially if it is
 attended with much discharge. 
IMPETIGO.
137
   The local treatment of impetigo is of even more import-
 ance than the constitutional, for  upon its judicious appli-
 cation, in  the first instance, most frequently depends the
 duration of the disease.   It is especially necessary to  keep
 constantly in view that the eruption is  of an inflammatory
 nature, and that even  in its  most chronic  stages a fresh
 outbreak  of inflammation, attended with the development
 of a new  crop of pustules, may be readily  excited.  The
 very production  of  the  disease in so  many cases  by the
 direct influence  of  irritants sufficiently  proves this, and
 should warn against  the use of irritating applications, which
 have been often too indiscriminately  recommended.   In
 the acute  stages, no  matter on what part of the cutaneous
 surface the eruption  may occur, alkaline ointments are of
 especial service; and should there be much local tingling
 and  irritation,  chloroform  will be beneficially combined
 with them, as in the following form:—•

     R. Sodas Bicarbonatis,.....gr. xx.
        Adipis praeparati,.....     £j.
        Chloroformi, .   .  .   .   .   .  .  m. iv. Misce.

  This ointment should be smeared pretty thickly over the
 pustules night and  morning, the surface  having been pre-
 viously Avashed with  equal  parts  of new  milk and tepid
 Avater.  To allay the irritation, unguents and washes,  con-
 taining various  preparations of lead, oxide  of zinc,  and
 of prussia acid, are  recommended by different  dermatolo-
 gists, but  I ha\re found  none of them so  useful as the
 above.  Owing to  the moisture  from  the  purulent dis-
 charge which  is  so  constantly  present in  impetigo, the
 addition of glycerine to the local  applications, so far from
 being attended with  benefit, usually proves injurious.
  In the chronic forms of the eruption,  the crusts or scabs
should be  always be removed carefully before  the use of
medicated applications ; this is done most effectually by the
employment  of  linseed-meal poultices, — wet  writh  the
weak lead-wash (see  page 74) when any tendency to local
inflammation is  present,—changed twice in the twenty-
four  hours ; the parts being sponged with a warmed solu-
tion  of half-a-drachm of carbonate of  soda in a pint of dis-
                         12* 
138
PUSTULE.
tilled water each time the poultice is  changed.  The alka-
line ointment above described may then be used; or, should
the disease be very chronic, an ointment of the dried sul-
phate of iron, in the proportion of from two to five grains
to the ounce of cerate, employed ; this preparation even
occasionally proves too stimulant, when the acetate of zinc
cerate  should be employed instead of it.   In some cases
of impetigo greasy applications are found to  aggravate the
local symptoms, and then lotions should be  substituted for
them, such as twelve grains of  the acetate of zinc, or six
grains of the  acetate of lead, or four grains of either the
sulphate of copper or the sulphate  of  iron, dissolved  in
eight fluid ounces of elder-flower or of rose-water.
   To the use of  more  active local stimulants,  as oint-
ments, baths or washes  of the  sulphuret of potassium, of
tar, of anthrakokali, of fuligokali of  the huile de cude,  or
of caustics as the nitrate of silver,  my experience is de-
cidedly opposed; as I have generally seen their application
excite an outbreak of inflammation, and the consequent
spread  of the  disease by the  development  of additional
pustules.
   When impetigo affects the scalp, the hair  should always
be carefully cut close, and the  crusts removed by the ap-
plication of  poultices  and the use of alkaline Avashes,  as
above  directed;  afterwards  the ointment of the bicarbo-
nate of soda, and a lotion of milk  and tepid water, will
be employed with benefit: the green iodide of mercury,
with the  hydrargyrum cum creta, and the dried carbonate
of soda, should be given  internally.  This  plan  of treat-
ment  seldom fails to  cure the disease, even  in the  most
chronic  forms, in from six  weeks to three  months, pro-
vided there is a careful attendant to  carry out strictly the
employment of the local remedies.   In any case  the hair
should not be  permitted to  grow  for some time after  all
traces of the eruption have disappeared.
   Dietetic and hygenic regulations are of much importance
 in the treatment of impetigo,  particularly  of its chronic
 forms; all heating and stimulating articles of food ought to
 be strictly prohibited, and  everything which could cause
 determination of blood to the surface of the body carefully
 avoided.  In children, the use  of a  purely milk and fari-
 naceous diet will be found to expedite the cure much. • 
ECTHYMA.
189
                       ECTHYMA.

  Ecthyma  (Papulous scall) consists in the eruption of
phlyzacious pustules, on a hardened, more or less inflamed
base, usually isolated, but  occasionally in small patches,
terminating in yellowish-brown scabs  or  crusts,—in very
chronic cases, of a livid hue,—which as they fall off, leave
small ulcers that heal with  superficial cicatrices.  When
this  cutaneous disease  attacks the young and the robust, it
is of an inflammatory  character,  but in the old and debili-
tated it assumes from the first an asthenic type : in both it
is  non-contagious.  In children it  is rarely met with, still
more rarely in  infants, occurring most frequently in old
persons and in adults.  The pustules may appear on  any
part of the cutaneous surface, but  they chiefly affect the
extremities, especially the thighs; they appear with the
next degree of frequency on the skin of the trunk of the
body or on the neck, being but seldom witnessed on the
face or the hairy scalp.
   The division of ecthyma into varieties, as made by Willan,
and  those dermatologists  who  have  adopted his views,
depended  either  upon the age of the patient or upon
accidental phenomena, haAing their origin in the constitu-
tion  of the individual  attacked.  This being manifestly a
bad  foundation  for a classification, though one not uncom-
monly followed as regards cutaneous eruptions, is  now
atmost  universally abandoned, and but two forms of the
disease are described  by  most modern writers:  these  I
shall adopt :—
                   Ecthyma acutum.
                       „     chronicum.

  The eruption  of Acute ecthyma is preceded by some de-
gree of fever, usually very slight,  amounting merely to heat
of the  surface,  thirst, and headache; in about thirty-six
hours  afterwards, small,  rounded,  slightly  elevated  red
spots appear on the skin, generally of one or both of the
loAver extremities, their appearance being  preceded  and
accompanied by  heat and sharp tingling of the parts about
to  be  affected, the constitutional symptoms at  the same
time  subsiding.  These spots, which are nearly the size of 
140
PUSTULE.
 a large  pea, and feAv in number, are  scattered over the
 cutaneous surface distinct from each other, the intervening
 skin being healthy; on the second day of their development
 the centres are raised by purulent effusion, which, increasing
 rapidly,  covers  within twelve hours the entire  of each
 inflamed spot, thus  forming the characteristic phlyzacious
 pustule of the disease, surrounded by  a narrow, inflamed
 areola, and situated on a  hardened base ; occasionally two
 or  three  of  the pustules, from being  developed close to
 each other become  confluent,  and not unfrequently a few
 psydracious pustules  form  in the neighbourhood,  being
 evidently produced  by an intensity  of the local inflamma-
 tion.   This  stage   of  the  eruption  is attended  almost
 invariably with  severe lancinating pain and a burning
 sensation, both of which are much diminished, sometimes
 cease completely, on the maturation of  the pustules.  The
 maturation takes place from  the fourth to the sixth day,
 the epidermic  covering giving way and the contained pus
 being  effused; a  brownish-yellow crust  or scab, occupying
 the site  of  the  pustule, then forms rapidly, and if it  be
 removed,  a  cup-shaped ulcer,  with  hard  edges,  will  be
 brought into view.   The scabs, if not interfered with, fall
 off sometimes in  a few days, -but they often do not separate
 for  two or three  weeks, and a small depression, like the pit
 resulting from small-pox, marks the  site of each pustule.
 It occasionally happens that purulent matter does not form
 in some of the red spots, and they terminate in resolution,
 a reddish-brown  stain, accompanied by  epidermic desqua-
 mation, remaining for some time afterwards.
  The acute form of the disease thus  terminates usually
 in from a fortnight to three weeks, but its duration  is not
 unfrequently prolonged for  five or six  weeks  by the de-
 velopment of successive crops of pustules, each crop running
 an independent course.  The usual seat  of this form of the
 eruption, as already remarked, is on the loAver extremities,
but it  also appears  on the shoulders, the chest, the neck,
 the  arms,  and the palms of the hands, and  in a few rare
 cases on the face and scalp.
  Ecthyma chronicum is a not uncommon eruptive disease
in debilitated  constitutions at every age, occurring  much
 more  frequently  than  the acute form  ; it often  attacks 
ECTHYMA.
141
unhealthy  infants and young children,  and from its fre-
quency at  the very early periods of life, it was  described
by  Willan as  then constituting a distinct variety, and
termed by him ecthyma infantile.   The eruption appears
as in the acute form, but there are  no preceding or accom-
panying febrile symptoms, and the local  suffering is  much
less,—diminished, not increased, vital action characterizing
it.   The pustules are generally diffused over the surface,
being rarely  confined to any special region, and occur iso-
lated,  or in  patches of tAvo or three; they exhibit a very
indolent progress,  maturate  slowly,  and form hard, dry,
brownish crusts, which either adhere  firmly, or, falling off
in a few  days, leave a superficially  excavated unhealthy
ulcer,  that discharges a bloody  purulent secretion.   The
matter by which some or all of the pustules are distended
in old  persons is often sanguinolent, and the subcutaneous
areolar tissue infiltrated  so as to constitute a prominent,
hardened base, of a lurid or dingy-violet aspect, to each
pustule ; these characters  induced Willan to regard the
eruption then as a distinct variety,  and to name it ecthyma
luridum.   The chronic character of the disease, as regards
duration, is due to the continued development, in constant
succession, of the pustules, until at length the integuments
of almost the entire body are involved in the eruption ; the
cutaneous  surface then presents  a  most unhealthy aspect,
large portions of it being covered with phlyzacious pustules
in their various  stages of development, hard, dark-brown
scabs,  superficial  ulcers discharging unhealthy matter, and
livid stains, the marks of spots that had healed.  The con-
stitution noAv, in most cases, sympathizes ; in old persons
extreme debility occurs, and dropsical effusion takes place;
and  the disease  in this, its  most  aggravated  form, well
deserves the name applied  to  it by  Willan—ecthyma
cachecticum.
  Ecthyma chronicum lasts  generally for four, five, or six
months, or even longer,  being  often complicated  in its
advanced  stages  with purigo, scabies, or chronic lichen,
and being a frequent attendant on chronic organic diseases
in old  persons ;  although it spreads to all parts of the
cutaneous surface, it is most thickly disseminated over the
limbs,  and  least so on the face or scalp. 
142
PUSTULE.
  Either form may appear at any age, but the acute is
most  common in adults, the chronic  affecting  chiefly the
very young and  the aged;  it attacks  both sexes, but after
the age of puberty males  are  more  liable to the disease
than females.  The causes of ecthyma are both  constitu-
tional  aud topical.   The  former are  usually what may be
termed hygienic and dietetic ; thus residents  in damp, ill-
ventilated habitations, insufficient  clothing, want of  due
attention to cleanliness, unwholesome  food, habits of dissi-
pation, &c, produce a state of the system  in which  the
disease is often  developed; and  the direct action of sub-
stances which imitate the skin constitute the latter.   Its
association with  chronic visceral  disease  has been noticed
above; it  is also a not uncommon sequela of acute  febrile
disease, more particularly typhus fever and dysentery.
  Diagnosis.—Ecthyma is in general readily recognizable
by the phlyzacious  character of the pustules, and the  iso-
lated  manner in which they are  developed.   It might be
confounded with either acne or  impetigo, but the charac-
ters by which it  is distinguished from  these eruptions have
been  already described when treating of  them.   The
smaller-sized  pustules bear some  resemblance to those of
modified small-pox, but the mode of eruption of that disease,
its appearance first on the face and upper part of the body,
and  the  accompanying fever,  are sufficiently diagnostic
marks.  The pustules  of  secondary syphilis  are, in many
cases, very similar to those of ecthyma, and are with much
difficulty diagnosed from the lurid form of the disease; the
latter, however,  occurs seldom except in  very old persons,
and the presence of the usual concomitant affections of the
throat and of the  bones in secondary  syphilis, together
Aviththe antecedent  history of the  case, marks the cutaneous
affections produced  by the venereal poison.
  Prognosis.—When uncomplicated, ecthyma is not a  dis-
ease dangerous to  life, the chronic form of the eruption is
always of prolonged duration, and  by its continuance the
general health is more or less injured.
   Treatment.—In the acute stages of  this  eruption  any
inflammatory symptoms that  may exist should be subdued
by the use of diluents and diaphoretics; minute doses of
tartar emetic dissolved in whey, in the proportion of half- 
E C T H Y M A.
143
a-grain to the pint, will be  found a useful form, and  the
solution  may be made to constitute the ordinary drink of
the patient; or the water of the acetate of ammonia may
be given in decoction of barley sweetened with sugar, and
flavoured with lemon-juice.   The  state of the bowels re-
quires careful  attention, and the secretions, if unhealthy,
should be regulated by the administration of mild mercurial
purgatives, combined with the  extract of taraxacum and
of colchicum,  but active purgation  is  contra-indicated.
The  only topical remedy requisite is  the  tepid bath, and
from half-a-pound to a pound of gelatine should be dissolved
in each bath if there is much local  irritation; occasionally,
in persons of a  full  habit of body, a few leeches will  be
applied with benefit in the neighbourhood of the eruption.
   The first requisite in the treatment of chronic ecthyma
is to remove those causes by which the state of the system
with which it is so frequently connected has been produced.
In infants the nurse should if  possible  be changed, or, if
this cannot be done, the child ought to be weaned, and fed
chiefly on asses' or goats' milk,  mild alteratives, as  the
hydrargyrum  cum creta, combined Avith myrrh  and  dried
carbonate  of soda, given,  and the  body Avarmly clad,  but
woollen  clothing, as  being apt to irritate, should not  be
worn  next the skin.   The  best local application is calamine
ointment, or the  affected  parts may be dusted writh finely-
powdered lapis calaminaris; emollient cataplasms or lotions
generally  aggravate  the  disease.   When  the  eruption
appears in old  persons, the first and most important point
is to change the  air, or at least the locality in  Avhich  the
patient may have been residing : good and nourishing food
should be given, and if there is much debility, wine or porter
alloAved.   Should there exist any visceral  organic disease,
the line  of treatment  must  be  directed principally to its
alleviation if  possible,  and topical applications employed
with caution, as the sudden repulsion of the eruption would
be likely not alone to aggravate it,  but might be dangerous
to life.   Tonics,  combined Avith alkalies and  sedatives, as
in the following form, will in general be found useful: — 
144
PUSTULE.
     R. Infusi Cinchonae,.......     fl 5vj.
        Aquas Calcis,.........     fl Sixss.
        Tincturae Lupulinae,
        Succi Conii,.........aa, fl 3y. Misce.

     "A wine-glassful to be taken three times a day."

  When, however, there is  much  debility present, alkalies
should not  be given,  but  the  mineral  acids,  either  the
nitric  or hydrochloric,  will then  be advantageously  pre-
scribed in combination with vegetable tonics ; in the lurid
form of the eruption, preparations of iron,  more particularly
the compound or aromatic  iron mixture, generally prove
most  efficacious.   For local applications many astringent
and mildly stimulating ointments may be employed ; a form
that I  have seen  productive of excellent  effect consists in
the addition of half-a-drachm of  oil of  turpentine  to the
compound lead-cerate.   This should be warmed and applied
in the  semi-fluid state, being gently smeared over the sur-
face with a feather.   The ulcers which form may be touched
daily with the solution of nitrate of silver—a scruple to the
ounce, or  dressed with  lotions of sulphate of copper or
sulphate of iron—from  two to  five grains to the ounce of
distilled water.
  In all forms of ecthyma  the  patient should  be kept in
the open air as much as possible,  if extreme debility or
accompanying organic disease does not prevent it.  During
convalesence, exposure to the sea  air, and  the use of the
chalybeate mineral  water  for  adults, will be found of
especial  service in  promoting the restoration  of  health,
and preventing a relapse; and for scrofulous children, the
employment of cod-liver oil  should not be omitted. 
PAPULE.
145
                  CHAPTER  V.

                       PAPULE

  Tins group of cutaneous diseases is characterized by the
eruption  of minute solid  elevations of the skin,—papulx
or  pimples,—generally reddish,  but sometimes of  the
natural colour of  the  part or even paler, which contain
neither serum nor pus, terminate  in  the  desquamation of
fine scales, and are almost  invariably attended with intole-
rable itching.  The latter symptom is so markedly a charac-
teristic of papular eruption that it has induced Cazenave to
place them in a subdivision of his sixth group, the definition
of which that he gives being " general or local hyperaes-
thesia."   By Erasmus Wilson they are made to constitute
a group,  " styled depositive inflammation of.  the derma;"
but inasmuch as some  forms of papula diseases  are not in
any of their stages accompanied or marked  by inflamma-
tory action,  and their treatment  is based on indications
directly  opposed to  the idea of inflammation having any
share  in their  production, his definition  is  not, I think,
sufficiently precise for a natural system of classification.
  Papular eruptions are non-contagious, occur at all  ages
and in both sexes, and affect males more frequently than
females.   The  papulae, which are either  disseminated and
distinct from each other, or aggregated in patches so as to
form groups, may appear  on a single region of the body
only, or  may  be diffused  generally over the skin;  they
vary in size from that  of the head of a small  pin to that of
a pea,  and are usually  developed rapidly, generally coming
out  in successive crops.   They terminate in resolution,
with desquamation of the epidermis in fine minute scales,
which  continue for some time; but occasionally superficial
ulceration of the integuments occurs.
  By  most dermatologists three forms of cutaneous dis-
ease,   characterized  by papular eruptions, are described
as originally arranged by Willan, namely,  Lichen, Stro-
phulus, and  Prurigo;  but the first  two are manifestly
                          13 
146
PAPULE.
merely varieties of the  same affection, their characteristic
phenomena are precisely similar,  and the only difference
between them is that the former occurs in infancy and child-
hood, and the latter at a more advanced age ; I shall, there-
fore, follow the example of  Rayer, Gilbert, Cazenave, &c,
and speaking of strophulus  as a species of lichen, reduce
the number  of papular diseases  to  two,  namely, Lichen
and Prurigo.

                        LICHEN.
  Lichen—including strophulus—many be defined to con-
sist  in the development  of numerous  minute  papulae of
the colour of the  skin or of a  reddish hue, aggregated in
patches or  disseminated over the  cutaneous surface, at-
tended with heat,  tingling, or even severe itching, and ter-
minating in superficial  ulceration  or  in  epidermic desqua-
mation.   A great  number of forms, both of lichen and of
strophulus, have been  described by Willan and  other wri-
ters on diseases of the skin, and  named  by them  either
from the  shape, as regards  distribution, which  the erup-
tion assumes, from the  colour of the papulae, from some of
the attendant symptoms, from  the particular structure of
the portion of the  integument, anatomically considered,
that may be affected, and from the  mildness or  severity
of the disease.  Thus there have  been constituted no less
than nine varieties of lichen, and five of strophulus ; they
may, hoAvever,  I consider, be all  conveniently  considered
in three divisions :—
                    Lichen simplex.
                       ,,    strophulus.
                       „    agrius.
  ^ Lichen simplex is at its  outbreak  very rarely attended
with any constitutional disturbance,  in  some cases  slight
febrile symptoms  for  a feAV days precede  the eruption,
especially in females,  but they seldom  amount  to more
than a feeling  of  malaise,  which  disappears  immediately
on  the development of the  papulae.   These are minute
very numerous, not exceeding in size rape-seed, of a bright
red colour, and irregularly scattered in patches closely set
together  over the  cutaneous surface; they usually appear 
LICHEN.
147
first on  the  upper  extremities, and  extend thence to the
trunk  and lower  extremities, being preceded by formica-
tion of the part  on which they are about to occur  The
eruption  is attended with heat  and sharp tingling, which
lasts until all trace of the papulae has disappeared; in some
cases, especially in young  plethoric persons, the  local  in-
flammation runs high, when the Avhole of the integuments
of the affected parts present a bright  scarlet color, accom-
panicd by a  sense of tension  and an  extreme degree of
itching.  Lichen  simplex may be  either acute or chronic;
in the former case the duration of the disease is  for about
a fortnight,  the  individual papulae are resolved in seven
or  eight days,  but  as  from  forty-eight to seventy-two
hours elapse between their  development on  the different
regions of the body which they attack, it is  prolonged for
this time.  In the chronic form, successive crops  of papulae
make their appearance as quickly as those Avhich preceded
them  fade  away,  and thus the disease may be  continued
for months, or even years.   The papulae in either case run
the same course,  attaining their greatest size on the third
day, at  which  time they are  markedly acuminate; they
then seem to remain stationary for two or three days more,
when they  fade someAvhat, are less prominent, and a mi-
nute scale  appears on the apex of each; this desquamates,
and a general  epidermic  desquamation from the affected
surface continues  for three or four days in the acute, and
for a longer period in the more  chronic cases.  In the
latter, the  skin after a short time  becomes thickened, evi-
dently from  depositive  inflammation, and  the   diseased
integument is then elevated above the level of the  surround-
ing skin.
   In  lichen  simplex the papulos  differ in  size  according
to the region of the body on Avhich they may occur, being
always larger on  those parts where the skin is softest, as
on the face, the shoulders,  and the anterior surface of the
trunk.  In the  debilitated, in the aged, and in those whose
skin is naturally of a dark or unhealthy aspect, the eruption
is usually of a dull,  livid  hue, and in the former is not
unfrequently complicated  with crimson blotches, or stains
of the integument; this form was distinctly described  by
Willan .under the appellation of lichen livid us.  In another 
148
PAPULE.
variety,  which  occurs  usually  in  persons  of  dissipated
habits, as noticed by this dermatologist, each papula in its
origin envelops a hair, so  that when  arrived at  its full
maturation it presents  a singular appearance, seeming to
be pierced thereby;  he consequently termed the eruption,
under these  circumstances,  lichen pilaris;  it is ahvays a
very  obstinate form, assuming  from  the first  a  chronic
character.
  Occasionally in lichen simplex the  papulae, instead of
being dispersed over the cutaneous  surface, are developed
in regularly-shaped  patches; Avhen these are circular or
oval the circumference is constituted of much larger papulae
than  the centre, so that a distinct border to each patch is
thereby formed ; this variety has been termed lichen circum-
scripius;  it  is of a chronic character; the rings enlarge
someAvhat by the  eruption of new papulae at their circum-
ference,  but its  duration  is rather   prolonged  by the
development  of successive patches in their neighbourhood,
as those which  first appeared commence to fade.  The
usual  seat of lichen  circumscriptus is on the backs of the
hands, the fore-arms, the cheeks, and  the trunk of the body ;
when  but one patch of it exists at a  time on the surface, it
has been termed lichen solitarus.   In  a few  rare cases,
as first noticed by  Biett, the eruption  of papulae assumes
the appearance, as  it were, of a piece of ribbon stretched
on  the  skin, generally commencing on the  chest, and
passing around the arm ; he named this form, lichen gyratus.
I do not know that it has been observed by any British or
German physician, but it is noticed as having been witnessed
by several French dermatologists.
  In children and young persons, especially of the female
sex, the itching  is at times most extreme, and  the papulae
are of a much larger size than usual; they are,  moreover,
occasionally to a  certain degree evanescent—thus in most
of their phenomena resembling urticaria, and the eruption,
too, appears, as  in  that disease, in  small patches.   It is,
however, distinctly papular, and has been well denominated
lichen urticatus.   It usually occurs  on  the  neck and side
of the face,  spreading  in  a few cases to  the  chest and
abdomen; is of  an acute  character,  seldom  lasting longer 
LICHEN.
149
than  a few weeks, and  is in general  witnessed only  in
spring and summer.
  Lichen strophulus (Cfum).—This is  a papular eruption
peculiar to the early periods  of life, being rarely seen ex-
cept in infants at the breast,, and occurring most frequently
a few days after birth.  The papulae  are of the natural
colour of the skin, of a reddish or crimson hue, or white ;
they  appear  most frequently on  the  face and upper ex-
tremities, but they also  in some cases affect the body and
the lower  extremities.    In  one  form, which  has  been
termed strophulus intertinctus,  popularly known as red
gum,  an eruption of  very minute  red papulae appears,
generally a few  days after birth, on the face and the backs
of the hands and arms ;  they are scattered over the surface,
and   intermingled  with  them are  small  erythematous
patches ; for two or three days their colour becomes more
vivid,  they  then gradually fade away and  disappear  in
from  a Aveek  to  ten days, with some slight epidermic  des-
quamation.   Smart itching would seem to accompany the
eruption from the uneasiness the infant exhibits.
   When lichen strophulus appears on the  skin at the time
the child  is  commencing to suffer from the irritation at-
tendant on teething, the papulas, being still of a red colour,
are much smaller and of a duller hue  than in the last-de-
scribed variety, but more numerous, and aggregated together
in semi-confluent patches on the face, the  chest, the upper
extremities, and often also on the abdomen and legs.   The
eruption  is  then  denominated strophulus confertus,  and
popularly known as tooth-rash ; it runs a somewhat similar
course, though  a little  more prolonged  than strophulus
intertinctus, and not unfrequently, more especially if the
child  suffers  much  from teething,  a  fresh outbreak of the
rash takes place as the first is • fading away.   In some
cases, the local and constitutional  inflammatory symptoms
are tolerably  intense, when the patches of papulae are of a
bright red colour, and less  disseminated,  occurring  in
clusters,  of  not  more  than  from five  to ten or twelve,
developed successively on various  regions of the body,  as
they fade  from  one, appear on another.  This variety of
the disease, which is rather uncommon, has  been termed
                          13* 
150
PAPULE.
strophulus volaticus—wild-fire rash ;  it is often of tolerably
long duration.
  The papulae in lichen strophulus are, as has been before
mentioned, occasionally of the colour of  the  skin, or even
whiter, and under such circumstances have been regarded
as characterizing a distinct variety  of the disease—white
gum ;  of it two forms have been noticed : one,—strophulus
candidus,—in which the papulae are of tolerable magnitude,
not surrounded by a red areolar, and generally disseminated
over the cutaneous surface,  but at  a distance  from each
other; and the other,—strophulus albidus,—in which they
are of small  size, and occur in  a few  patches, each  patch
having a red border; in the former case they are usually
distributed on the  neck, the shoulders, the arms, and the
lumbar region ; in the latter, on the face, the neck, and the
chest.  Both are attended, apparently, with much itching,
but no constitutional disturbance, and seldom last longer
than for  a  few weeks.
  Lichen agrius is occasionally a sequence of lichen sim-
plex, but more frequently presents its  peculiar phenomena
from the  first.  In the latter case its  occurrence is preceded
for  two  or the  days by smart febrile symptoms, and a
remarkable burning heat and redness of  the skin, so much
so as at times to lead to the apprehension that  scarlatina
is about  to set  in; the fever abates considerably, or alto-
gether subsides  on  the  appearance of the rash, which  is
developed in the form  of numerous  bright red, minute,
accuminated, shining papules, clustered  together on  an
uncircumscribed inflamed patch of the skin, often of con-
siderable extent.  The  papules do not enlarge in size, but
become more elevated from lymph  being  effused at their
base into the subcutaneous areolar tissue, which is in con-
sequence swollen and hard.  An extreme  degree of pain-
ful  puritus attends the  development of  the eruption, and
is constantly present  during the entire of its course, com-
pelling the patient  to rub and tear  the skin; the itching,
which is  incessant, is much augmented by anything  which
increases the heat of  the surface, especially the  warmth of
the  bed, and  thus renders rest  or sleep in bed  almost im-
possible.   As the disease ad\rances, the papules ulcerate  at
their  apex, and give  exit  to a  sanious  ichor, which con- 
LICHEN.
151
cretes into thin, friable, yelloAvish scabs:  the skin becomes
more and more inflamed, thicker, dry, and rugose, and ec-
zematous vesicles and pustules of acne or impetigo appear,
mingled with the lichenous eruption, or,  OAving to the in-
tense degree of local  inflammation, are  developed  on the
surrounding integument.   In  this  extreme  form  of  the
eruption, the skin presents an hypertrophied aspect, is of
a  dark livid color, uneven on the  surface, rugose,  and
fissured, and discharges a copious serosity.
   In the  comparatively milder cases of  lichen agrius, the
eruption  commences  to  fade about the  tenth or  twelfth
day, the subcutaneous effusion is absorbed, the local  irri-
tation  diminishes, and the disease  terminates in  from a
fortnight to three weeks  with  epidermic desquamation.
More usually,  however,  its duration is  prolonged for six
weeks  or three months,  even in  cases not at all aggrava-
ted, and it not unfrequently lasts four years, with occasional
remissions during cold weather.
   This form of lichen especially affects certain regions of
the body, more particularly the face—where its most usual
seat is on the forehead, and the backs of the hands and
fingers ; when it  occurs on  the  face, the SAvelling  of the
integuments is usually much greater than when it attacks
other regions of the body; the features, presenting a tu-
berculated aspect,  are completely altered in expression,
and the eyes are sometimes  almost entirely closed from
the thickening of the upper eyelid.   On the backs  of the
hands  and fingers the  eruption is in general  attended  with
much  discharge, and  in  some  cases complicates scabies,
when it causes an extreme  degree of suffering.
   Heat seems to have a peculiar influence  both in producing
and aggravating lichen agrius; it is thus not unfrequently
developed in hot summer Aveather in this country in persons
predisposed to  skin diseases ; but it is  in warm climates
that this influence is especially witnessed, and the eruption
is  consequently so frequent there that it has been regarded
as constituting a distinct variety, termed, lichen tropicus—
the prickly-heat of the East Indies.  The following graphic
description of  the eruption, which is especially interesting
as embodying his personal  experience of it, is from the pen
of  the  late  Dr. James  Johnson.   " Among the primary 
152
PAPULE.
effects of a hot climate may be noticed the prickly-heat, a
very troublesome visiter, which few Europeans escape.   It
is  one  of  the miseries of  a tropical  life,  and a  most
unmanageable one it is.  From mosquitoes, cock-roaches,
ants,  and  the numerous other tribes of depredators on our
personal property, we have some defence by night, and in
general a respite  by  day ; but this unwelcone  guest assails
us at all, and particularly  the most  unseasonable, hours.
Many a time have I  been forced  to spring from table, and
abandon the repast which I had scarcely touched, to writhe
about in the open air for a quarter of an hour: and  often
have I returned to the charge Avith no better success against
my ignoble  opponent!   The night  affords  no asylum.
For  some weeks  after  arriving in India I  seldom could
obtain more than an hour's sleep at one time  before I was
compelled to quit my couch with no small precipitation, and if
there were any water at  hand to sluice it over me, for the
purpose of allaying the inexpressible irritation !   But this
Avas  productive  of temporary relief  only, and what Avas
Avorse, a more violent paroxysm frequently succeeded.   The
sensations arising from prickly-heat are perfectly indescriba-
ble, being compounded  of pricking, itching, tingling, and
many other  feelings for  which I have no appropriate appel-
lation.  It is usually but not invariably, accompanied by
an eruption  of  vivid red  pimples, not  larger in general
than  a pin's head,  which  spread over  the breast,  arms,
thighs, neck, and occasionally along the forehead close to
the hair.  This eruption often disappears  in a great measure
when we are  sitting quiet, and the skin is  cool; but no
sooner do we use any exercise that brings  out a perspiration,
or swallow any warm or stimulating fluid, such as  tea, soup,
or wine, than  the pimples become elevated, so as  to be dis-
tinctly seen  and but  too sensibly felt."
   Causes.—Lichen  occurs  at any age, but  its   different
forms seem to prevail at different periods of  life: thus, as
has been already remarked, lichen  strophulus is  a disease
of early infancy, very seldom appearing after the process
of first dentition is completed, and being most frequent for
a  month after birth,—in fact feAV infants then escape it;
lichen agrius  is most usually an eruption of adult life and
of old age;  and  lichen  simplex affects young persons and 
LICHEN.                   153
those in the prime  of life.  The predisposing and  often
also the exciting causes of this eruption are very obscure ;
it  is certainly witnessed most  frequently in persons of a
nervous temperament, with a fine, easily-irritated skin, and
in whom the cutaneous capillary circulation is very active,
but with deficient perspiration.  The occurrence of lichen
strophulus in  infants  immediately after birth may be ac-
counted  for by the numerous local irritants to which their
fine, delicate skin is then necessarily exposed, such as the
effect of sudden changes of temperature, of the water and
soap used • in washing, of the friction employed in drying
the surface afterwards, of the clothing, &c.   The action of
local irritants  has a  decided  effect  in the  production of
lichen at all ages and in most cases : thus it is  caused on the
forhead  in men by the pressure of a tight  hat, on the face
and hands by harsh dry winds, and by solar heat or that
arising from a very hot fire,—the latter is not an unfrequent
cause of the eruption in some trades, such as blacksmiths,
furnace-men &c,—and on the legs by the friction of worsted
stockings, particularly when  the  veins are  in a varicose
condition.  In certain occupations lichen is  developed  on
the backs of the hands  and on the fingers—in the same
manner  as other  eruptions  are—from the  irritation  of
certain substances; thus it is witnessed in  grocers, bakers,
washerwomen,  &c, when it is described as constituting one
of the forms of the so called grocer's, baker's, or washer-
woman's itch.  In many cases lichen seems to be connected
with derangement of the digestive organs, and its appear-
ance on  the  skin in  persons who had long  suffered  from
painful  affections of the stomach or head was noticed  by
Bateman and Biett as a favourable circumstance.   The use
of stimulating drinks, or of heating articles of food  and
of spices will, in some individuals, be followed by a lichen-
 ous eruption.
   Diagnosis.—Lichen simplex is  in general easy of recog-
nition, in  consequence of its distinctly papular character ;
the disease with which it is most likely to be  confounded is
prurigo, the elementary character of the eruption in both
 being the  same ;  but in the latter the papulae are larger and
 more  globular,—their apex  being rather flattened  than
 acuminate, and they are generally of the same colour as 
154                   PAPULE.
the part of the skin on  which they appear; the itching,
also, Avhich accompanies lichen  simplex is not of the same
acrid, burning nature as that which is so characteristic of
prurigo.   When the papulae begin to fade and to desqua-
mate  at  their apex, the eruption might be  mistaken  for
psoriasis guttata, from  which  it is  distinguished ^ by  the
scales being much thinner, more minute and  branlike, and
by the papular elevation  of  the surface from which they
separate, as may be recognized with the aid of  a lens, or
felt by passing the finger over the  part.   From  scabies
and eczema, lichen simplex is  diagnosed by the vesicular
character of both these eruptions and the copious discharge
with which they are attended.   Lichen circumscriptus is
liable to be confounded with herpes circinnatus, or erythema
circinnatum; from both it is distinguished by the character
of the eruption, papulae being never witnessed in  any stage
of either of these diseases.  From urticaria, lichen urticatus
is  often with much difficulty diagnosed; the chief  distin-
guishing characters are the wheal-like elevations with  the
paler  centres, and  the  more decidedly evanescent nature,
of the former.
  The only eruption with which lichen strophulus could be
confounded  is  prurigo, but the age at which it occurs is
sufficient to distinguish  it from that disease;  moreover, in
those forms of strophulus in which the papulae are red they
are darker coloured than in prurigo, and in the white varie-
ties they are much paler.
  The more aggravated  cases of lichen  agrius, in their
advanced stages, bear much resemblance to chronic eczema
rubrum, and are  often  with difficulty diagnosed from  it;
but careful examination will scarcely ever  fail in detecting
the papular character of the former ;  in it, too, the integu-
ments  are more  swollen,  thickened,  and  tubercular,  the
serous discharge and the epidermic desquamation considerbly
less, while the  itching is  more intense; the peculiar  red
cracks and fissures  from which the bloody ichor  oozes are,
moreover, not seen as in eczema.   On the face, lichen agrius
may  be  mistaken for acne  rosacea, from which it is
distinguished by the pustular nature and deep crimson or
violaceous hue of the latter; they also affect different re-
gions of  the face, lichen being generally situated on  the 
LICHEN.
155
forehead and the sides of the cheeks in front of the ears and
lips, Avhile acne rosacea occurs almost invariably on the nose
and the most prominent portions of the cheeks.  Impetigo
occurring on the face  in adults has been confounded with
lichen agrius, but  the pustular  character  and  greenish
honey-like scabs of that eruption sufficiently characterize it.
This form of lichen is not so liable to be mistaken for psori-
asis as lichen simplex, the attendant serous  discharge and
the characteristic itching marking especially the difference
between them.
  Lichen is  a very frequent form of syphilitic eruption;
it is then characterized by the peculiar dull coppery hue it
presents, by its  being  always of a chronic character, unat-
tended with  any inflammatory symptoms, either local  or
constitutional, by the  absence generally of itching,  and  by
the presence  of the other secondary  symptoms of  the ve-
nereal disease, together with  the  history of  the) individual
case.   In  infants  hereditary syphilis must  be  carefully
distinguished from  lichen strophulus; the  former rarely
presents a papular  form, and it occurs in patches or coppery
stains, generally attended with a serous  or  sero-purulent
discharge, on various parts of the body, but especially about
the pudental region, and  on  those parts of the skin  on
Avhich the hair groAvs.
   Prognosis.—In  infants and young children, the occur-
rence  of lichen strophulus  is quite unimportant, as  it
generally runs its course in a few days, being unattended with
the least danger or injury to health, requiring notice  merely
in consequence of the accompanying itching, rendering the
little  patients fretful.  In  adults  and old persons an erup-
tion  of  lichen, though  never attended  with  danger, is
extremely troublesome, in  consequence of  the local  annoy-
ance  and suffering  by Avhich it  is accompanied, and the
tendency more especially of lichen agrius, to become chronic;
like most other  cutaneous  eruptions the longer its duration
has been, the more rebellious is it to treatment.  The dis-
ease is also more obstinate on the face or hands than when
it  is situated on those  parts of the body that are ordinarily
covered; and the complication of  other cutaneous eruptions
with  it  invariably  renders  the  treatment more difficult.
In giving a  prognosis in any of the severe forms of  lichen 
156
PAPULE.
it should be  remembered that relapses are very liable to
occur, the least exciting cause, such as even the heat of the
sun in summer, being sufficient to reproduce the disease.
   Treatment.—In all papular eruptions a manifest indica-
tion of treatment is derived from the  hyperaesthesia of the
cutaneous structure which accompanies them in their acute
as well as in  their chronic  stages, and this  should always
influence our  choice of remedies, whether tonics or antiphlo-
gistics, according to individual circumstances, may be re-
quired.   In  their early stages, local applications will in
general be found  sufficient to  check the progress of the
eruption, unless when symptoms of inflammatory action are
present, but these are usually of a trifling nature and of short
duration; when,  however,  they  have become ehronic, the
most active constitutional  alterative treatment is required,
and even under its most judicious employment they not un-
commonly baffle the physician's art for a length  of time.
  In lichen simplex occurring in young persons of a robust
constitution,  restricted diet should be  enforced at  its com-
mencement, together  with rest in bed if the  eruption is at
all  extensive, and the administration of  diaphoretics, the
bowels having been previously opened  by a mercurial purge,
provided the  papulae  are well developed  on the  skin: the
antimonial diaphoretics, combined with guaiacum  and  Do-
ver's powder, as in somewhat the following form, are usually
productive of more benefit than saline diaphoretics:

    R.  Antimonii Sulphureti praecipitati.  . . gr. xx.
        Guaiaci Resinae, in pulvere,.....gr. xxiv.
        Pulveris Ipecacuanhae compositi,   . . gr. xij.
   Ope  mucilaginis misce et in pilulas duodecim  divide.
          " One to be taken every sixth hour."
  To allay the  itching and local  irritation, tepid baths of
fresh water may be employed daily, and the  skin, having
been well dried, smeared afterwards with  olive oil,  to every
ounce of  which twenty  minims of chloroform have  been
added.  When  the general  inflammatory symptoms  are
subdued by this treatment, if the disease exhibits any ten-
dency to  become chronic,  the compound  lead-cerate with
glycerine  may  be applied to the  surface, and  the parts
sponged twice daily Avith an alkaline spirituous wash. 
LICHEN.
157
  In any of the forms of lichen strophulus, medical interfer-
ence is scarcely required, and  especial care should be taken
that no treatment, whether local or  constitutional, be em-
ployed by which the  eruption might  be repelled.   If  any
derangements  of the digestive organs  exist,  they may
require the use of mild alteratives or  gentle mercurial pur-
gatives,  and when the eruption occurs  at  the  period  of
dentition, the gums ought to be lanced freely.  The annoy-
ing pruritis, which so constantly seems to  accompany
strophulus, is best  allayed by the use of the tepid fresh-
water bath with gelatine, and  the application of olive oil to
the spots of eruption ;  cold cream is also useful for  this
purpose, or  the acetate of zinc cream, to every  ounce  of
which two drops of oil of bitter almonds have been added,
may be employed in more aggravated cases.
  In the early stages of lichen agrius, while the inflamma-
tory symptoms are present, the  treatment  should be  de-
cidedly antiphlogistic, but unless in strong, healthy, young
persons  residing in the country, general bleeding is not
admissible,  the local  abstraction  of blood,  by  means  of
leeches applied in the neighbourhood  of the eruption, being
in most cases sufficient.   Even in the chronic stages of the
disease, this form of  local bleeding is in  general  attended
with the best results, as  it relieves the congested state of
the capillary circulation which is present, but the leeches
should never be applied on any part of the skin which is
affected, as  their bites might give rise there to troublesome
ulceration.   At  first the  irritation caused by the eruption
is best alleviated by gelantine baths and soothing ointments
or lotions ;  of  the former the carbonate or acetate of  lead
cerate with chloroform, the compound lead cerate with glyce-
rine, the oxide or carbonate of zinc ointment, with Avhich oil
of bitter almonds or prussic acid has  been combined, or the
hemlock ointment,  will be used with benefit; of the latter,
the weak lead wash, to which glycerine has  been added in
the proportion of  a  drachm  to the  ounce, equal parts of
camphor mixture and distilled vinegar, a lotion containing
a drachm of succus conii, half-a-drachm of glycerine, and a
grain of carbonate of soda  to the  ounce of elder-flower
water, or alkaline washes with prussic acid, as in the  fol-
lowing form, may be  employed :
                          14 
158
PAPULE.
     R. Sodas Biboratis,.......Sss.^
        Aquae Rosae,........flSviij.
        Acidi Hydrocyanici diluti,  .  .  .  . fl 3y •  Misce.

If any connexion  can be traced between  the appearance
on the cutaneous surface of the eruption and disease  of
some internal organ, or deranged function,  the remedial
measures employed must be especially directed towards the
alleviation of the former, and the correction  of the latter.
With this view saline and mercurial purgatives are gene-
rally required in most cases, and when debility exists, their
employment may be conjoined advantageously with chaly-
beates or vegetable  bitters, and the  dilute mineral acids.
Lichen is not unfrequently associated, in old  persons,  with
the gouty or rheumatic diathesis, and in such  cases,  pre-
parations of colchicum,  combined with  the liquor potassae,
or the carbonate of ammonia, should  be prescribed.
  In the chronic stages of lichen agrius more active  con-
stitutional treatment is  usually required, while at the same
time attention is paid to any complication that may exist.
Iodine and  arsenic,  either separately or in combination, in
some of the forms  described in former chapters,  will  be
found  necessary, and they may be given with  tonics  or
diaphoretics, according to individual circumstances.   When
there is general debility present, more especially an anemic
condition of the system, iodine  combined with  iron in the
form of the syrup, or pills of the iodide of iron is most useful.
Tincture  of aconite is also  an excellent remedy, more
especially if the hyperaesthesia of the cutaneous surface is
Avell marked, but  its administration  must, as in all other
diseases, be carefully watched;  there is nothing  to contra-
indicate its  employment at the same  time with the power-
ful alteratives above mentioned.  Sulphur and  its prepa-
tions  are highly recommended* by many practitioners  in
chronic lichen, but I  must confess that they have not proved
so successful in my hands as they are stated  to have done
Avith others.   It was at one time too much the custom  to
administer   sulphur  in  nearly  every form  of cutaneous
eruption, chiefly, I  believe,  in  consequence  of its being
evolved so manifestly by means  of the insensible perspira-
tion ;  but for this  very  reason its use often proves  highly 
PRURIGO.
159
injurious, owing to the direct stimulant action it thereby
exercises in diseases which are of an inflammatory nature,
or which are liable to be aggravated by determination of
blood to the cutaneous capillaries.
  Most of the local applications already spoken of will be
found beneficial in chronic lichen agrius, but even in the
same case they must  be  constantly varied,  according to
the severity of the local symptoms ; when all inflammatory
tendency  has subsided, an  ointment containing tAventy
grains of the iodide of sulphur to an ounce of white Avax
ointment,  to which six minims  of  chloroform  are added,
will  be found productive of excellent  effect, an  alkaline
spirituous wash being at the same time used.

                       PRURIGO.

  Prurigo.—It is very  doubtful  whether this disease
should be termed  an eruption  of the  skin or  not, so fre-
quently does it occur without  any visible phenomena to
indicate  its existence,  the only symptoms present  being
obstinate  intense itching, without  heat, pain, or sensible
elevation  of the  surface.   But  as in many cases it is at-
tended  with the  development  of papulae, it must,  in an
artificial  arrangement  of skin diseases, be  classed with
lichen.  The papulae, when they do occur, are of a some-
what larger size, rounder and less acuminate than those
of lichen; and are of the colour of the skin, or  of  a yel-
lowish hue.  The disease  is essentially of a chronic nature,
is not contagious, and is neither preceded nor accompanied
by   constitutional  symptoms;  nevertheless,  when it  has
existed for some time, the health becomes  more or  less
deranged, in consequence  of the extreme suffering caused
by the itching and local irritation attendant on it.
   Three forms  of prurigo have in general been  described
by dermatologists : Prurigo mitis, Prurigo formicans, and
Prurigo senilis;  the first  two are distinguished from each
other merely by the degree  of severity of the symptoms,
and may therefore be  considered together ;  the  third, al-
though denominated simply from its occurrence in old age
only, yet  requires to be noticed separately, in consequence
of  some  of its  phenomena being  peculiar and charac- 
160
PAPULX
teristic.   I shall therefore describe the disease as consisting
of two species, terming them,—
                    Prurigo vulgaris.
                            senilis.
   Prurigo vulgaris, then,  may be either mild or severe,
the latter being the more  frequent.   The mild variety is
developed  by the eruption  on the  cutaneous  surface  of
scattered papulas, about the size  of a millet-seed, Avithout
the least redness, inflammation, or sense of heat;  they are
of the colour of that part of the integument on which they
may be seated, but little elevated, and scarcely to_ be dis-
tinguished unless Avith the  aid  of a lens, or by passing the
finger over the surface.    The attendant pruritus  is not
very  severe,  although sufficiently sharp  and  stinging  to
cause the patient to scratch the  affected parts with the
nails; the papulae  are thus torn, and a minute,  blackish
crust  thereby formed on their apices, which gives a remark-
ably characteristic appearance  to  the affection.
   In  the severe variety of prurigo vulgaris  the disease
may commence with or Avithout the eruption of papulae,
but in all cases they are usually developed in some of its
stages; Avhen they do occur they  are more numerous than
in the mild form, of the same colour, shape,  and size,  or
sometimes  even  larger.   It is, however,  the  remarkable
cutaneous hyperaesthesia and  consequent  intense pruritus
which  especially mark the  aggravated character of the
affection, and from  whence it  has derived its appellation
—formicans,  the sensations accompanying it being  often
compared to  those produced by the sting of an ant.  This
comparison,  however,  very  faintly  expresses the  suffer-
ings attendant on the disease :  not a single spot of the skin
in its  entire extent but  is more or less the seat of  an ex-
treme  degree  of itching,  which  compels the  individual
affected to  tear with his nails  and rub the surface all but
unceasingly ; at times comparative cessation of the pruri-
tus occurs, occasionally lasting for  two or three hours, more
usually of shorter  duration, but  it  is again exacerbated
by  the most  trifling exciting  cause,  the  friction of the
clothes, changes of temperature—especially  the  heat  of
the fire or  the warmth of the bed,—mental  emotions, &c. 
PRURIGO.
161
In consequence of heat increasing  much the local symp-
toms,  the itching is  always  remarkably  aggravated at
night, rest is thus  compleetly destroyed, sleep being  ren-
dered  impossible,  hour after hour  is passed  tearing the
skin, and  the sufferer is  often  compelled  to seek relief
by lying on  the floor without any covering.   In one case
of extreme severity which I attended,  the  exacerbations
and  remisions assumed a  well-marked, intermittent, semi-
quotidian type; the itching commenced every afternoon
at about two o'clock, and  continued  until  six  o'clock,
when it gradually abated, and  there was comparative ease
until the same hour on the following morning; it  then re-
turned and lasted again for the  same length of time, but
the night sufferings were tenfold more severe than those
of the day ; this intermittent character of the pruritus had
lasted, at  the time I saw the patient,  a young man of
twenty-three years of  age, for more than two years, and
his health, both mental  and bodily, was sensibly affected
from the constant suffering and loss  of sleep.
  When  the disease has lasted  for any time, the cutaneous
surface is torn and fissured from the constant scratching;
if papulae existed, their site is marked by minute, blackish
crusts or small excoriations, and the skin is  thickened, un-
even, and  coarse,  being  found, on  close examination, as
remarked by  Wilson, "raised  into  small, flat elevations,
caused by the swelling of  the little angular  compartments
between  the  linear  markings."   The  natural colour of
the skin is also much  altered,  its aspect being of a dirty
brownish-yellow hue.
  The milder form of  prurigo vulgaris seldom lasts  for a
longer period  than two or three weeks, but the duration
of the severe variety is in some  cases almost  indefinitely
prolonged,  recovery rarely taking place  in a shorter time
than from  four to six months.   The papulae in both are
deAreloped in the first instance  of the chest, the neck, the
lumbar region, the shoulder, and the outside of the thighs,
from whence, when the disease lasts for more than a month
or tAvo, they spread to the arms  and legs, but do not ap-
pear on  the  face, the scalp, or the  hands, although  these
parts in aggravated cases are rarely  free from more or less
pruritus.   Such of the papulae as escape  being torn by the 
162
PAPULE.
 nails terminate in slight furfuraceous  desquamation.  The
 disease  is not unfrequently  complicated  by the simulta-
 neous occurrence of scabies and eczema, and in some cases,
 of ecthyma.
   Prurigo  senilis occurs, as  its  specific  name  indicates,
 only in  advanced life; the  pruritus, which is  usually of
 remarkable intensity, is attended always with an eruption
 of papulae; these are of larger size than in either of the
 forms of prurigo vulgaris, but they are  few in number,
 more dispersed over the surface of the body, and of a dull
 dingy-yellow colour; soon torn with the nails, small blackish
 crusts appear on  their apices, which also  constantly bleed
 slightly when irritated.  The  chief peculiarity, however, in
 prurigo  senilis is, that it  is almost  invariably attended
 with the appearance of innumerable pediculi on the integu-
 ments of every  part of the body,—a  complication  never
 absent in the poor and in  persons of filthy habits.   Their
 presence aggravates much the other symptoms of the disease:
 the skin  becomes of a livid colour, thickened, rough, with a
 leathery aspect, and  covered  with superficial excoriations,
 and  small pustules and indolent  boils form in different re-
 gions of the body ; the pediculi are reneAved  nearly as quickly
 as they can be removed from the surface, which has caused
 a controversy as  to whether they are developed  from  the
 integuments or not. By some dermatologists the occurrence
 of the pediculi is considered as  only an accidental circum-
 stance, and not constituting a  symptom of  the disease : by
 others it  is regarded more correctly, I think, as an essential
 feature of the eruption, and they have, therefore, following
 Alibert,  denominated the form thus characterized, prurigo
pedicularis.
  Many of the French school  describe, as a distinct disease
 of the skin, this development  of pediculi on the  cutaneous
 surface of the body, generally terming  it Phthiriasis, and
 dividing it into three species, as it may be general or partial,
 —Phthiriasis  corporis, Phthiriasis  capitis, and Phthiriasis
pubis—considering the  simultaneous  appearance of the
 papulae of prurigo as only a complication ; but as I have
 almost invariably seen them occur together in old persons,
 I think it more correct  to describe  this singular affection
 as a variety of prurigo senilis. 
PRURIGO.
163
  Prurigo  vulgaris very frequently  affects  some  special
region of the skin from  Avhich it does not spread, but be-
coming chronic there  causes extreme  suffering, and is very
obstinate.  It thus attacks the scrotum in males, and the
pudendal region in females:  the former, termed prurigo
scroti, is  a  very troublesome affection, being attended with
a constant itching, which, instead of being relieved, is much
aggravated by scratching with the nails, yet the sufferer
from it cannot resist the  almost unceasing inclination which
exists to  attempt thus to alleviate the tormenting pruritus;
the habit thence acquired  can scarcely be got rid  of, and
even long after all apparent symptoms of the disease have
disappeared, the integuments are continually fretted  and
torn.   In females, prurigo pudendi  is  situated chiefly on
the mucous membrane of the labia, but often extends to the
entire surface, both cutaneous and mucous, of this region ;
it is  a most  distressing and  obstinate  disease, and  not
uncommonly^ produces  symptoms analogous  to those of
nymphomania.  Another frequent form of  local prurigo
is prurigo podicis;  in it  a constant itching of the verge of
the anus exists, and papulae, Avhich are often not present in
the other local  forms of  the disease, are  here almost inva-
riably developed, and sometimes attain a considerable magni-
tude ; occasional intermissions  of the pruritus occur, but the
least irritation, augmented heat of the surface, or derangement
of the digestive organs, causes  an exacerbated return of this
tormenting sensation.   Other regions of the skin are at
times the seat of severe itching, and  have been described,
but without sufficent  reason,  as being  then affected with
prurigo,  thus  dermatologists  have  spoken of prurigo ure-
thralis, prurigo prseputialis,  prurigo pubis,  and prurigo
palmaris:  the  latter  has  been specially  mentioned  by
Alibert as  affecting the soles of the feet, of which he states
that he Avitnessed many examples.
   Causes.—Prurigo may occur at any age, but is most
frequently seen in old persons, and more commonly in males
than females : young persons  are more liable to its  attacks
than adults, and it has been witnessed  even in early infancy.
That  state of the constitution in Avhich  cutaneous irritability
exists, as exhibited by the occurrence  of troublesome ulcers
from  slight causes, and  an inaptitude, so to  say, of even 
164
PAPULE.
the most trifling abrasion to heal, peculiarly predisposes to
its developement;  there is usually in such a condition an
impoverished blood circulating in the vessels, and a highly
irritable nervous' system.  Bad or insufficient diet, want of
care as to  cleanliness, unhealthy  habitations,  sedentary
occupations, or confinement  to the house caused by ill-
health, defective clothing, dissipated  habits, &c, are  both
predisposing and exciting causes of prurigo.   I have often
thought that in gaols and workhouses, amongst the  aged
inhabitants of which the disease is so common, and  also
amongst the poor, it may be caused by  the sameness of
food, which, too, is often defective in  nutritive qualities.
Other  cutaneous  eruptions Avhich are attended with  local
irritation, more especially scabies  and lichen, not uncom-
monly  are exciting causes of this affection ; and it is in old
persons a frequent  accompaniment of convalesence  from
debilitating  diseases, particularly  fever,  dysentery,  and
chronic diarrhoea.
  Diagnosis.—The most characteristic symptoms of prurigo
are the intense pruritus, the blackish crusts Avhich are pro-
duced on the papulae, and the  alteration that takes place in
the appearance of  the integuments.  The  diseases  Avith
which  it is  most  likely to  be confounded are lichen and
scabies, and the mode of diagnosing it from them has  been
already noticed when  describing these eruptions, but, as
has been before remarked, they often co-exist.
  Prognosis.—Prurigo, when it becomes chronic, is one of
the most  obstinate  diseases  of the skin; in old persons
seldom yielding to any  treatment.  Although prurigo vul-
garis cannot be said to  be attended with danger to life, yet
it  renders  life miserable, sometimes for years, and  from
being a constant cause of irritation, may to  a certain extent,
affect the mind, as is witnessed in some cases.  The senile
form of prurigo, although it is not in itself a mortal  affec-
tion, nevertheless seldom disappears  unless  with life, and
when it occurs as a complication of some organic or chronic
disease, unquestionably  hastens the fatal termination.
  As regards the  pathology  of prurigo,  it is  evidently
chiefly a hyperaesthesia of the  cutaneous structure; the
changes in the state of  skin which attend  it being usually
produced by the local irritation thereby occasioned. 
PRURIGO.
165
   Treatment.—If this view of the pathology of the disease
is  correct, it  is manifest constitutional remedies are most
to be relied upon in its treatment, nevertheless, as in other
nervous  affections, topical medication  should not be ne-
glected, and is often attended with the best results.   The
state of the general health should in all cases first receive
attention, for, until this is regulated as far  as practicable,
the employment of remedies more immediately directed to
the disease will be found useless.  With this view, mild
mercurial and saline purgatives may be prescribed to cor-
rect the secretions from  the  digestive organs, and when
there is a deficiency of bile in the discharges, as is not un-
frequently the case in adults and  old persons, dried car-
bonate of soda  and extract of  taraxacum  should be com-
bined with the mercurials.  In females, the association of
the disease with derangement of the menstrual function is
often witnessed, and when sueh exists, there is generally
an anemic state of the system requiring the use of prepara-
tions of iron, but  they should never be prescribed except
in combination with sedatives, as otherwise  the stimulant
action  is apt  to augment the pruritus;  the same observa-
tion applies to the employment of chalybeates in the old
and debilitated, for whom they are also generally indicated
in prurigo.   They may be advantageously combined, as in
the following form:—
     R. Misturae Ferri compositae, .*  .   .   fl 3viij.
        Infusi Humuli,......fl Siijss.
        Succi Conii,.......fl |ss. Misce.
     " A table-spoonful to be taken every sixth hour."
   Or Dover's powder may be given in rather large doses
at  night, preparations of  iron  being administered during
the day.  In very young persons antiphlogistics are some-
times needed as preludes to  other remedies, but in no case
should the strength be much weakened, as then the disease
is more apt  to become chronic.   When prurigo has lasted
for any time, or has resisted other plans of treatment, more
active medicines of the class which especially influences the
nervous  system should be prescribed: nux vomica or its
alkaloid, and tincture  of  aconite, thus often prove useful;
the former has succeeded in my hands when all other reme- 
166
PAPULE.
dies seemed to fail; it may be given in the following form,
a combination which will be found  to promote  a healthy
condition of the digestive organs, and to correct the  loss
of tone which they exhibit usually in this disease :—

  R. Extracti Nucis Vomicae,.....gr. iij.
     Fellis Bovini Inspissati,.....gr. vj.
     Extracti Taraxaci,.......gr. xxiv.
     Pulveris Myrrhae,.......gr. xviij.
        Misce et divide in pilulas viginti quatuor.
          " One to be taken three times daily."

The  tincture of aconite should be given in the ordinary
doses, from  five to eight minims of the Dublin prepara-
tion, or half that  quantity of Fleming's tincture, and its
effects  carefully watched.   I have  also administered   the
succus conii, in doses of a drachm three times a day, in an
ounce of the camphor mixture Avith magnesia, with excel-
lent  effect in some obstinate cases of senile prurigo.  Pre-
parations of sulphur are recommended  by many in  the
treatment of this disease,  and in the very chronic forms
the sulphurous mineral waters, as those of Lucan, of Har-
rowgate, of  the  Pyrenees,  &c,  prove  of  unquestionable
benefit.  Indeed, in all cases change of air, if possible, to
the original sources of mineral  waters, the saline  in  the
early stages, the  chalybeate in  the more  advanced,  and
the  sulphurous when 'the  disease  is  very  chronic  and
obstinate, so  that they may be drank there,  is highly
advisable.
   The local treatment is now to be spoken  of: and at first
nothing  is requisite further than the daily use of the hot
fresh-water bath, to which, if the itching is extreme, gela-
tine  should  be added, or alkaline baths  may be employed,
if the eruption is well developed on  the skin; as the disease
advances and becomes  chronic, sulphuro-alkaline baths—
three ounces of sulphuret  of potassium, and an ounce of
carbonate of potash to thirty gallons of  hot water—will be
used with  benefit;  and in  senile prurigo,  especially  that
form in Avhich  pediculi  cover the body,  the surface  should
be smeared half-an-hour before  going into the bath  with
mercurial ointment  diluted  with three parts of prepared 
PRURIGO.
167
lard, and a drachm of glycerine added to each ounce.   To
allay the pruritus, A^arious lotions and ointments have been
recommended ; of the former, those containing  the vege-
table acids, such  as lemon-juice, vinegar, and cherry-laurel
water,  are especially  useful; black-wash has also proved
very serviceable when  the disease is local; and lotions, con-
taining corrosive sublimate, muriate of ammonia, watery
extract of opium, prussic acid, preparations  of lead or of
sulphur,  may  be  tried  when other applications fail.  From
the use of chloroform in the form  of ointment,  as recom-
mended  in the Chapter  on Urticaria, I have derived most
excellent results; in fact, latterly have I have seldom had
occasion  to employ any other application; but the  sub-
stances mentioned above, as being used in lotions or washes,
may also be applied as. unguents, and the addition of gly-
cerine  will  generally  be found  of advantage.   In very
obstinate cases the chloroform may be combined with iodide
of lead, as follows :—
   R. Iodide Plumbi,......gr. xij.
     Unguenti Cerae Albae,   ...       ^j.
     Chloroformi,......m. viij. adm. xij.
     Glycerinae,.......fl 3j.  Misce.
When  greasy applications are used, alkaline tepid baths
should be employed daily to cleanse the skin, the patient
remaining in the  Avater for at least twenty minutes.
   Strict attention to  diet and regimen is requisite in all
cases ; stimulant food  or drink being especially avoided. 
168
S Q U A M E.
                   CHAPTER VI.

                       SQUAME.

There is no class of diseases of the skin  so well charac-
terized  by the apparent phenomena as that in Avhich the
formation of a scale constitutes the essential feature; epi-
dermic desquamation, as has been in  the  previous  pages
so frequently noticed, is present in many cutaneous  erup-
tions, but that differs  in many respects from the secretion
and  subsequent  shedding  of  true scales,  which consist,
according to the admirable  definition of  Willan, of " a
lamina of morbid  cuticle, hard, thickened, whitish, and
opaque."  Although  in some  of the  forms more or less
change  from the  primitive  characters of the  eruption
takes place in the progress of the disease,  it is never such
as to mask their  scaly nature, and the diagnosis is conse-
quently  attended with less  difficulty than that  of  most
other cutaneous  affections.  Squamous eruptions may be
defined to consist  in the secretion of dry, laminated whitish
scales on the cutaneous surface, usually occurring in patches,
often of  a circular form, but sometimes generally diffused,
and covering an extended portion of the integuments.   The
scales, which are  somewhat elevated above the level of the
surrounding skin,  readily fall  off, to be  again rapidly
renewed,  and the portions of  the cutaneous  surface  on
which they are formed  are of a smooth, glistening aspect,
reddish and dry.
   Scaly  diseases  are essentially of a chronic, non-inflam-
matory nature, are slowly developed, and are not propagated
by contagion.  They  may  appear  on any part of the body,
but they  chiefly affect,  at  least  in the first instance, the
extremities, whence they usually spread to other regions,
being rarely confined to a  single locality, with the excep-
tion  of pityriasis, Avhich occasionally occurs on some special
portion of the skin.  They are developed also at  all seasons
of the year, and are not apt, like other cutaneous  diseases, 
PSORIASIS.
169
influenced  by the  atmospheric temperature, to disappear
and again  re-appear at certain times.
  The eruptions included in the order Squamae were divided
by Willan  into four groups,—Lepra, Psoriasis, Pityriasis,
and Icthyosis,—and his  arrangement has been followed by
many  modern  dermatologists;  recently, however, it  has
been very generally admitted that Icthyosis was incorrectly
classed by  him amongst  scaly diseases, and doubt has been
thrown on the  propriety of  describing psoriasis and lepra
as different forms, they being, moreover, evidently regarded
by the ancient  medical writers as constituting merely varie-
ties  of the same  eruption.   Icthyosis cannot  Avith  any
regard to accuracy in classification, be grouped in this class,
for it is not attended with a separation—throAving off scales,
or desquamation, one  of the most  characteristic  signs of
this  order  of cutaneous eruptions;  the epidermis is in it
truly hypertrophied, and  I  shall therefore describe  it as
constituting one of that group of skin diseases which I have
termed Hypertrophies.   To even a superficial  observer it
must be  evident that psoriasis and lepra have no essential
differences, and they  require a precisely  similar plan of
treatment; regarding them, therefore, as distinct  affections
could  only tend to complicate their study.  The number
of scaly diseases of the  skin is  thus  reduced to tAVO—Pso-
riasis, Pityriasis.

                         PSORIASIS.
   Psoriasis (Dry  tetter ; Dry scale)—under Avhich term
it will be understood I include Lepra—is  characterized by
consisting  in the formation on  the  cutaneous surface, and
subsequent desquamation, of true scales, the scales being
of tolerable consistence, dry and friable, of a silvery or
greyish  Avhiteness,  and  separating in laminae of  about the
size and consistence of particles of  bran.   The  eruption
appears in small,  round, or  irregularly-shaped spots, dis-
tinct from each other, scattered over the cutaneous surface
in  large, circular patches, depressed in the centre,  or in
masses so  closely aggregated and confluent as to envelop
an extended portion of the skin in one vast  coating of scales
in  consistent layers.  The surface of the  integument on
Avhich they are  situated is raised, reddish, and apparently
                         15 
170
S Q U A M E.
inflamed, but unattended with any discharge; nevertheless,
when the eruption has been of long duration, fissures and
cracks through the  deeper-seated tissues form, from which
an ichorous, bloody secretion exudes.   Psoriasis^ has been
considered by many writers on diseases of the skin to be a
special chronic inflammation of the cutaneous structures,
the specialty consisting in the development of scales; it
cannot, however, I  think be  regarded  as an inflammatory
disease, for it is not attended with heat or  other local sign
or symptom  of inflammation, except  a slight degree of
itching, unless when the  affected surface is irritated by
some cause.
  The eruption appears in the form  of minute,  slightly-
elevated papulae, with a small scale  apparent at the apex
of each on careful examination, and, no matter what pheno-
mena it may afterwards present, this is its primary aspect;
coming on slowly, it runs  generally a  most tedious course,
often  lasting for  many years, and sometimes even for a
long life.   The  several  varieties  of  both psoriasis and
lepra which have  been described  may be conveniently re-
duced to three:—
                   Psoriasis guttata.
                        „    aggregata^
                        ,,    lepraeformis.
  Psoriasis guttata.—This,  which is  the mildest  form of
the  disease, is unattended in any of its stages with con-
stitutional symptoms; a slight degree of itching of the skin
occasionally precedes its  appearance,  but  even this  is not
a constant  sign.   Numerous minute, papular elevations of
the  epidermis, at  first  not  exceeding in size the point of
a pin, are  developed on  the cutaneous surface, scattered
irregularly but distinct from each other, except in  the
neighbourhood of the joints, on the prominences of  which
they are usually more or less aggregated.   On the apex of
each little elevation a  minute scale forms, which, at first
slightly adherent, desquamates shortly after  its  appear-
ance, to be  succeeded  by another somewhat larger and
more consistent; this scale  is shining, of a silvery white-
ness, and about the thickness of thin Avriting paper.   The
raised spots on Avhich the scales are situated enlarge slowly, 
PSORIASIS.
171
not attaining the size of the head of a pin for several days,
and very gradually acquiring  a magnitude of from two to
three lines in  diameter, when  they are of a  someAvhat cir-
cular shape, but irregularly circumscribed.   In some parts
two or more spots coalesce, and  thus form small patches,
rarely,  however, in  this form of the  eruption,  exceeding
the size of a sixpence, except, as  above remarked, near  the
joints, Avhere  they occasionally occupy a portion  of the in-
tegument an inch or two in diameter.  With the progress
of .the disease the scales  continue  to be continuously de-
veloped, and  shed as rapidly as they are  secreted ;  the
affected spots are irregularly  elevated, of a reddish colour
in young  persons, but of a dull  brownish  hue in the  old,
contrasting well with the shining, grayish-white scales, and
present an irritated aspect.   The only annoyance  accom-
panying the  presence of the eruption on  the  body,  the
disfigurement it  occasions excepted, is a slight  degree of
tingling scarcely amounting to itching,  caused by  the
separation and shedding of the scales.
   This form of psoriasis rarely  becomes chronic;  in three
or four weeks after  its first appearance the scaly desqua-
mation begins to diminish in quantity, neAV spots, Avhich
continued  to  be  developed  on  the sound  skin amongst
those which had  preA'iously existed,  cease to form, the ele-
vated  patches gradually sink  to the level of the  surround-
ing integument, and the disease usually terminates in from
six weeks to two months, faint reddish  stains, which after
a short time  fade aAvay, marking the site of the eruption.
It may occur  upon  any  part of the body, but  is most
usually situated on the chest, the back, the arms, the face,
and the scalp.
   In some rare cases, as originally noticed by Willan, the
eruption is developed in the form  of  narroAV patches or
strips, consisting of the minute  scaly elevations  set closer
to  each other than  usual.  These  stripes  or bands, which
generally appear on  the trunk of the body, assume a  sin-
gular shape:  " some of them  are nearly longitudinal, some
circular or  semi-circular,  with vermiform  appendages:
some  are  tortuous or  serpentine,  others  are  shaped  like
earth-worms or leeches ; the  furrows of the cuticle, being
deeper than usual, make the resemblance more striking by 
172
S Q U A M E.
giving to them an annulated  appearance."1  This, which
is  manifestly  only an  accidental variety  of psoriasis  gut-
tata,  has  from its  peculiar aspect been  named psoriasis
gyrata.
   Psoriasis aggregata.—I  have ventured  to  change, the
specific appellation of  this form of the eruption, which by
Willan  and his folloAvers has  been denominated diffusa,
by Rayer confluens,  and by  many other dermatologists
vulgaris.   The latter term indicates correctly enough that
it  is  the  most common form  of the disease, but does  not
afford any information as to its characteristics, while  the
first is not sufficiently specific, psoriasis  guttata #nd  pso-
riasis lepraeformis being  often as generally diffused  Avith
regard  to  locality over the cutaneous surface;  the  name
applied by Rayer is objectionable, solely because, in the
English language, the Avord ' confluent'  conveys the idea
of the presence of fluid.   Reluctant, then, as I am to alter
the nomenclature of  skin  diseases, although  anxious to
reduce in number the terms used,  I have  thought it well in
this instance to do so by employing a specific denomination,
which while being frequently  employed to designate other
diseases of the cutaneous structure, and  thus not being an
innovation, would be both more correct  and more expres-
sive.
   This form  of psoriasis,  developed like that last described,
without  constitutional disturbance, appears as numerous
minute, rounded elevations of the epidermis, closely aggre-
gated together in irregularly circumscribed patches, varying
in size from that of a  silver fourpence to that of  the palm
of the hand,  but very  irregular, both as regards shape and
extent;  on these the scales are formed  from the first, minute
and tolerably adherent at  the commencement of the disease,
but gradually acquiring  a  greater magnitude,  when they
are shed and again secreted Avith astonishing rapidity.  The
scales are of the  same colour and  consistence as in psoriasis
guttata, but  desquamate  in rather larger pieces, their  re-
production, too,  takes place  much  more quickly, so that
they  are consequently desquamated  in  greater quantity.
With the progress of the eruption, new patches form on the
intervening  sound  skin, which, sometimes  coalescing Avith
      1 Willan  on Cutaneous Diseases: London, 1808, 4to. p. 1C1. 
PSORIASIS.
173
those that first appeared, increase their  size often  con-
siderably ; the  diseased surface is  now  distinctly  raised
above the level of the surrounding integument, rather more
so at the outer border than in the centre, of a dull, reddish
colour,  and  covered with  shining  greyish-white  scales.
There is no discharge, either serous or purulent, but fissures
or cracks are generally found through  the affected  parts,
which present an irritated aspect^and through Avhich blood
occasionally  exudes.
   This  form of the disease  often  does not  attain its full
development  for  many  months, although several of the
patches  acquire their utmost magnitude in  three or four
Avecks, after  Avhich time  they do not increase in  size, but
continue to secrete  the  characteristic  scales incessantly.
Its duration is essentially chronic, lasting usually for years
if not submitted to the employment of  remedial measures.
The disappearance of the eruption is in all cases slow and
gradual, the  first sign of amendment being the cessation  of
the development of neAV patches, a  diminution of the scaly
desquamation, and a sinking of  the elevated  surface to the
level of the healthy integument; reddish stains remain for
a considerable time on the surface, even after the disease
is apparently cured, and from these a fine epidermic des-
quamation, though small in  quantiy, continues for  some
weeks.
  Either of the forms of psoriasis now described, when they
become  very  chronic, may assume an extremely aggravated
character,  and present local phenomena  justly entitling
them to the appellation which dermatologists then usually
apply to designate their severity and obstinacy to  treat-
ment—psoriasis inveterata.   In it  the various patches  of
the eruption  coalesce, so as  to  cover completely the limb
on which they may be situated, or even the trunk of the
body;  the entire of  the  cutaneous surface is one mass  of
dry, hardened, thick scales, or rather is  enveloped in  a case
of them which covers the integuments like a coat of  mail.
Through this, deep fissures are formed, generally in straight
lines, but sometimes  following the course of the polygonal
and lozenge-shaped linear furrows  of the  epidermis, so  as
to give  the  diseased surface a striking resemblance to a
piece of tesselated pavement.  From the fissures an ichorus
                        15* 
174
S Q U A M E.
and bloody pus exudes, the parts are constantly torn with
the  nails,—itching, which is much aggravated  by heat,
being a constant accompaniment of this inveterate form,—
and the entire of the affected region is a mass of leprous
irritation, attended with a foul discharge, and a shoAver of
desquamating scales flies off on the least motion, the bed of
the patient presenting an appearance as if bran  had been
thickly strewn in it.
  The most usual site of psoriasis aggregata is the extre-
mities, but it at times affects the entire  body,  being  least
frequent on the  face,  where it is always less general  than
on other parts of the  cutaneous  surface.  In some cases it
appears  on special regions of the skin, and under  such
circumstances has  been particularly  described,   but  the
guttated form of the eruption is almost invariably present
on the rest of the body at the same time.  The local forms
have been named, from the parts affected, psoriasis labialis,
psoriasis palbebrarum, psoriasis  capitis, psoriasis  scrotalis,
psoriasis prseputialis, psoriasis  pudendalis, psoriasis pal-
maris, and psoriasis unguium;  of these the two  last only
require to be specially noticed.
  Psoriasis palmaris has, in common with certain  forms of
lichen and eczema, been regarded as one of the varieties of
the so-called baker's and grocer's  itch ;  it may appear on
the palmar aspect of the  hands, extending also to the wrists
and the  under-surface of the fingers.  In its development
it  is  attended Avith more local symptoms than any other
variety of the disease, inflammatory redness, accompanied
by heat  and itching, marking its advent; the  skin on the
palm of the hand then becomes swollen, irregularly elevated,
and of  a reddish hue, and the itching generally increases
much, being at  times as intense as  in scabies  or  prurigo.
Large dry whitish scales, of  tolerable thickness   and con-
sistency, are rapidly secreted  on  the  affected   surface;
these soon desquamate, and are reformed again and again,
as in  the other varieties of the eruption.   When it becomes
chronic,  the itching and heat diminish, but the integuments
of the palm of the hand and of the palmar surface of the
fingers become hardened, thick  like leather, of a whitish-
yellow colour, corrugated, scaly, and fissured; the motions
are then limited and  painful, the  fingers cannot  be  com- 
PSORIASIS.
175
pletely flexed or extended, and any sudden movement tears
the fissured parts, and causes them to bleed. In a rare form
described by Rayer, and termed by him  psoriasis palmaris
centrifuga, the eruption begins by the formation of a small,
rounded, squamous elevation  in the centre of  the palm,
around it a series of eccentric, raised, red circles are de-
veloped,  from each of which epidermic desquamation takes
place ; the  eruption spreads in this  manner until it covers
the entire palmar aspect of the  hands, which is then deeply
fissured and painful, and bleeds from the slightest cause.
Psoriasis attacks the backs  of the hands also in some
instances, and occasionally the soles of the feet.
   The eruption extends to the nails in most cases of chronic
psoriasis-of the hands, but Avhat has been described as pso-
riasis unguium is a  change from their healthy condition,
with or Avithout the existence of the disease on remote parts
of the body ; one or  more of the nails presents a brownish-
yellow,  scaly  elevation  near  its  root,  which  gradually
extends  so as  to occupy the entire surface ; its  texture
becomes brittle, breaking and scaling off constantly ; it ac-
quires a dirty yellowish hue, and not uncommonly the entire
nail is  shed, to  be  succeeded by  the growth of another
equally diseased.
   Psoriasis leprceformis, which as already remarked, is the
form  of scaly eruption described by  most dermatologists as
a  distinct disease, and  termed by them  ' Lepra,', is  chiefly
characterized by  the  development of the patches in usually
a  perfectly circular,  but  sometimes  in an ovoid shape.  It
commences Avithout either constitutional or local disturbance,
in the form of numerous small, round, reddish stains, per-
fectly distinct from each other, and scarcely elevated above
the surrounding skin, on which shining silvery-Avhite scales
soon  appear.  Gradually but sloAvly,  the circles enlarge
from their circumference, Avhich is  somewhat more raised
than  the centre, attaining a size varying  from  a few lines
to one or  two  inches in diameter; some of the patches
 coalescing, they  occasionally  cover an extended  surface of
 the integument, and  acquire an irregularly rounded shape,
 —this is almost  invariably the case on the convex aspect
 of the joints and in their neighbourhood, on which parts the
 eruption presents an appearance scarcely to be distinguished 
176
SQUAMA
from psoriasis aggregata;  but  the circumference of the
patches, no matter how large they may be, is always more
elevated than the centre, which, after some time, assumes a
comparatively healthy condition, its colour becoming more
natural and but slight desquamation of fine epidermic scales
taking place from it.  From  the borders,  however,  the
constant  secretion and shedding of true scales continues;
they become  thicker and more solid, retaining  their whi-
tish aspect, and' are sometimes imbricated on  each other
at the outer  border of  each patch ; the  integument  on
which the eruption is situated also becomes somewhat hyper-
trophied.
  Psoriasis lepraeformis always runs a very chronic course,
not exhibiting any tendency of itself to  disappear, the  dis-
ease being kept up more by the  desquamation of scales
from the patches  of  eruption originally formed, than  by
the development  of  new spots ;  at  length, when under
treatment it begins to amend, the central  healthy surface
extends towards the circumference, upon which  fewer and
thinner scales are  secreted ;  the eruption at the same time
ceases  altogether to spread, and, finally, only slight stains
with furfuraceous epidermic desquamation remain, as  an
indication of  the parts Avhich were affected :  these in most
cases  gradually  wear away,  but they sometimes  last for
years,  and scales form on them in spring and summer, or
on the least exacerbation, either from local causes or from
irregularities  of diet, relapses thus frequently occurring.
  A variety of this form of the eruption has been described
under the name  of Lepra nigricans, in which the colour of
the diseased patches is dusky-brown or livid, and the scales
are very thin, soft, and of a dull, greyish-white aspect; in
all  other respects it resembles psoriasis lepraeformis,  and
its peculiarities evidently depend  on the eruption affecting
old persons  or  those  Avith  a broken-doAvn constitution, in
whom only it  is witnessed.   The Lepra alphoides of Willan
is a variety of psoriasis guttata, in which the spots are some-
Avhat larger, and the scales more silvery-white  than usual.
  The leproid form of psoriasis  chiefly affects  the extre-
mities, yet it sometimes attacks the face and  scalp,  and
the trunk of the body:  I have  seen it occur very exten-
sively on the  scalp, where the patches coalesce and envelop 
PSORIASIS.
177
the entire of the head in one vast crust  of  scales, being,
however, present at the same time on other regions of the
body ; on the face it is almost invariably in  rather small
patches distinct from  each other, but  most numerous on
the forehead and the upper  parts of the cheeks, just be-
neath  the eyes.  The  spots  of this form  of the eruption
not unfrequently assume a somewhat symmetrical arrange-
ment on the two halves of the body, appearing on the  cor-
responding  portions of the cutaneous surface at  each  side
of the mesial line simultaneously, and in patches  of nearly
similar shape and size  ; the same  fact is also witnessed at
times in the  other varieties  of psoriasis, but it is of more fre-
quent occurrence in this form of the disease.
   The psoriasis annulata of  some dermatologists, the orbi-
cularis of others, corresponds in all respects Avith psoriasis
lepraeformis.  And the variety termed  infantilis presents
no peculiarity, except  its  occurrence at a very early age,
Avhen, in consequence  of the fineness of the skin, the  sur-
face is more easily irritated, and  the local symptoms  are,
therefore, more prominent.  In all the  forms  of  the erup-
tion these, as has been remarked, are in general very trifling,
but  Avhen  any  do  exist,  they are much  aggravated by
warmth, such as that caused by the heat  of the bed.
   The chief annoyance which psoriasis causes is the  dis-
figurement  it occasions when situated  over any  of the or-
dinarily exposed regions of  the body;  but if the eruption
has  existed for any length of time, and  becomes chronic,
the health may be  more or less affected from the obstruc-
tion to free  cutaneous transpiration which  it must produce;
and thus, should any acute febrile disease attack a person
affected  with  the  eruption, the danger  arising  from the
former may be increased, and the treatment rendered more
difficult.   It  is probably due to this cause,  also,  that
diuresis  and diarrhoea are such frequent  accompaniments
of scaly diseases of the skin;  the latter complication  is
often very incontrollable, and the appearance of the stools
at times is  such as to  warrant the belief,  that it is caused
by an epithelial desquamation from the mucous membrane
of the intestinal canal, analogous to the shedding  of altered
epidermic scales from  the  cutaneous surface.
   Causes.—Psoriasis occurs at all ages and  in both sexes, 
178
S Q U A M E.
being probably equally frequent in males and  females;  its
special  causation is, like that of all cutaneous  eruptions,
enveloped in much  obscurity.  That it is  sometimes pro-
duced by the action of certain  irritating matters  on the
skin cannot be doubted ; yet we see the same local forms
of psoriasis arise in persons who, from their occupation or
position  in life, are not exposed to the causes which pro-
duce  it  in  bakers,  washerwomen,  shoemakers, and indi-
viduals of other trades.  That squamous diseases are some-
times hereditary is  also true, but their hereditary nature
is  of  a singular  character ;  thus, so far as my  own expe-
rience Avould lead me to infer, the disease does not descend
directly from parent to child with  the same  regularity as
other hereditary diseases, but the predisposition  frequently
appears  to be derived  from  an uncle  or aunt, whose OAvn
children  may be free  from the disease;  and it  also seems
not uncommonly to lie dormant in a family for a genera-
tion, and again re-appear.   In a case which I not long
since  attended, one son of a family was* affected from his
childhood with psoriasis of  an inveterate form;  none of
his brothers or sisters had  any cutaneous eruptions, nor
had his parents or grand-parents, but a paternal uncle was
affected  with a similar disease, and  also a first cousin not
the child of this uncle: it  was, moreover, stated that a
grand-uncle was  a sufferer  for years from  a cutaneous
eruption.   A someAvhat  similar hereditary  transmission
of the disease has fallen  under my notice in several  in-
stances,  namely,  that  while  the  immediate  descendants
have escaped, one or more members of collateral branches
have been affected.  The true hereditary nature of psoriasis
may therefore be doubted, and the  cases which  occur, and
are adduced as proofs  of it, might be accounted for in the
same manner as those in wrhich no such  origin can be traced,
and which are usually  stated to depend on some constitu-
tional peculiarity, not  better understood  iioav than  in the
days of Willan, who described it as characterized by " a
slow pulse, or a languid c-irculation  of the blood, and, what
must  be generally connected Avith it, a harsh, dry, imper-
meable state of the skin and cuticle."   The latter  part of
this observation has been adopted by Mr. Erasmus Wilson,
who says that " the disease  appears  for the most part in 
PSORIASIS.
179
those  who  are remarkable for a dryness  of the skin."
Yet I cannot  help  thinking that this is a confounding of
the effect with the cause, and  that it would  be rather
hazardous to predicate the likelihood of psoriasis occurring
in an individual because his skin was unusually dry or harsh.
The  other causes, ordinarily enumerated by dermatologists
as being likely to produce  psoriasis, are  similar to those
supposed to excite other diseases of the skin, such as irre-
gularities of diet, insufficiency of food, the use of salted or
highly-seasoned provisions, derangements of the digestive
organs, andr in the female,  deficient  or excessive menstru-
ation ; but none of  these  can be  supposed to act unless
when original predisposition to the disease exists.
   Diagnosis.—The  distinction between psoriasis and all
other diseases of the skin, except pityriasis, is well marked
by the presence of the characteristic scales ;  several other
eruptions are, as has been remarked  when  speaking of
them,  accompanied  by a form  of desquamation, but  this
is present in only certain of their  stages, and the desqua-
mation consists merely of the shedding of slightly altered
epidermis, in minute, very thin, furfuraceous particles, not
to be confounded with a true scale ;  this takes place espe-
cially in chronic eczema, in herpes,  and in lichen, but in the
tAvo  former there is more  or less  serous  or  sero-purulent
discharge attendant on some  part of their course, and in
the latter papulae are to be distinguished on careful exami-
nation.  When either of the two latter  diseases  assumes a
circular form, as in herpes circinnatus or lichen circum-
scriptum, it  is  more apt to be confounded with psoriasis
lepraeformis, but the characteristics just noticed  then serve
also to aid the diagnosis, and the eruption in  neither of
them  presents the  distinctly rounded shape A\'ith the de-
pressed centre and  scaly circumference of this variety of
the disease.   Psoriasis very rarely occurs on the scalp, un-
less when the eruption is present at the same time on some
other part of  the body, and this serves  to a certain extent
to distinguish it from other  scalp affections; the scales,
too, when  they arc secreted  on  this region, are thicker
and more solid than when situated elsewhere on the cuta-
neous surface, and consequently much more so  than those
of any other  eruption that may occur there, than which 
180
SQUAME.
they are also more persistent, often constituting  a firm,
imbricated, adherent, dry crust, the outer layer of which
only desquamates.   Secondary  syphilitic eruptions not
unfrequently assume a scaly character, and are with diffi-
culty diagnosed from the ordinary forms of psoriasis ; the
history of the case and the concomitant symptoms are the
differential points to be chiefly depended  on;  the colour
of the  parts of the cutaneous surface which are affected is,
moreover, of a dull coppery or livid hue.
   From pityriasis  the  eruption is distinguished  by the
absence in that affection of elevation of the diseased parts,
Avhich  are of a yelloAvish or reddish-yellow colour, by the
scales  being  fine and  thin, and  by their  being generally
diffused over the cutaneous surface, not in distinct  patches
or spots.   The chief diagnostic marks  between  it and
icthyosis are the thick, hardened, and rugose condition of
the skin in the latter, and  the non-existence of any scaly
desquamation.   The aggregated  form  of  psoriasis is dis-
tinguished  from the guttated variety without any diffi-
culty, but in  some cases a distinction can scarcely be made
betAveen it and psoriasis lepraeformis, a matter of but little
import, as the treatment for  both is in all respects  similar.
  Prognosis.—Squamous eruptions  are  essentially of a
chronic nature, but even when of years' duration, scarcely
ever affect in any respect the general health.   Developed
under  the influence of a peculiar  constitutional  state of
the skin, essentially of an  obstinate character, and most
apt to re-appear  even  in months or years after they seem
to have been completely cured,  length of time is as im-
portant to  their  perfect removal as  the  most judiciously
planned course of treatment.  The physician should, there-
fore, in every case, be most careful not to promise a speedy
cure, and always, before prescribing, explain to his patient
the chronic character of  the  disease, and that it requires a
steady perseverance in the use of remedial measures for at
least two or three months before  even  an  apparent amend-
ment will be perceptible.   The anxiety of mind which an
individual labouring under a cutaneous eruption suffers is
very great, and this, too, adds to the  difficulty of treat-
ment.   The promise of an eventual cure, though  after a
lengthened period, tends to alleviate this  anxiety, and 
PSORIASIS.
181
prevents the repeated disappointment, changes of medical
advisers, and  trials  of new plans of treatment, Avhich  the
hope  deferred, when  a speedy cure  has  been promised,
causes.
  Pathology.—" It  is an admitted fact," writes Cazenave,
" that the therapeutics of these diseases rests upon  purely
empirical grounds, and that,  unhappily,  there exists no
sure guide  to direct to a rational  mode  of cure."   This
statement, sufficiently true of  most eruptions  of the skin,
is  equally so  of many other diseases of  the  body,  and it
should teach us not  to despise the light thrown on patho-
logy by the experience derived from therapeutics.   When
it is found that a certain class  of remedies acts beneficially
on  deranged  conditions of the animal economy, concern-
ing the true  nature of which  doubt exists, it cannot be
termed a petitio principis to infer that such derangements
have a similarity in a greater or less degree to affections
the  nature of which  is known, and which are benefitted
by the same class of remedies.  In the treatment of scaly
diseases of the skin, iodine, in  some of its various combina-
tions,  and cod-liver  oil are especially useful; and I  would,
even from  this therapeutic fact alone, be  inclined to look
upon  the peculiarity of constitution  in which  they occur
as nearly allied to the scrofulous; in fact, that their ap-
pearance is but one  of the protean forms in which scrofula
may be developed.  And, independently of the beneficial
effects of iodine, if we look to  the remedies ordinarily pro-
posed as specifics for  their cure,—of course I  speak only
of those administered  internally, or, so to say, constitution-
ally,—what are  they but tonics, alteratives, or diaphore-
tics,  generally employed  in  the treatment of  scrofulous
affections ?  Again,  if we lay aside  the  analogy derived
from therapeutics, in how many points do  not scrofula  and
scaly eruptions of the skin agree ?—their hereditary nature,
their slow development, the period of life at which  they
appear, their production by innutrition or mal-innervation
of the system, their  obstinacy,  their liability to recur or be
again reproduced, the diathesis of the individuals in whom
they appear, &c.
   Treatment.—In   consequence  of its extreme obstinacy
and usually chronic character, there is probably no eruption
                         16 
182
SQUAMA
 of  the  skin, for  the treatment of which  so  many varied
 remedies have beenyand still are proposed, as for psoriasis.
 Some trust altogether  to topical  medication for  its cure,
 while others rely exclusively on the employment of consti-
 tutional remedies ;  both  are needed, and neither should
 be  neglected :.  the former must be used Avhen the eruption
 has lasted for  any length of  time, or where it affects an
 extended surface of  the skin,  to produce  a  new local  ac-
 tion,  and  to remove the diseased condition of  the integu-
 ments ; while the latter  is required to correct any deviation
 from  a healthy  state,  whether functional or organic,  of
 the internal organs which may be present,  and to alter the
 constitutional  derangement,  to  the  existence of which
 the  eruption  is  due.  Before commencing  any  plan  of
 treatment, therefore, it  is  necessary to take  into  account
 the age, constitution, and  diathesis of the patient, the ex-
 tent of surface affected, and the previous  duration of the
 disease.
   In strong, healthy,  plethoric young  persons of either
 sex, when  the eruption is of the guttated  form, or affects
 only  a small portion of the skin, its progress will generally
 be  stopped, and  a cure effected  by the use of tolerably
 active ^saline cathartics every second or_jthird day,  pre-
 ceded "by a general  blood-letting, ajid: The daily use of a
fresh-water bath,  at  the temperature of 98°.   In persons
 of  a  sanguine  temperament, or of very plethoric  habit of
 body, the bleeding may be  repeated, but in  all cases only
 a moderate quantity of blood should be  draAvn, for when
 much has been removed  at a time, or the operation fre-
 quently repeated, the eruption is apt to  take on an aggra-
 vated character, and to become chronic.    The best cathar-
 tics that can be used are the saline purging mineral waters,
 such  as those  of Pullna, of  Seidlitz, of Cheltenham, of
 Leamington, of Droitwich, of Kreuznach,  &c.;  or, in their
 absence, the compound saline powder  may be given  in
 the dose of two drachms, dissolved in half-a-pint of luke-
 warm water, to which  from  twenty to thirty minims  of
 the liquor potasse, or preferably, Brandish's alkaline solu-
 tion,  and  the same quantity of some aromatic tincture,  as
 of orange-peel, should be added ;  in either case the purga-
 tive should be taken in  the morning early before breakfast. 
PSORIASIS.
183
By these simple means, continued  for five or six weeks,
many of the milder cases of psoriasis may be cured, but
more generally, and  invariably when  the eruption has
existed  for some time  before it is submitted to treatment,
it is only alleviated thereby.
   When the disease affects old  persons or individuals  of
a  weak  constitution,  all  debilitating  remedies must be
carefully eschewed; in its early stages  then  stimulating
diaphoretics, combined with tonics, should  be employed,
and the tepid bath, or  tepid douch if the eruption be  local,
used  once  or twice a week when  the patient's strength
admits,  or the hot vapour  bath  may in some cases be sub-
stituted  with  benefit  for  the water bath.   Guaicum and
mezereon often  prove  the  best diaphoretics in these  cases
of psoriasis, and they may be given in combination, as in
the following form:—
     R.  Tincturae Guaiaci  Ammoniatae, .   .  .  fl 3j.
         Tincturae Serpentariae,   .....  fl  3ss.
         Mucilaginis Acaciae,......m. xx.
         Decocti Mezerei,.......fl  3viss
         Decocti Dulcamarae,......fl  3j.
                 Misce.  Fiat haustus.

       " One such to be taken three times a day."

   In scrofulous  children, the progress of the disease may in
its early stage be stopped and a cure effected by the  admi-
nistration of cod-liver oil; and this medicine proves also
very successful  in many cases of the  local forms of  the
eruption in adults:  but with children or  young  persons
the employment of the tepid bath at the  same time should
not be neglected.
   In the more aggravated forms of psoriasis,  however,  or
when the disease has become chronic, recourse  must be had
to the more active alteratives, some  of which have acquired
a  sort of  specific reputation for the  treatment of  scaly
diseases  ; and of all that have been used none effects a cure
so frequently as arsenic, whether it be given  alone  or its
administration  conjoined Avith the  application of  various
local agents.   In every case the beneficial action  of this 
184
S Q U A M E.
medicine is more  decided  and  more speedily manifested
Avhen iodine  or the iodide of potassium is employed at the
same time, or alternated Avith it, and in those cases—not
few in number—in which arsenic, no matter how prescribed,
disagrees, the preparations of iodine suffice usually to  cure
the  disease.   Arsenic  may be prescribed   either in the
fluid form  or in that of pill, but, hoAvever given, the  dose
should be small, increased very slowly, and  continued for
a lengthened time, at least for several months.   Of the
liquid preparations, the liquor  arsenicalis of the  Pharma-
copoeias, Fowler's  solution,—a convenient name  for  pre-
scribing  Avhen it  is requisite  to conceal from patients  or
their friends  that arsenical preparations are being adminis-
tered,—is probably the best, or the liquor arsenici chloridi,
De Valangin's mineral solution,—introduced into the last
edition of the London Pharmacopoeia,—may be used ;  they
should  not be  given  at  first  in  a larger  dose than four
minims  three times a  day in  an ounce  of decoction of
dulcamara, to Avhich, except in  persons  of  a full habit  of
body, tAvo  drachms of  syrup of mezereon may be added.
The arseniates of  ammonia or of soda may also be given in
solution in water,  with a little syrup, or in some vegetable
infusion or decoction, in the dose of a tAventieth  of a grain,
very gradually increased to the fifteenth of  a grain, three
times daily.   The following form, for the administration of
the arseniate of ammonia, was first proposed by Biett  :—

     R  Ammoniae Arseniatis, .   .   .   .  gr. iss.
        Aquas destillatae,.....fl giij.
        Spiritus Angelicae,.....fl ?vj. Misce.

" One tea-spoonful, gradually increased to three, to be taken
           for a dose in some aromatic Avater."

   Donovan's  solution  of  the  hydriodate of arsenic and
mercury, which has  become officinal in the last edition  of
the Dublin Pharmacopoeia, is another  liquid form that has
been often  employed  successfully in  the  treatment  of
psoriasis ;  in consequence of its containing  mercury  it is
especially  applicable for those cases in which the eruption
is  either a  secondary  symptom,  or is  connected with a 
PSORIASIS.
185
 syphilitic taint in the system ; but, from my own experience,
 I do not think that mercurial preparations in any form are
 generally applicable  for scaly diseases, except  in the local
 forms appearing in children, and I have  not unfrequently
 seen their use followed by an aggravation of the symptoms.
 I have consequently, for some  years back, substituted for
 Donovan's solution a  compound in which mercury is replaced
 by the iodide  of potassium ;  this mixture may then  be
 termed an Ioduretted solution of the Iodide of Potassium
 and Arsenic ;  it is prescribed in the following form:—

        R. Liquoris Arsenicalis,        .  m. Ixxx.
           Iodidi Potassii,.....gr. xvj.
           Iodinii puri,......gr. iv.
           Syrupi  Florum Aurantii, .  .   fl lij.  Sohre.

 This solution, which  is of  a rich wine-yellow  colour, and
 keeps  unchanged for years, contains in each fluid drachm
 five minims of arsenical solution, a grain of iodide of potas-
 sium, and a fourth of a grain of iodine.   Forty minims of
 it at first may be given three times a day in simple water,
 or in any tonic or  diaphoretic vegetable infusion or decoc-
 tion, as individual circumstances may  indicate, and the
 dose gradually increased to  eighty minims  : it is of course,
 scarcely necessary to observe that  this compound, as are
 all which contain  iodine, is  incompatible with vegetable
 preparations in which starch is present, or with the stronger
 acids.   In  cases in   which from any reason  it may be
 advisable not to prescribe  arsenic,  the Fowler's solution
 can be omitted from  the above  mixture, and, unless in the
 inA'eterate forms of the eruption, or when it  has been of
 very long standing, the iodine  preparations should  in the
 first instance be tried alone.
   Where it  is Avished  to prescribe arsenic in the  solid form,
 the best preparation of it is  the iodide, which may be given
in pill, made with  conserve of roses or with hard manna
 and mucilage, in doses of from  the twelfth to the tenth of
 a  grain, three times  daily, very gradually increased  until
the fourth of a grain  is taken at each time; the arseniates
of ammonia  or of soda may be given in the same form.  In
the more  rebellious  cases of the disease, and especially
                          16* 
186
S Q U A M E.
 Avhen it  occurs in persons of a debilitated constitution, an
 excellent and favourite  formula for the administration of
 this powerful  agent, is what  has been termed the  Asiatic
pills,  in  consequence  of their being   first  beneficially
 employed  in  the East  Indies,  whence we  derived our
 knoAvledge of their efficacy ;  they are prepared by rubbing
 together a drachm of arsenic and nine drachms of poAvdered
 black pepper, Avith sufficient liquorice powder and mucilage
 to make  800 pills.  Each of these contains about a 13th of
 a grain of arsenic, and one or tAVO may be given daily. No
 matter what preparation of arsenic  is employed, it should
 be administered after meals, as it is then less apt to derange
 the stomach, and  the effect should  be carefully  Avatched:
 the continuance of headache,  of sickness and pain in the
 stomach, of dryness of the fauces,  or of tenderness with
 heat and redness of the eyes for a few days,  requiring its
 omission for a short time, and the administration of an
 active cathartic, when it may be again resumed. It generally
occurs that in the treatment  of scaly diseases  by arsenic
 or by  iodine,  the eruption at first presents an aggravated
 appearance, the affected parts exhibiting an irritated aspect,
 and the  scaly desquamation  being  much augmented, but
these symptoms soon pass away, and signs of amendment
begin  to  show themselves.   In all cases the use of the
remedies which have proved successful should be persisted
in for  some weeks after the disease is apparently cured, so
as to prevent a relapse.
  Chronic cases of psoriasis are very frequently complicated
with derangement of the digestive organ, evidenced by va-
rious dyspeptic symptoms ; the most  prominent of these are
nausea and  vomiting, immediately after  meals.   This con-
dition must be remedied by appropriate alterative and  tonic
treatment, previously to the employment  of medicines Avith
the vieAV  of acting directly on the eruption, for if arsenic or
iodine, in any form, be given while this condition is present,
they will tend to increase the existing irritation, and  their
expected  beneficial  action be thereby  prevented.   The
tepid fresh Avater, the douche, or the vapour  bath, should
be employed at leat once or tAvice a week, in addition to the
use of the internal remedies now recommended.
  But  cases of psoriasis occur Avhich resist with obstinacy 
PSORIASIS.
187
the administration, even though much prolonged, of either
or both of these powerful medicines, and then recourse must
be had to some of the many other remedies, both constitu-
tional and topical, which have at times  proved useful, and
have consequently found warm  advocates.   Sulphur and
its preparations have been highly praised by  many practi-
tioners for their efficacy ; and in the  very inveterate forms
of the eruption occuring in languid constitutions, or  when
there is no determination of blood to the affected parts, nor
local irritation, the sulphurous mineral waters, both taken
internally and employed in the form of tepid bath, cure the
disease when other remedies have failed, but  to derive the
full benefit from  them, their  use should be  continued for
several months, othenvise the  eruption is sure to re-appear.
When the mineral waters cannot be procured, or the patient is
unable to go to their sources, Avhich is always most advisable,
sulphur may be given internally, and  baths  or lotions of
the sulphuret of potassium used.   In the local forms of the
disease the iodide of sulphur  ointment  is a most  valuable
topical application, but it should be used only of moderate
strength, from eight to twelve grains  to the ounce of white
wax ointment, and  its efficacy is much increased by the
addition of a drachm of glycerine to each ounce.
  M. Cazenave has recently administered the  carbonate of
ammonia, in the treatment of psoriasis, with marked success;
he prescribes it in the dose of  about two  and a half grains,
from one to three times a day, in a table-spOonful of syrup
of sarsaparilla.   "In  general, the symptoms  it causes are
scarcely  to be  noticed ;  some slight disturbance  of the
digestive organs, and occasionally slight heat and tingling
of the skin.  Yet, after an interval of time, varying usually
from three to  eight days, when good  results follow, the
scales begin to be detached, those Avhich succeed them are
more and more fine and of a duller aspect,  and the  patches
on which they are situated lose their red tint and gradually
fade a\vay; after a longer or shorter  period a  complete
cure, and  one  which  is  often permanent takes  place."*
When carbonate of ammonia  Avas  thus administered, M.
Cazenave found it to occasion  diarrhoea, preceded by colic?
lassitude, sometimes headache,  slight acceleration with dimi.
  1 Annales des Maladies de la Peau et de la Syphilis, torn. iii. p. 315. 
188
S Q U A M E.
 nished fullness of the pulse, alternations of  heat  and cold
 of the surface, &c.; these symptoms disappeared on omitting
 the  use of the medicine for  a  few days, and  this  fact,
 together with  their similarity to  those  caused by arsenic,
 led him to draw an analogy bet\veen the mode  of operation
 of the two medicines.
   Amongst other constitutional plans of treatment proposed
 for  psoriasis, bringing the system under the  influence  of
 mercury has proved successful in the hands of some practi-
 tioners ; it  is chiefly  applicable, as already remarked, to
 those  cases in  which a venereal taint  exists;  but it  may
 also be used in the milder forms of the eruption, Avhen  they
 do not  yield to the more simple  treatment  recommended
 above.   The preparations of  mercury which are preferred
 are  those that act slowly,  and rarely produce salivation,
 such as the  red iodide or corrosive sublimate;  the latter is
 very frequently prescribed in  decoction of cinchona bark,
 a good combination, although not  strictly chemical.
   Copland relies  chiefly on the employment of  emetics and
 purgatives  at  the  same time, and  their use is  certainly
 attended Avith  much  benefit in most  cases, previously  to
 commencing the administration of  the more active altera-
 tives.   The alkalies,  especially the liquor  potassae,  have
 also  been highly recommended, particularly in  the  local
 forms of the eruption, but  in  any cases in  which I tried
 them the result was  not  satisfactory.   From  its original
 use by Biett, and the favourable notice  taken of  its action
 by Rayer, tincture  of  cantharides has been  rather exten-
 sively  administered,  especially on the  Continent in the
 treatment of psoriasis ; it certainly succeeds in some cases
 in which other  remedies have  failed, but its employment,
 even in small quantity, must be carefully watched, in  con-
 sequence of the dangerous effects it is apt to produce on the
urinary organs.   It may be given in doses of five minims,
 gradually increased to fifteen or tAventy,  three times a  day,
in at least an ounce of some emulsion or of decoction  of
linseed or barley.   Numerous  other medicines, especially
 diaphoretics, diuretics, tonics,  and stimulants, have  been
 employed in this  disease, but  none require mention here,
with perhaps the  exception of tar  or pitch, Avhich, when
given internally,  and at  the  same time  applied to the 
PSORIASIS.
189
affected surface, is  regarded by some physicians as quite a
specific ; I consider it, however, much inferior in its me-
dicinal efficacy  to  most of  the  other therapeutic  agents
Avhich have been now noticed.
  Local  applications, ointments, lotions,  baths, &c, have
been at  all times favorite methods of treating psoriasis,
and many have  attempted to cure the disease by  their use
alone; with this view, also, it has  been proposed  to  de-
stroy the eruption  by the  free application  of nitrate of
silver to the affected parts, but such a proceeding tends
only to aggravate the morbid  state of the cutaneous sur-
face, and is not altogether  unattended with danger  The
simple /resA-water tepid bath  has proved,  in my expe-
rience,  the best topical remedy, I  might almost say  the
only one needed, and it  should be  employed at least once
a week in  all forms of psoriasis; its use tends to  restore
the natural secretion of the skin, and to prevent  the accu-
mulation of scales.  When the  eruption is  local, and  at-
tended with symptoms of irritation or inflammation, sooth-
ing unguents, as those containing chloroform, preparations
of  lead, zinc,  &c,  or poultices prepared  with  the lead
wash,  often prove  highly  serviceable ; and  in the more
chronic  cases,  when  neither inflammation  nor inflamma-
tory irritation is present, stimulating applications  are  oc-
casionally  reduired;  of  these,  probably  the best   is  the
iodine of sulphur  ointment spoken  of before, or the  fol-
lowing, which was  highly recommended by the  late  Dr.
Anthony Todd  Thompson :—

     R. Calomelanos,.......3 J*
        Unguenti Picis liquidae,  .  .  .  .  5 iv.
        Adipis  praeparati,.....I j-  Misce.

   Of other local applications it will be sufficient to  enume-
rate blisters, creasote, turpentine, tincture of iodine, corro-
siA'e sublimate  in  lotion, black and  yellow wash, citrine
ointment, &c.;  the  alkalies, when  applied topically, gene-
rally, I think, prove injurious.
   Strict attention  to diet and regimen is  especially requi-
site in the treatment of  psoriasis; a milk diet should  be,
if possible, enforced, except in  cachectic  or broken-down 
190
S Q U A M E.
 constitutions, and when from this  or any other  cause it
 cannot be  altogether  adopted,  farinaceous articles  and
 milk should  be made as much as  possible a portion of the
 general food, and in addition, fresh meat, plainly dressed,
 or  poultry, should alone be allowed.   From its  being so
 much easier to carry out dietetic rules in hospitial patients
 than with those in private or in  dispensary practice, more
 satisfactory  results  are usually  obtained in treating the
 former, and consequently, perfectly  accurate  conclusions
 as  to the effects of remedies in the treatment  of  any dis-
 ease, whether of the skin  or not, can only be  draAvn  from
 hospital experience..

                       PITYRIASIS.
  Pityriasis is a scaly cutaneous disease, characterized
 by  an abundant  secretion and  desquamation  of minute,
 furfuraceous, white,  and shining  scales, from  slightly ele-
 vated,  irregular patches of the skin,  of  a yellowish, red-
 dish-yellow,  or dark-brown colour,  varying in extent, or
 from the surface  of  the body generally.  It is  attended
 usually with  smart itching of the parts affected, sometimes
 with painful inflammatory tingling,  and both are  much
 augmented by any cause that may produce increased -ca-
pillary circulation of the  integuments.   It is non-conta-
gious,  unaccompanied  by  constitutional  symptoms,   and
 although attended in its early stages, and in some cases
throughout its  entire duration, with more or less local in-
flammatory action, almost invariably  runs  a very chronic
 course. Pityriasis is, for the  purposes of description, na-
 turally divided into  varieties,  as it may affect the cuta-
neous surface generally, or some special region of the skin.
Willan, who  has  been followed amongst  others by Caze-
nave and Schedel, described but one local form of it—that
 of the scalp, and  divided the eruption,  when  it  affected
the body generally, into three varieties,  according to  the
 colour  which the diseased  patches  of  integument  pre-
sented, namely, Pityriasis rubra, Pityriasis nigra, and Pity-
riasis versicolor.   Both Rayer and  Erasmus Wilson  con-
sider the first of  these  only as being  a scaly disease,  and
regard the  other  as simply alterations in the  colour of 
PITYRIASIS.
191
the skin, accompanied by  a foliaceous  or  mealy desqua-
mation, and not by the separation of true scales.  As, how-
ever, in both forms there is a squamous secretion, differing
only in degree from the first, I prefer  to regard them as
sub-varieties of general pityriasis.   Adopting, then, strictly
the division of the disease  into two  forms,—general and
local,—they may be  termed :—

                    Pityriasis diffusa.
                       „     localis.

   The early stage of pityriasis diffusa in marked by a sen-
sation  of heat  and tingling on  various  parts of the cuta-
neous  surface,  usually on  the neck,  the chest, the  abdo-
men,  the back, and sometimes on the face and hands;
uncircumscribed  patches of a yelloAvish or  reddish-yellow
colour, scarcely  elevated above the  surrounding integu-
ment,  appear on the places  which had been the seat of the
itching,  and on them  minute, branny, micaceous  scales
soon form, at first in small quantity, but afterwards in very
great  abundance,  desquamating freely when the spots are
rubbed, or  should the  eruption be general, on the least
movement of the  body.   The affected patches vary much
in shape  and size, being  often  of  an irregularly rounded
form separated  at first  by healthy  skin,  over Avhich, in
most cases, however, the scales gradually extend, and, be-
coming confluent, cover  the  body almost universally; the
furfuraceous desquamation is then extreme, and is attended
Avith much itching, especially Avhen the surface of the body
is heated, and the disease assumes a very obstinate charac-
ter.   The skin from  which the desquamation takes place—
which  in  the  commencement presents various shades of
red and yellow intermixed,  whence  the specific appella-
tion of pityriasis versicolor has  been  applied to this form
—gradually becomes of a lighter  shade of  yelloAV, and in
many  instances the  secretion  of  scales then  ceases, yel-
loAvish  stains remaining on the surface for some time ; but
in others  the  desquamation, attended with more or less
itching,  lasts  Avith  extraordinary  obstinacy for months,
or even  years,  after  the  skin has  resumed  its natural
colour. 
192                   S Q U A M E.
  In  some cases  the  eruption is more partial, being con-
fined  almost  exclusively to the integuments of the thorax,
usually appearing on the  chest; the  spots or patches  as-
sume  from the first a  bright colour, so marked that in  the
commencement they  can  scarcely be  distinguished from
erythema; they  are  also attended with much heat  and
itching, indicating the inflammatory nature of the  disease ;
the characteristic scaly secretion  and desquamation soon
appear, however,  and determine  its  nature.   This form,
Avhich is  also very obstinate, has  been termed pityriasis
rubra ;  it is of much less  frequent occurrence than pity-
riasis  versicolor, but oftener witnessed than the next sub-
variety.
  Pityriasis nigra is a very rare form of the  eruption ; it
does  not seem to  differ  in any  respect from pityriasis
rubra, except in  the colour of the diseased patches, which
are dark-brown or nearly black, and usually appear on one
or both of the lower extremities ;  according to Cazenave's
observations, the black  tint is in  some cases so superficial
that, on removing the epidermis, the derma is seen  beneath,
of a  red, shining aspect; in  others,  hoAvever, the colour
affects the sub-epidermic layer of the derma.   In both
pityriasis versicolor and pityriasis nigra, the chromatoge-
nous  functions of  the  derma must  be more or  less dis-
ordered, to account for the peculiar colouration of the skin
which accompanies them.  As before  remarked,  Rayer
considers the changed colour as their essential charcteris-
tic, and  he consequently terms the former  Chloasma, and
the latter Melasma; this view has been adopted by Wilson
also.
  Several local  forms  of pityriasis  have been described
chiefly by Rayer; thus he notices it specially as  it affects
the eye-lids, pityriasis palpebrarum;  the mouth and lips,
pityriasis oris et labiorum; the prepuce and pudendum,
pityriasis prseputialis et pudendalis ; the feet and hands,
pityriasis palmaris et plantaris ;  and the scalp, pityriasis
capitis.  None of these, except the last, differ essentially
from  the  eruption as it affects the body generally, and do
not, therefore, require  to be  specially described; many
dermatologists, indeed, and I think with much correctness, 
PITYRIASIS.
193
admit the existence of but one local variety of pityriasis,—
that of the scalp.
  The development of pityriasis capitis is not accompanied
by any sign of constitutional or local disturbance, but soon
after its eruption it gives rise to much itching, without heat or
redness of the surface.   The disease consists in  the secre-
tion of numerous  minute, papyraceous, dry, and shining
scales, in most cases scattered over the entire of the head,
without any sensible elevation of the surface, and perfectly
free from moisture.  I cannot describe the precise manner
in which the  eruption originates,  as  I have never seen it
until the squamous secretion was fully  developed, there
being no symptoms to direct the patient's attention  to it
until then.   The  presence  of the scales produces much
itching, compelling the individual affected to  scratch  the
head, by which  they are very  readily detached in large
quantity, in the state of a fine poAvder or dandruff;  their
removal is rapidly succeeded by  a further  secretion.  If
the condition  of the scalp in pityriasis capitis be examined,
the surface is found  to  be  closely covered with  the imbri-
cated scales, Avith small intervals here and there ; the skin
of  the unaffected parts presenting a  smoother or more
polished appearance  than natural.   On removing one of
the  scales we  find  that  the spot on which it is  seated is
raised, and that another finer scale may be removed from
it;  and  it is not until after the  removal of several scales,
each finer than the preceding, that we arrive at the reddened
and inflamed  surface  of  the scalp, Avhich is somewhat  de-
pressed.  The chief annoyance Avhich it causes is itching;
the patient, in scratching himself to allay this troublesome
symptom, removes large  quantities of dandruff;  and in the
child the irritation is often  so great that the scalp is torn,
becomes inflamed,  eczematous  vesicles appear, and  the
original affection is thus  complicated.
  Although the hair in  this eruption is not apparently
diseased, it grows weak and thin, and falls  out on  the
slightest cause, so that,  when of  long duration, baldness
may result, which, except in very old persons, is, hoAvever,
only temporary.
  Pityriasis diffusa may occur at any age, but it is most
common in adults; it seems to  affect both sexes with  an
                         17 
194
S Q U A M E.
equal  degree of  frequency.   Pityriasis capitis  is  most
usually met with in infants at the breast, the frequency of
its  appearance decreasing with the advance of years  to-
wards puberty, at  Avhich age it is of very rare  occurrence,
but it again  appears at the approach of old age.   It thus
seems to be most frequent when  the head is least covered
with hair, and it is also most  generally seen in individuals
whose hair is naturally  thin.
  The causes of pityriasis are very obscure ; in most cases
it is  manifestly a constitutional affection, but in  some
instances it is evidently produced  by the action  of local irri-
tants.   Thus its occurrence on  the scalp  may be  often
accounted  for by the use of hard brushes or a fine tooth-
comb, or from not drying the head sufficiently after it has
been washed; appearing, too, most frequently at those ages
in which  the scalp is least covered with hair, it may be
then caused by the  sudden  changes  of temperature to
which  the surface  is consequently exposed.   The eruption,
when general, appears to be more or  less  connected with
some  deranged state  of  the  nervous system, especially
when this state  is accompanied by increased cutaneous
susceptibility, and is also not  unfrequently  attendant on a
disordered condition of the digestive organs.  I  can confirm
the observation of Cazenave that in some cases, especially
in  nervous  females,  pityriasis capitis  succeeds repeated
attacks of  nervous headache.  The  use  of  stimulating
cosmetics, whether in the form of lotion or of pomade, is a
not unusual exciting cause of  the eruption.
  Diagnosis.—Pityriasis  is  distinguished  from psoriasis
by the  fineness  and thinness  of  the scales,  which are not
thicker than the healthy scarf-skin, even when the disease
is very chronic ; by their being  desquamated  in excessive
quantity ;  by the parts affected being scarcely  elevated
above the surrounding integument; by the  peculiar colour
of the surface of the skin on which the eruption is situated;
and by the attendant pruritus.  It might  be  confounded
with chronic lichen or  eczema, in consequence of the fur-
furaceous desquamation which attends the advanced stages
of both these diseases;  pityriasis, however,  is not preceded
by  any eruption, is never accompanied by  any discharge,
and in it  the skin is never chapped nor fissured.   From 
PITYRIASIS.
195
icthyosis  the diagnosis is made  without  difficulty, the
•peculiar dry, hard, rugose, and, so to say, horny condition
of the integuments being sufficiently characteristic of that
affection.   Pityriasis capitis is distinguished from the other
eruptions which occur on this region of the body by its true
scaly nature, the scales being  minute,  dry, papyraceous,
and imbricated, though scarcely,  if at  all, elevated above
the surface of the scalp, and readily separated in the form
of a fine powder  or  dandriff;  by there  being no attendant
inflammation  unless  it  be produced  by some  irritating
cause ;  by the absence of discharge;  by the  hair being
unaltered, but falling  out  more easily  than natural; and
by its not being contagious : it occurs, too, most generally
in advanced periods  of life, being rare  in childhood, ado-
lescence, and manhood.
  Prognosis.—Trifling an eruption as pityriasis seems  to
be, it is one  of extreme obstinacy, and  not unfrequently,
when it has  continued long, causes more or less derange-
ment of the general  health,  chiefly from the mental an-
noyance which its persistence occasions  ; this is especially
witnessed when it affects the scalp of females at or about
the  age of puberty, to whom  the falling out of the  hair
and the continued desquamation  of dandriff are a source
of constant  distress :  I have seen more than one instance
in which extreme nervous and general  debility Avas  pro-
duced by this cause alone.  The longer pityriasis has lasted
the  more difficult  it is to cure, and relapses  after appa-
rently  perfect  recovery are very likely to occur.  That
the continued existence of the eruption  generally over the
surface of the body may not be altogether unattended Avith
danger is proved by Rayer's narrative  of a case in which
he saw  it prove fatal.
   Treatment.—In the treatment  of pityriasis, as of many
other cutaneous  diseases,  it is too much the habit to re-
sort to the indiscriminate use  of active stimulants  both
internally and as topical  applications ;  I do not mean  to
undervalue the benefit derived  from their employment  in
many chronic eruptions,  but I must protest against the
custom  Avhich for some years back has become  so general,
of having recourse to them in all cases  without regard  to
the fact that a majority of the affections of  the skin are 
196
S Q U A M E.
inflammatory in their  origin,  and  that  even  in their
advanced stages, when all tendency  to inflammatory action
has apparently  disappeared, local  irritation or capillary
excitement often causes  a fresh outbreak of the eruption,
or an  aggravation  of the symptoms.   These remarks,
while they are true of many cutaneous diseases, are espe-
cially applicable  to that now under consideration,  which,
though  much less inflammatory than many others, is  ex-
tremely liable to be reproduced by the action of stimulants,
—whether constitutional or local,—a fact that  every one,
who has had  any experience in the treatment of this class
of affections, must, I feel certain, have observed.
  When pityriasis  is of the diffuse form, if it occurs  in
strong,  healthy, young persons, a small general bleeding
proves often  of service  in its  early stages,  but the with-
drawal of blood is not admissible  otherwise;  tepid gelatine
baths should  be  used for  at  least  half-an-hour daily,  or
every second day from the first, and purgatives be freely
administered : of the latter class of medicines none prove
so useful  as  the alkaline cathartic  mineral  waters, either
thermal or cold, according to the age  and constitution of the
patient;  for  example, those of  Carlsbad or Marienbad;
but a combination of mild mercurials with  alkalies, as in
somewhat the following form, should be prescribed  at the
same time:

  R. Pilulae Hydrargyri,.......gr. ix.
     Sodae Carbonatis siccati,.....gr. vj.
     Extracti Taraxaci,.......gr. xij.
     Extracti Hyoscyami,   ...... gr. iij.
               Misce.   Fiant pilulae sex.
" One to be taken every second  day  half-an-hour  before
                        dinner."
  When the mineral waters cannot be procured, a drachm
of the sulphate of soda—previously deprived of its water
of crystallization by exposing it to a red heat—and tAventy
grains of the bicarbonate of soda, dissolved in  half-a-pint
of tepid Avater, may be given in the morning after the pill.
  Should the eruption resist  this plan of treatment, and
exhibit  a tendency to become  chronic, alkaline  baths— 
PITYRIASIS.
197
four ounces  of the carbonate of  soda, or tAvo  ounces of
purified carbonate  of potash, in sufficient fresh water for
an ordinary bath, at the temperature  of from  80° to 92°
Fahr., according to the  season  of the year—may be sub-
stituted for those of gelatine ;  and the surface of the body,
previously well dried after leaving the bath, should  be
anointed with  a pomade, composed of four ounces of pre-
pared lard, well beaten up with  an equal quantity of elder-
flower water, then squeezed as dry as possible, and half-an-
ounce  of  glycerine added.  The mercurials and alkaline
saline  cathartics must still be continued; but  should  the
eruption become essentially chronic, the more active consti-
tutional alteratives, iodine  and  arsenic separately or com-
bined, as recommended for the treatment of psoriasis, must
be prescribed.   In cases in which the pruritus  is extreme,
chloroform, added  to the  pomade  above recommended, in
the proportion of from eight to twelve  minims to the ounce,
Avill be found the most effectual application for allaying it;
lotions and ointments containing prussic acid  or the pre-
parations of lead, have been employed usefully for the same
purpose.
   In  some of the  local forms  of  pityriasis,  the vapour
douche bath is of  especial service, and the constitutional
treatment  applicable to the general disease  is also indi-
cated.   When  the scalp is the part  affected, the hair should
be cut close—not shaved off—and  so  kept during the pro-
gress  of the treatment:  this is not requisite in old persons
when the  hair  is thin on the head.   In the early stages,
weak  alkaline  ointments  and lotions,  with  the  addition of
glycerine  to either, will be found the most beneficial  appli-
cations, but  when   the  eruption  is of  long standing,  or
occurs in persons  of  debilitated constitution,  the  tannic
acid or dilute  citrine ointment,  should be substituted  for
the former, the lotion being still used  each time  before
the ointment is applied.   When the eruption  appears  on
the scalp of scrofulous children, cod-liver oil will be bene-
ficially administered, but for those  Avho are not scrofulous
the alterative poAvders of the iodide of mercury and hydrar-
gyrum cum creta, as I have recommended for other diseases
of the scalp,  are better adapted.   In  very obstinate cases
of any of the local forms of this  eruption, more stimulating
                          17* 
198
S QU A ME.
 applications may be tried, such  as  ointments containing
 calomel or white precipitate, in the proportion of a drachm
 of either to the ounce of prepared  lard, or of white wax
 ointment, with the  addition of glycerine, or lotions con-
 taining  the  cyanide of mercury or corrosi\re sublimate;
 but their effects must  be carefully watched, as they often
 cause  a sudden aggravation  of  the  symptoms.   For  the
 same reason the sulphurous mineral Avaters and sulphurous
 baths should be used with caution, yet they unquestionably
 prove at times of much benefit in chronic cases of  the dis-
 ease in persons of a  languid circulation.
   Dietetic rules  are most important in  the  treatment of
 pityriasis,  and when the digestive organs  are deranged,
 remedies calculated  to restore their healthy tone should  be
 employed.   The  food ought to be light but nourishing,  as
 the strength must be  supported, and therefore milk and
 farinaceous articles of diet are especially indicated :  in the
 case of children,  a strictly milk and  vegetable diet should
 be enforced.   Stimulating or  heating drinks must be alto-
 gether prohibited, and the surface of the body kept as much
 as possible of a uniform temperature, extremes of heat and
 cold being avoided.   In consequence of the liability to re-
 lapse, whateA'er treatment may be found  to be successful
 should be continued for at least a month or six  Aveeks after
an apparent care has been effected. 
hypertrophie.              199
                CHAPTER   VII*.

                     hypertrophie.

   In the Order Hypertrophie, I purpose to include all
diseases of the skin which are specially characterized by
an hypertrophied condition, attended with a morbid change
from their  normal state, of any or all  of the anatomical
elements which compose the tegumentary membrane.  The
affections to be described in this division are of  a chronic
nature  both in their development and  progress,  rarely
exhibiting in any of  their stages  signs  of  constitutional
disturbance or  inflammatory action, either local or general,
yet some of them are unquestionably of constitutional origin,
Avhile others are manifestly produced by the direct  action
of irritant causes. I have already mentioned the objections
Avhich exist  to the employment of the term " Tubercula,"
for the  purpose of designating a group of diseases of the
skin, or to its retention at all in cutaneous nosology; applied
formerly  to  include several  affections,  nearly all modern
dermatologists Avho still  retain it have restricted  its appli-
cation to some forms of secondary syphilitic eruptions, to
Lupus,  and to Elephantiasis;  now  of these  it is evident
that the first will be  both more correctly classed  and more
conveniently described with the other  syphilitic diseases
which affect the skin;  the second is  specially characterized
by its malignant nature ; and therefore the third  only can,
with any degree of accuracy, be designated as a tubercular
affection, and yet although placed by Willan and Bateman
in this class, it differs essentially from their own definition
of a tubercle.
   The  appellation I  propose  has the advantage of  not
being an innovation  in cutaneous nosology ; it has a place
in all modern natural systems of classification of  affections
of the skin, as constituting a special group, and I only seek
to extend its signification as in any  artificial arrangement
may be  correctly done,—there  being no  necessity here for
regarding  the so-called  natural  affinities, similarity of 
200              hypertrophie.
elementary lesion or of external phenomena sufficing for
the grouping of diseases.  The order might  certainly  be
made to constitute several groups were strict accuracy in
arrangement the sole or even chief object in my inquiry;
but regarding all systems of classification as  altogether
secondary, and useful more for the  purpose of description
than for affording any aid either in diagnosis or treatment,
I think it better to make as few divisions as possible.  The
following are the diseases I shall describe in this Chapter:
—Icthyosis, Molluscum, Stearrhoea, Elephantiasis, Verruca,
Clavus, Callositates, Condylomata, Naevus.

                       icthyosis.
  Icthyosis (Fish-skin disease) is characterized by a morbid
alteration and hypertrophied  condition of the epidermis, by
which it is converted into thick, dry, horny, adherent scales,
the orifices of the hair follicles and of the sudiparous and
sebiparous glands being thereby obstructed.  This affection,
classed by Willan and those  Avho have adopted his views,
amongst the  Squamae, is, as  I  have stated  in  the last
Chapter, distinctly separated from the eruptions contained
in that group, by its not being attended with any desqua-
mation of scales.   Most modern writers on diseases of the
skin differ as to what are the anatomical  lesions by which
it is constituted, and consequently, as to  the precise  posi-
tion which it should  occupy in a nosological  arrangement.
Mr. Erasmus Wilson,- in his earlier writings, regarded it as
consisting in  a hyperformation of the epidermis, but he has
changed his opinion, and more recently announced his belief
that the morbid condition of the  integuments is composed
of  concretions of altered sebaceous  substance; repeated
observation, aided by microscopic examination, compels me,
however, to differ with so eminent an authority, nor have I
been able even to comprehend the grounds on Avhich he has
come to this conclusion.  Dr. A.  T. Thomson did not live
to publish his opinions in the posthumous Avork which bears
his  name ;  but that he had not been  able to satisfy his
mind as to the  nature  of the disease is evident from the
account of it given by his editor, Dr. Parkes.   By Cazenave
and the majority of the recent French dermatologists,
icthyosis is looked upon as a  lesion of epidermic secretion, 
ICTHYOSIS.
201
and is, therefore, made  to constitute a distinct group, of
Avhich it is the type.   Gustav Simon, whose views I adopt,
regarding icthyosis as an hypertrophy or increased develop-
ment  of the  epidermis,1  places  it in  his classification
amongst the Hypertrophiae
   Willan and Bateman described two forms  of the disease,
terming the one icthyosis  simplex, and the  other icthyosis
cornea; they differ, however, merely as  to  the  degree in
which the epidermis is altered, and  therefore  cannot be
correctly separated from  each  other  for the purposes of
description ;  other varieties have also been  constituted by
different Avriters according to the  appearance which  the
altered integuments may  present   in certain cases:  thus
Wilson divides  the disease  into Icthyosis  squamosa  and
Icthyosis spinosa; a  form  has  been  termed  Icthyosis
hysterix by Fuchs; and  another,  Icthyosis scutellata by
Schbnlein.
   Icthyosis  may be  congenital, but  more usually, com-
mencing a few months after birth, lasts  for life, affecting
generally after  a short  time the entire  of  the  cutaneous
surface, except the palms of  the hands, the soles of  the
feet,  the eyelids, the lips,  and the prepuce.  It consists at
first of an hypertrophied condition  of the epidermis, which
is dry, harsh, and corrugated, the natural linear markings
dhriding it into distinctly separated, polygonal and lozenge-
shaped compartments.  This change, pxcept in congenital
cases, in which at birth it  is very general over the body, is
first witnessed in certain regions only, namely, the ankles,
the knees, the backs of the hands, the borders of the axillae,
and the neck ; the morbid alteration  becoming  gradually
more aggravated on these  parts, extends  superficially also,
affecting next the scalp, the fronts  of the  legs, the backs of
the arms, the folds of the groins, the breasts, and the lower
part of the abdomen ;  by  degrees,  however, if the disease
be  unchecked by treatment,  the epidermis of the entire
body,  with  the  few exceptions noticed  above,  becomes
engaged.
   When icthyosis is congenital, the skin of  the infant at
birth is dry, rough, uneven, and of a greyish-brown colour,
  r Die Hautkrankheiten durch anatomische Untersucliungen: Berlin.
Second Edition, 1851, p. 49. 
202              HYPERTROPHIE.
but the epidermis is little hypertrophied ;  this condition of
it may continue for years, or even for life, accompanied by
a constant mealy exfoliation, without being further aggra-
vated, constituting the mildest cases of the affection. More
generally, hoAvever, the epidermis  soon becomes thickened,
hypertrophied, and of a scaly aspect, bearing at times much
resemblance to the scales  of a fish,—whence the name
derived from the Greek  word, w^s*  a fish, was applied to
the disease; the  surface is  deeply furrowed, shining, and
of a sallow or greenish hue, free from hairs, and  devoid of
any secretion  or natural moisture;  in parts  the fissures
occasionally extend quite through the hypertrophied  epi-
dermis, and the  derma beneath  is seen to be somewhat
redder than in its healthy state, but it is not inflamed; the
superficial thickened layers may be  removed in  scales by
the nail,  when the surface on which they rest presents also
a similar appearance, but  the  epidermis is rapidly repro-
duced again in the same unhealthy condition.
  Although, as has been mentioned, the orifices  of the sudi-
parous, and sebiparous glands are quite obstructed, there
are no constitutional symptoms caused thereby, the general
health does not appear to suffer in any respect, nor is the
altered  state of  the  integuments accompanied  by  heatt
itching, or  any other sign of local irritation.
  In some  cases  the epidermis is  much more altered from
its  normal condition than  has  been described  above, pre-
senting the appearance of innumerable short  spines aggre-
gated together without any intervening space, over all those
parts of  the body which the disease affects;  this form has
been termed spinosa by Wilson, but Dr. Copland  regarding
it as consisting in an hypertrophied and elongated condition
of the papillae of the skin, proposes to name it  papillary
icthyosis.  The surface of the body of persons afflicted with
it presents a singular  and remarkable  aspect, being of a
greenish-brown colour, and so hard as to feel like horn and
to produce a grating noise when the hand  is passed quickly
over it, yet  more or less elastic and yielding when pressed;
the diseased epidermis is firmly adherent to the derma, and
if attempted to be torn off with the nail, the part on Avhich
it is situated bleeds and is painful.  The spiny  elevations
may be separated from each other, when it will be seen that 
ICTHYOSIS.
203
they are of a greyish or yellowish-white  colour,—the dark
tint existing only on the surface exposed to the air,—and
that they vary in elevation from an eighth to a quarter of
an inch; some of them, however,  attain a much greater
prominence  than this, forming excrescences,  or,  as  they
have  been  termed, horns, fully an inch or even  more in
length.   On the parts of the body which are exposed to
pressure, as on the buttocks and on  the joints, callosities
form, and in extreme cases the power of motion may be
much limited.   This form of icthyosis is almost invariably
congenital, not  attaining its complete  development,  how-
ever, until at or about the age of puberty.
  Since this disease of  the skin was first noticed,  it has at
all times attracted much attention, owing to  the  singular
condition of the integuments by which it is characterized;
individuals affected with it in an aggravated  form having
been exhihited for money, in the case of males  being termed
porcupine men, and of females, mermaids, the latter  from
the supposed resemblance of the skin to the scales of fishes;
but it has  been more aptly compared  to the hide of  an
elephant or of a rhinoceros.  Not being  of frequent occur-
rence, moreover, in its full development some of these  cases
have been carefully described, the most celebrated probably
being that of the family of the Lamberts, which occurred in
the beginning of the last century, and to which I shall have
occasion again to refer  as illustrating the hereditary cha-
racter of the disease.
  Whether  icthyosis is general or partial, the superficial
layers of the hypertrophied epidermis are constantly being
shed  as a fine mealy desquamation, or, when softened by a
Avarm bath, may be rubbed off with the hand, but are again
rapidly renewed;  the disease is always more marked on the
regions of the body noticed above, as the parts where it first
appears, and especially in the neighbourhood of the joints ;
on the scalp the epidermis is not so much thickened as else-
Avhere, yet most of the hair  is shed when it  occurs there,
and what remains is thin and weak.   Although the general
health  seems  to  be unaffected in  persons the subject of
icthyosis, attacks of diarrhoea are of constant occurrence,
probably owing  to the nearly complete obstruction of the
cutaneous transpiration;  and for  the same  reason  those 
204
HYPERTROPHIE.
parts of the integuments which are not engaged, especially
the palms of the hands and the  soles of the feet, are con-
stantly bedewed with moisture:  the urinary and pulmonary
secretions are also said to be increased in quantity, but in
four cases of the disease which I have had under treatment
this was not  so.   The affected parts  are constantly below
the  natural  temperature, and  persons  afflicted with  the
disease usually suffer much from coldness of the surface of
the body.
   The nature of the anatomical changes which  constitute
icthyosis have  been carefully  investigated, both micro-
scopically and  otherwise.  The following description  of
them is given by Franz   Simon:  " The  scales  Avere of a
grey or black colour ; when placed in water they softened,
and on then  placing  a  section  under  the  microscope I
found  that the  abnormal structure was formed of  com-
pressed epithelial  scales.   On incineration  the  scales  left
an ash, containing  carbonate and phosphate of lime  and
peroxide of iron ; the latter was in such abundance as to
communicate a yellow colour to the ash.   The ash yielded
by the incineration of the ordinary thickened skin on the
hands  and feet is  perfectly white, and  contains a mere
trace of peroxide of iron."1  This account, directly opposed
to the views propounded by Erasmus  Wilson, which  have
been before referred to, is confirmed by Gluge,  who states
that on microscopic examination he found the scales to be
composed of epidermic cells.
   Causes.—Obscure  as are the  causes  of skin diseases,
generally speaking, there is probably not one of which so
little is known as  to how or under what circumstances it
is produced,  as  icthyosis.   When  congenital, it has been
ascribed, like all the other deviations  from a normal state
which  are observed occasionally in the foetus, to the effect
of the mother's imagination  while pregnant, it being popu-
larly believed to be caused by a longing for some peculiar
fish, or by fright arising  from  something connected  with
fish ; but it need scarcely be remarked that these causes of
the disease are altogether without foundation.   It occurs
in both sexes, but  is much more frequent amongst  males
than females, in the proportion, according to Biett's obser-
   1 Animal Chemistry ; Sydenham Society's Edition, vol. ii. p. 483. 
ICTHYOSIS.
205
yations, of one of the latter to twenty of the former ;  this
is well established by the report  of  those  cases in Avhich
icthyosis has been hereditary, as  it not unfrequently is,—
for example, in the family of the Lamberts above referred
to,  in which  the disease was transmitted for several gene-
rations from father to child,  the  female members of  the
family being in  no instance  affected.   This  hereditary
transmission of icthyosis has been noticed in the majority
of instances, but many cases of the disease occur in children
born of parents healthy in all respects, and in whose families,
as far as could be ascertained, no  trace of the disease ever
existed.   It is seen at all ages, but is usually congenital, or
developed Avithin  the first year of life, very rarely appearing
for the first time  after the age of puberty, yet  it has been
witnessed as a primary affection in old persons,  but always
in a modified form.  All the examples of icthyosis which I
have seen have been in persons, Avhether  children or adults,
of a well-marked  scrofulous diathesis.
   Diagnosis.—With no  other disease  of  the skin   can
icthyosis be confounded, so distinctly characterized is it by
the abnormal condition of the epidermis :  in the cicatrices
of wounds and of  burns  a peculiar warty growth is occa-
sionally developed, which, having  been first well described
by the celebrated French surgeon of the  name, has been
termed the warty ulcer of Marjolin ; this disease presents
characters someAvhat resembling those of icthyosis, but it
may be at once distinguished by its local nature, occurring
only in those parts of the integuments  which  have  been
previously the seat of some severe injury.
  Prognosis.—Icthyosis  has  been in all ages regarded
as being incurable ; it is at all events a most grave affec-
tion, and one which usually lasts  for years, if not for life.
When it presents  the aggravated  characters of the seArere
form, as above described, it should be regarded as beyond
the reach of medical skill, but if  it be submitted to treat-
ment in its early stages, and while it is yet of  a compara-
tively mild form, affecting the  surface  only partially,  the
progress of  the disease  may  be arrested, and  its  further
development prevented if it cannot be completely cured.
   Treatment.—From  the extreme obstinacy and  general
incurability of icthyosis,  many plans, as may be supposed,
                          18 
206
HYPERTROPHIE.
have been recommended for  its treatment, both constitu-
tionally and  topically.   The latter have  consisted chiefly
in means  to  soften and  promote the desquamation of  the
altered and hardened epidermis, and  the former in the  ad-
ministration  of the most powerful remedies which experi-
ence has shown to act specially upon the skin.  Warm water
and vapour  baths, with  the  preceding or subsequent em-
ployment of  oleaginous and greasy applications, constitute
the chief part of any method  which has proved at all suc-
cessful in the treatment  of icthyosis; their action is evi-
dently due to a direct effect in softening the hypertrophied
integument,  and thus promoting its separation;  but  ex-
perience has shown  that unless the state  of  the constitu-
tion on which  the abnormal  secretion depends be at the
same time changed, it is  again rapidly reproduced  in a
similarly  diseased condition.   " The easiest  mode,"  says
Willan, of removing  the  scales, is to pick them off carefully
with  the nails  from any part of the  body while  it is im-
mersed in hot water.  The layer of cuticle which  remains
after this  operation is harsh and dry, and the skin did not
in the cases  I have  noted recover its usual  texture and
softness :  but the formation of the scales was prevented by
a frequent use of the warm bath, with moderate friction."
More active  local applications  are recommended by  some
writers  on the  disease, such as sulphurous  baths,  stimula-
ting lotions, containing corrosive sublimate and other pre-
parations  of mercury, caustic,  potash, &c.
   In an account recently  published  by Professor  Banks1
of two cases  of  the disease which he treated  successfully,
cod-liver oil was employed  topically, and at the same time
administered internally;  at bed-time the patients  were
placed in a vapour bath, and  the surface of the body well
rubbed afterwads with the oil,  a flannel dress being always
worn next the skin, with the  view of keeping the surface
constantly impregnated  with it.   The use of  this  remedy
was, he says, suggested  to him  by the marked connexion
which  he has  seen  to exist  between icthyosis  and the
strumous diathesis.
   The internal administration of pitch was highly recom-
mended in this disease by Willan and Bateman, and  their
1 Dublin Quarterly Journal of Medical Science, New Series, vol. xii. p. 80. 
ICTHYOSIS.
207
experience of its benefits has been confirmed, especially by
Dr. Elliotson:  they ordered  it to be made  into pills with
flour, and increased the dose gradually, until from half-an-
ounce to an ounce was taken daily, and often continued for
months.   But both Rayer and Biett state that although
they gave this remedy a fair trial, it failed completely in
their hands.  The cold water treatment has also been tried
in the treatment of icthyosis, but in one case which I saw
it did not produce the least good  effect;  in this same case,
enveloping the affected  parts with wet  lint, covered with
oiled silk, also failed.
  The following plan of treatment I have employed in four
cases of icthyosis, in three of which  the disease was local,
being confined to the lower extremities in two, and engaging
the upper also  in the  third, and in these the recovery was
complete and permanent; in the other, the  integuments of
the body generally, except the face, the palms of the hands,
the soles of the feet, and some patches of the trunk, were
affected  with  the disease, which  commenced five  months
after birth, and was of three years' duration when I first
saw the child.  Here after a year and a half of treatment,
the epidermis had regained a tolerably healthy condition,
being only slightly hard and rough,  but if the local appli-
cations were omitted  for four or five weeks, it again began
to present a somewhat thickened appearance : this  case is,
consequently, still under treatment.   The remedies I used
were the iodide of  potassium and iodine, from one to two
grains of the former, and from a  sixteenth to an eighth of
a grain of the latter, according to the age of the child, given
once daily, in  from one to two ounces of the decoction of
elm-bark, made with  the recent inner bark, stripped  from
the growing tree; and an  ointment, containing  twenty
grains, gradually increased to one drachm, of the iodide of
potassium, a drachm of glycerine, and an ounce of prepared
lard, with  which  the  affected  parts were  well  anointed
morning  and evening; an alkaline bath—one  drachm of
carbonate of soda  to  each  gallon of fresh water, at the
temperature of 90° Fahr.—having  been used for fifteen
minutes previously to  each inunction, the body being^ well
rubbed  with a flesh-brush  while  in the bath.  An inner
calico dress was worn constantly, and milk diet was strictly 
208              HYPERTROPHIE.
 enforced.  I have had no opportunity, however, of trying
 the  effects of this method of treating icthyosis in adults,
 the four cases in which it proved so successful being children
 below the age of eight years.


                       MOLLUSCUM.
   Molluscum.—The origin of the employment of this term
 to  designate a  diseases of the cutaneous  structure, which
is chiefly interesting in consequence of its extreme  rarity,
has  been  a matter of  discussion.  Used  by Willan  and
Bateman at a time when they themselves, not having seen
the affection, obtained their knowledge of it from the  account
of a case—published in 1793 by Ludwig—that occurred in
the practice of  Professor  Tillesius of Liepsig,  it is most
natural to infer that its application was derived from  the
description  therein contained, in which the small tumours
that constitute the disease are said to  consist in " verrucis
mollibus sive molluscis ;" yet nearly all the French derma-
tologists ascribe its employment to some imaginary resem-
blance between them and the minute excrescences that form
on the bark of the maple tree.  It  is characterized  by  the
development on  the skin of round, slightly umbilicated, soft
tumours, varying in size usually from that of the head of a pin
to that of a nut, but described as occasionally acquiring  the
magnitude of a pigeon's egg; they are of a yellow or pink-
ish-white  colour,  sessile,  rarely  pedunculated, scattered
irregularly over  the surface, yet occurring not unfrequently
in small groups, of slow growth, and unattended with either
local pain or constitutional irritation.   When  pressed  be-
tween the fingers, a small quantity of a thick, whitish fluid
exudes from the  minute aperture that forms the umbilicated
apex of each tumour, the exudation being evidently altered
sebaceous secretion.   They appear on all parts of the cuta-
neous surface, but  are most freqently witnessed on the face,
and  most rarely  on  the  extremities;  their  duration is
uncertain, in some cases ulcerating and falling  off  sponta-
neously, their site being marked by  a  slight cicatrix, in
others lasting for  life, without undergoing any increase in
size, but the skin covering them becomes darker coloured or
brownish, and  the tumours themselves  acquire a  certain 
molluscum.                209
degree of hardness.  The internal structure of the tumours
of molluscum is cellular, a transverse section often exhibit-
ing five or six divisions, each of which corresponds to a duct
of the  sebaceous  follicle, and contains altered  sebaceous
matter.
   Bateman,  after  witnessing  some  cases of the disease,
described it as consisting of two varieties, which  he named
molluscum contagiousum and molluscum non-contagiousum,
but inasmuch as it is doubtful that the latter, as described
by him, was truly molluscum, and at all events as the dis-
tinction he drew cannot be regarded as sufficient to consti-
tute a specific  difference, his division must  be  abandoned.
The  eruption  consisting admittedly  in a  hypertrophied
state of the sebaceous follicles, and  being therefore  of the
same nature, anatomically considered, as Acne,  some recent
French writers, epecially MM. Caillault1 and Bazin,2 have
regarded molluscum as a species of that disease, the former
termed it Acne molluscoides, and the  latter Acne varioli-
formis : the absence of local inflammation, however, clearly
distinguishes it from  that affection.   The  best division of
the disease, I consider, is that proposed by  Dr. Craigie,  in
an able essay published in the seventy-fifth volume  of the
Edinburgh Medical and Surgical Journal, namely, into

                   Molluscum acutum;
                       ,,     chronicum.

   Acute molluscum agrees, in all respects, with  the form
which is generally regarded as being contagious;  it  occurs
usually on the face and neck of children, and from them is
conveyed to adults, almost invariably, however, of the same
family.  It is developed at  first in  the form of minute
papulae, scarcely noticeable, and unattended with any local
symptoms, these gradually increase, until, in from six Aveeks
to two months, they  attain  the  size  of a  small currant,
which they resemble much in shape, being somewhat pellucid,
and sessile on  the portion of integument from which they
grow.  Their duration is seldom  prolonged for more than
six months,  but their progress is often more speedy, termi-

   1 Archives Ge'ne'rales de M6decine, 1851, vol. xxii. pp. 46 and 316.
   2 Journal des Connoissances Me'dicales, 1851, p. 277.
                          18* 
210              HYPERTROPHIE.
nating either  by ulceration, which first commences at the
apex, an  opening being there formed through which the
altered  sebaceous matter contained in them is  discharged,
Avhen the small tumours collapse and shrink away, or by an
attack of  local inflammation, when they slough off, leaving
a pit like  that resulting from small-pox.  In most cases the
molluscous growths are developed in successive crops.
  In  chronic  molluscum,—the molluscum  pendulum  of
Willan,—the tumours, which are more generally distributed
over the surface  of the body, attain a much larger size, and
are more  frequently pedunculated; they  are  sometimes
very few in number, may even be solitary, but occasionally
several of them  are developed on  different  parts  of the
integument at the same time.  This form is most frequently
witnessed  in adults, and runs an essentially chronic course,
lasting  often  for life if uninterfered with, yet  with but
little increase in size.  Occasionally, as in the acute variety,
inflammation attacks some of the tumours and they slough
off.
  The chronic and acute forms of molluscum differ  espe-
cially, to use the words of Dr. Craigie,  " in the circumstance
of the latter being propagated by a specific  matter, while
the former is, so far as is hitherto known, entirely incapable
of such communication."  This contagious property, though
its  existence is  denied by  many modern writers  on the
disease, is, I think, too  well established  by the numerous
cases which have been recorded  by Bateman, Craigie,
Thompson, Carswell, Henderson, Willis,  &c, to  admit  of
doubt.   M. Caillault, in the  essay on the  disease recently
published  by him, to which I  have referred above, states
that he himself did not believe in  its contagious  nature
until it was proved to him  in April, 1851, in one of the
wards at the Hospital St. Louis, at Paris, fourteen children
out of thirty having taken the disease in the course of three
months from a little girl who had  been admitted with nume-
rous molluscous tumours on the face.  Mr. Erasmus Wilson,
while denying the communicability of molluscum by con-
tagion,  narrates  a case  in  which one child of a  family
having  been brought to him affected with the disease, it
appeared  in a  few weeks afterwards in the mother and two
other children,  an infant,  and a girl six years old ;  he 
MOLLUSCUM.                211
adds :  " I quieted her alarm relative to contagion, but was
much struck by the fact of the almost simultaneous appear-
ance of the disease upon four members of the same family.1
I have myself witnessed two instances in which the acute
form of this affection was communicated by  children to
adults, in  each case members of the same family."   I have,
therefore, no doubt in my mind  as to its  possessing the
property of being propagated by  direct contact, as from
persons sleeping  together, or in the case of children while
at play.
   As regards the causes of molluscum, in either of its forms,
but little is known ; the  acute variety is most frequently
met with in children of the female  sex, rarely occurring in
adults unless when it is communicated to them by children ;
the chronic form as already remarked, is generally witnessed
after the age of puberty, and is not unfrequently connected
with a deranged condition of the general health,  while the
former occurs in the most healthy individuals, the skin of
those affected, however, is usually fine and soft.
   The  diagnosis of this  disease is unattended with diffi-
culty ;  from wrarts, for which the little  tumours might be.
mistaken, they are distinguished  by their shape, their soft-
ness, their colour, and the central depression at their apex;
from fatty, or other pendulous tumours, in addition to these
characteristics, their slow  development and growth aid as
diagnostic marks.
   Prognosis.—The chronic variety of molluscum may last
for life Avithout the least injury to  health or impairment of
the  constitution,  but  occasionally  troublesome  symptoms
may arise from attempts  made  to destroy or remove  the
tumours.   In one instance communicated  to  me  by Dr.
Lees, the case of a female, aged 18, who was under his care
in the Meath Hospital,, the application of potassa fusa was
followed by erysipelas,  which terminated fatally.   Acute
molluscum generally disappears spontaneously in from four
to six  months.
   Treatment.—Internal remedies  do not appear  to have
any effect over molluscum, and  are therefore not required
in its  treatment, except  such as may be calculated to re-
store a healthy condition of the system generally, should it
          'On Diseases of the Skin, Third Edition, p. 387. 
212
HYPERTROPHIE.
be deranged.  Local  applications are  not advisable in the
chronic variety of the disease, but the tumours may be
snipped off  with  a sharp  pair of scissors, and the surface
then touched with lunar caustic, provided the patient be in
a state of good health, but when such is not the  case this
should first be attended to.  In the acute form, the employ-
ment of a slightly stimulating lotion, as of sulphate of zinc
or sulphate of iron, ten grains of either to an ounce of dis-
tilled water  and a drachm of rectified spirits, hastens  the
throwing off of the small tumours.

                      STEARRH03A.
   Stearrho3A is  a disease of the sebaceous follicles, char-
acterized—as the name o^ap ptw indicates—by augmented
secretion and discharge of their  natural contents,  the folli-
cles themselves and their excretory ducts being at the same
time somewhat  hypertrophied.   The increased  secretion
may consist merely in an  excessive amount of the natural
oily matter or smegma destined for the preservation of the
skin from  external irritants, or in its  discharge on  the
cutaneous surface in a vitiated condition, where it concretes
and forms a thick adherent layer, varying in colour from a
rich  yellow hue to nearly black.   The former is of very
frequent occurrence, and  can scarcely be  regarded as con-
stituting a disease, while the latter, a rather rare affection,
is  of extreme  obstinacy, usually resisting treatment  for
years.   Three varieties of  the  disease, thus  constituted,
require to be noticed :—

                   Stearrhcea simplex.
                       „    flavescens.
                       „    nigricans.

   Stearrhoea simplex (Sebaceous flux) is marked chiefly by
an oily or greasy state of those parts of the integument in
which  the sabaceous  follicles are numerous,  as  the nose,
the cheeks,  the ears, the scalp,  and other regions where
hair grows ; it is an accompaniment usually of  a coarse,
sallow condition of the skin, and is generally witnessed in
a class of persons who are liable to be affected with acne, 
STEARRHCEA.
213
 as noticed in the description of that disease.  The orifices
 of most of the sebaceous follicles are usually much dilated,
 but  others, becoming obstructed, present the appearance
 regarded as  being characteristic of  acne punctata.   This
 state of the cutaneous  surface  is manifestly hereditary in
 most cases, and  is a constant  accompaniment,  or rather
 may be regarded as a  sign of the  scrofulous diathesis; it
 lasts generally during  life, appearing in youth,  but  being
 less  marked in old age ; and although indicative, cannot be
 considered as a cause, of an unhealthy constitution; when
 it exists,  the natural perspiration is deficient  in quantity,
 and  congestive or inflammatory affections of some of the
 internal organs, assuming, hoAvever, a scrofulous  character,
 are more apt to occur.
   Stearrhoea flavescens.—It is  only of late  years that this
 affection, which is of rather rare occurrence, has attracted
 the attention of dermatologists ; Rayer was  the first  to de-
 cribed it  under the name of sebaceous flux, and after him
 it was specially noticed by Biett, who,  regarding it cor-
 rectly as dependent on a  diseased condition  of the seba-
 ceous  follicles, although admitting the  difference  which
 exists  between it and  the  true pustular acne,  made it a
 species of that eruption, under the name of acne  sebacea.
 Erasmus  Wilson gives  an illustration of the disease in his
 beautiful  Portraits of Diseases of the Skin, where he terms
 it Inflammatio Folliculorum, while  in his octavo work  he
 describes  it under the name I have adopted.
  It is characterized by an exudation from the  sebaceous
 follicles of their natural secretion,  more or less  altered,
 on the surface of the  skin, where it forms  a  yellowish or
 greenish-yellow crust or layer—in the former  case resem-
 bling the  cerument  of  the  ear, of  variable  thickness and
 consistency, at times so often  as to be  readily wiped  off,
 but more generally hard and firmly adherent.  By expo-
 sure  to the action of the atmosphere the effused matter
gradually acquires a darker tint, presenting  at length a
brownish  hue,  and numerous cracks or  fissures divide it
into  small packets,  which  often correspond with the  li-
near markings  of the skin.  The portion of  integument on
which  the diseased secretion had been seated, if  examined
after its removal, is found to be more or  less injected, not 
214
HYPERTROPHIE.
unfrequently inflamed, and the  sebaceous  follicles hyper-
trophied,  with  their  orifices  enlarged and filled with the
peculiar matter, the presence of which constitutes the dis-
ease.   The crusts on the surface are rapidly renewed after
their  removal, and, if uninterfered with, soon form a layer
three or four lines in  thickness.  The parts  affected are
the seat of sharp tingling, occasionally of stinging  -pains,
accompanied by heat  and itching.   There is  generally,
also, a  deranged state of the health, evidenced more espe-
cially by  the condition  of  the  digestive organs, in  those
persons on whose skin the  disease  appears, and  from its
occurrence most usually on  the face, causing, in  conse-
quence, much disfigurement, great mental  distress is occa-
sioned.
  Stearrhoea flavescens, as  is evident from the description
now given, is an  affection  of the  sebaceous follicles, and
is, therefore, witnessed only on  those regions  of the skin
where these  glands exist, being of  most  frequent  occur-
rence in the parts in  which  they are most numerous;  it
therefore  appears usually on the nose, the cheeks, the eye-
lids, the ears, and the scalp,  but is also seen  occasionally
on other portions  of the integument.   It  runs essentially
a chronic  course, spreading  in general but  slowly from
where it  is first  developed,  and, if removed by artificial
means, being again quickly  reproduced.
  Stearrhoea nigricans, although differing from  the form
now  described  apparently  only in  the colour of the ef-
fused diseased  secretion, which is  nearly jet black, de-
serves a special  notice, in consequence of  the  singularity
of  the  appearance which  is  presents, and  its extreme
rarity.  In it the  matter discharged from the follicles is of
a thinner  consistence than  in stearrhoea  flavescens,  and is
from  the  first of  the  same dark colour, which, moreover,
stains linen, or any other  substance  with which it may
come  in contact.  From the few cases of the disease  which
have been  recorded, it would appear also to  be  attended
with  more local irritation, at times amounting  to  severe
pain and burning heat.   Its occurrence is accompanied by
general  constitutional  disturbance,  and in one case re-
corded  by Mr.  Teevan,1 which  had been  first under the
        'Medico-Chirurigical Transactions, vol. xxviii. p. 611. 
STEARRH03A.
215
care of Dr. Read of Belfast, if the  secretion of the disease
matter on the surface was arrested by  local treatment,
black vomiting, and  the  discharge of a black substance
from  the bowels  and kidneys,  took  place immediately.
The black secretion  in this patient,  a young  lady,  was
analyzed by Dr. G. 0. Rees, and found to consist  of  car-
bon, iron, lime, albuminous matter, fatty matter, and alka-
line chlorides and phosphates.  The instances  of this pecu-
liar affection which have  been published were  seemingly
even more obstinate than the second  form of the disease
which I have described : it was in all of them situated on
the same region of the skin.
  The causes of any of the  forms  of stearrhoea  are very
obscure; the first  is both congenital and  hereditary, but
the others have not been proved to  be  either ;  they appear
only in persons who have attained the age of puberty, and
are very rarely witnessed in advanced life, yet I have seen
one example  in which stearrhoea flavescens was  developed
on the nose after the age of seventy; they occur, too, with
much greater frequency in  females than in males, and in
the former their connexion  with  suppressed  menstrua-
tion or uterine  derangement, has been in some  instances
noticed;  but in the majority of cases their  development
is preceded and accompanied rather by  derangments of
the digestive organs.
  Diagnosis.—Stearrhoea simplex  cannot  be confounded
with  any other  affection of  the skin; the other forms,
however, in consequence chiefly of their rarity, are often
not recognized when they  occur,  and therefore  occasion
much doubt as to their nature.   Thus, an  account of five
cases of what, from the description and accompanying illus-
trations  I  conceive to be stearrhoea flavescens,  has been
recently  published by Drs.  Addison and  Gull,1  but deno-
minated  by them Vitiligoidea plana and Vitiligoidea tube-
rosa, from a supposed correspondence between  the affec-
tion and the incorrect definition of vitiligo, Avhich was given
by Willan; and the case of  Mr. Teevan, above referred to,
was originally communicated to  the  Medico-Chirurgical
Society  of London,  as  being an  example of  Pityriasis
nigra.
       ) Guy's Hospital Reports, New Series, vol. vii. p. 265. 
216
HYPERTROPHIE.
  Prognosis—Stearrhoea flavescens and Stearrhoea nigri-
cans are both most obstinate affections, and appear to be
equally rebellious to all plans of treatment, but are chiefly
important in consequence of the  disfigurement which they
occasion, being not in the least degree attended with any
danger to life.   In the former, I have seen the sebaceous
follicles take on  an active inflammatory action when caustic
applications  were applied  to  the  diseased surface,  and
indolent  pustules form, which, on the continuance of the
irritation, terminated  in obstinate ulcers, with  hardened
elevated 'edges.
   Treatment.—The first and most important point to be
attended to  is the restoration of a healthy condition of the
system;  this is  best  effected by the internal administra-
tion of alteratives, combined with  alkalies, such as the
hydrargyrum cum creta-with dried  carbonate  of soda, or
cod-liver  oil with  lime water,  according  to the circum-
stances of each case; the  latter combination  is readily
taken in  milk, from one to  four drachms of the oil being
given  three times  daily, in  one ounce each of lime water
and new milk, previously mixed.   As soon  as the state of
the digestive organs is improved, or the menstrual func-
tion restored, preparations of iodine,—especially the syrup
of the iodide of iron,  or the iodide  of potassium in some
tonic  vegetable  decoction or infusion,—will be prescribed
with benefit.  Of course the employment of  purgatives,
when  requisite,  should  not  be omitted.  The local appli-
cations that are found most useful are generally stimulating
and astringent lotions and ointments.  The affected surface
should be sponged three or four  times a  day with the
spirituous lotion recommended for  acne simplex (see page
123),  an  ointment containing ten grains of the iodide of
potassium to  the  ounce of  cold cream being  applied at
night,  or  a  solution of the  iodide of iron,—two grains to
the ounce of rose or  elder-flower water, and dilute citrine
ointment  may be  used.  No matter what remedies, how-
ever, are employed, they must be continued for a very long
time, and local  means  will  be found unavailing until the
general health is restored.   The application of caustics  I
have invariably seen productive  of  injurious consequences.
When  the crust  of effused  sebaceous matter is hard,  dry, 
ELEPHANTIASIS.              217
and  adherent to the surface, it should  be removed by the
application of poultices or of water dressing, previously to
the use of topical remedies.

                     ELEPHANTIASIS.
   The  term  Elephantiasis   has been applied, both in
ancient and  modern  days, to  designate two perfectly dis-
tinct diseases of the integuments ; the one, which has been
specifically denominated  elephantiasis  Cfrsecorum;  is be-
lieved  to be  the true lepra or leprosy  of antiquity, while
the other, which, from having been first accurately described
by the  Arabian physicians, has been termed elephantiasis
Arabum, does not bear the least analogy to it.   Consistent
with the scope of this work, neither of them requires  or can
obtain  a detailed notice, inasmuch  as the former is never
witnessed in  European countries in the present time, and
the latter is of extremely rare occurrence.
   Elephantiasis Crsecorum is characterized by the develop-
ment on  the  integuments of numerous  globular tumours,
varying in size from that of a pea to that of an apple, soft
and yielding to the touch, at first of a dusky or livid hue,
but  aftenvards  becoming brownish-yellow or of a bronzed
tint.   They occur most usually and in greatest  number on
the face, but  may appear also on every region of the body;
the skin of the part affected is  much hypertrophied, raised
into irregular  elevations, and  of an unhealthy  diseased
appearance,  causing  the  sufferers  from the   disease to
present  a hideous  aspect, described by those who have
Avitnessed it  to  be revolting in the  extreme, whence they
have in  all  ages been regarded with abhorrence, as indi-
viduals specially afflicted.  Both mind  and body share at
length  in  the local  disease, the senses become  obtuse,
fatuity  creeps on,  and  all the  bodily  functions are de-
ranged.  Eventually the tumours ulcerate, exude an ichor-
ous  matter, and form  unhealthy, open sores ; the bones
soften, and become affected Avith caries ; mortification not
unfrequently attacks  the smaller joints, and  death soon
terminates sufferings which are extreme.
   This  disease,  which  is still  endemic in many countries
in tropical climates, Avas in the  middle centuries of common
                         19. 
218
HYPERTROPHIE.
 occurrence  in temperate  latitudes also,  hospitals being
 specially built and endowed for the reception and isolation
 of those whom  it attacked: Professor Simpson, of Edin-
 burgh, has published a most interesting and learned history
 of those that existed in England and Wales j1  there were
 several of  them in Ireland also, and the name of ' Leper
 Hospital' is still retained  for  the  infirmary in  the city of
 Waterford,  now happily no longer  required for  the recep-
 tion of individuals affected with a disease  similar to  that
 for which it was  originally built.   In some of the  more.
 northern regions of Europe, a form of elephantiasis  Grae-
 corum is even in the present day of not unfrequent occur-
 rence ,  it is known in Sweden and  Norway by the name of
 'Spedalskhed,' and has been  recently described and illus-
 trated in a magnificent  work, undertaken by the desire and
 at the expense of the Norwegian Goverment, by two Danish
 physicians,  Danielssen and Boeck.
  Elephantiasis Graecorum was, in  former times, regarded
 as highly contagious, but it is more probable, judging from
 the accounts of  it  which have come down to us,  that it was
 rather  endemic  than infectious,  and that it was directly
 caused by misery, deprivation, and filth.  Treatment seems
 to have had but little  effect over it, for although isolation
 and hygienic measures then and in the present day checked
 its  progress,  it  almost  invariably re-appeared in those
 whom it had selected as its victims.
  Elephantiasis Arabum (Barbadoes leg.)—The popular
 name for this singular  affection indicates its frequency of
 occurrence in the West  India Islands, where it is endemic,
 but cases of it  are also witnessed  in Egypt, in America,
 in various  countries  of Europe, and, as  Avas  remarked
 originally by Dr. Graves,2 are not very uncommon in Ire-
land ; it is, however, less frequently seen  now than at the
time his account of it was published, twenty-six  years ago.
  The disease consists  in an extreme degree of hypertro-
phy, affecting ■ one or both  of the  lower extremities, the
scrotum, the hands  or arms, and occasionally even the face,
and the mamma and pudendum  in females ;  the enlarge-
ment  affects  equally the skin and  the subcutaneous and
   1 Edinburgh Medical and Surgical Journal, vols. lvi. and lvii.
   2 Dublin Hospital Reports, vol. iv. p.  51. 
ELEPHANTIASIS.
219
deep-seated areolar tissue, so as to produce an enormous
swelling  of  the part attacked, one of the legs  not unfre-
quently exceeding  in  magnitude the girth of the body.
It commences usually with  symptoms of local inflamma-
tion chiefly engaging the lymphatic  system, and general
constitutional derangement; these attacks are of  frequent
occurrence,  and  after  each,  the  parts  engaged become
more and more  swollen, chiefly  from  effusion  into  the
areolar texture; but in some cases, especially in temperate
climates, the enlargement comes on slowly,  and gradually
augments without any apparent disturbance of  function,
local or  general.  When the  affection is fully developed,
the  integuments, Avhich  are  enormously  thickened,  are
generally of a whitish  colour,  rough  and swollen, and
present deep furroAvs, occasionally the seat of ulceration,
a thin, ichorous discharge, which concretes into hard, scaly
incrustations,  then  issuing from  them.    To the  great
hypertrophy of the  integuments is due the name of this
disease, but in order to distinguish it from that last described
the term  Pachydermia, first proposed by Fuchs,  has been
adopted by many modern dermatologists.
   When the scrotum  is the part  affected,  as it  very fre-
quently is in the  coloured population of tropical  climates,
it  attains at times at enormous magnitude ;  Horner, in his
Medical  Topography of Brazil, narrates two instances  in
which the tumour situated there measured four feet in cir-
cumference.   The upper extremities, when attacked by
the  disease, do not acquire as large  a size as the lower,
manifestly in consequence of their containing less areolar
tissue.  The palms of  the hands and soles of the feet  are
never affected.
   The causes  of  elephantiasis Arabum are altogether  un-
known, if we except its apparent  connexion with inflam-
mation of the  lymphatics ; it is not contagious ;  it affects
both sexes equally, and occurs at all ages, but is more fre-
quent in  adults than in children.   Its much greater preva-
lence in hot countries,  and its being more frequent there
in those districts  which are  characterized by the  presence
of moisture, indicate the effect  of heat and damp conjoined
as an exciting cause.
  There  is no difficulty in diagnosing this  disease in its
advanced stages;  in its commencement it  might  be mis- 
220
HYPERTROPHIE.
taken for angeioleucitis, from  which it appears to differ
simply in its symptoms  being less acute, and in its  never
terminating  in the formation of purulent  abscesses.  Its
duration is  essentially chronic, but although its  presence
renders life a burden, it in very rare cases seems to prove
fatal.
  An anatomical  examination  of the parts in this form
of elephantiasis exhibits the derma and epidermis usually
much hypertrophied, the former  sometimes  constituting
a layer  an inch in thickness, but the enlargement  of the
affected regions is due chiefly to the change in the areolar
membrane, from  the deposit sometimes  of fat, but more
usually of a substance almost as firm as fibrous tissue, and
of a lardaceous appearance, which to the  naked eye re-
sembles the  natural structure compressed.   Lebert and
Gustav  Simon, who examined  the  new  deposit with  the
microscope,  found it to consist  in fibrous bundles of pure
areolar tissue, fully developed, or in the process of  forma-
tion, with numerous fat cells in the interstices.
  Treatment.—In the early or inflammatory stages of ele-
phantiasis Arabum, antiphlogistic treatment is clearly in-
dicated, but this must be constitutional  and  not  local; if
a limb be the part  affected  it should be kept at rest, and
placed in the horizontal position above the level  of the
body.  Active purging  seems to have  been  the plan  of
treatment that proved most successful in those cases which
have been reported, and even in the chronic stages, when
other remedies  generally fail  to prove beneficial,  it  has
been  useful.   When the  disease becomes  chronic, iodine
frictions and firm bandaging have also been recommended,
but they usually fail to  produce any manifest  effect: am-
putation  of  the parts, if possible, has been then advised,
and  ablation of the hypertrophied  scrotum has, in many
instances, been resorted to  with  success;  but as regards
the  limbs, the removal of one of them  has  been  usually
followed  by the development of the disease in  another,
thus, in a case reported by Cazenave, in which a leg, the
seat of elephantiasis, was removed, the arm became affected
soon afterwards. 
VERRUCA.
221
                       VERRUCA.

  Verruce  (Warts,) both in consequence of their  ap-
pearance  being familiar to  all from their  extreme  fre-
quency, and  of their  unimportance, scarcely require  de-
scription ; they consist  in a hypertrophied  condition of a
small patch of the papulae of the skin, by which  a round
tumour, with a flattened top, varying  in size from  that of
the head of a pin to that of a large pea, is formed.  They
are of most frequent occurrence on the hands, next on the
face,  and are rarely witnessed  on those parts of the body
which are ordinarily covered.  They are  generally placed
singly on the integuments, but  occasionally two or three
originate close to each other, and these sometimes coalesce.
Warts appear in the early periods of life, being seldom
developed for the first time in adults ; they often disappear
spontaneously,  and  even  suddenly, at the approach of
puberty, but sometimes, becoming indolent,  are permanent.
   Some persons are peculiarly  liable to warts,  and the
tendency to them seems to be hereditary; their immediate
cause has not been satisfactorily ascertained, but that it is
more or less connected with local irritation, and the effects
of  the atmosphere on the skin, is evident from their being
almost altogether confined  to those parts which are ordina-
rily exposed to the action of the air.  Small growths, soft
to the touch and slightly pediculated, are of frequent occur-  •
rence on  the  face and neck, particularly of females, and
are also regarded as a  variety of wart; they appear to me
to consist in the hypertrophy of a single papilla, but  Mr.
Erasmus  Wilson believes  them  to  be " the emptied tegu-
mentary sacs of small sebaceous tumours."
   Warts  are easily removed by the application of some
strong  caustic—strong nitric acid  is, in my opinion, the
best—to their apex; the layer  thereby cauterized  should
be  pared off in twenty-four hours, and the caustic again
applied, and this process repeated until the entire  of the
abnormal structure is  destroyed;  when the wart is small,
a single  application sometimes suffices, provided a large
drop of the acid is placed on the apex, and permitted to
soak into its structure.   The soft pediculated warts are
                           19* 
222
HYPERTROPHIE.
   readily destroyed by strangulation, by means of a hair or
   a thread of fine silk being tied tightly round their neck.

                           CLAVUS.
     Clavi (Corns).—These excresences, almost peculiar to
   the feet,  being equally common, although causing  a much
   greater  degree  of local  uneasiness and  suffering,  do  not
   require more notice than warts.  They consist in thickening
   and hardening of the epidermis of some prominent  portion
   of the integuments, usually over one or more of the joint8
   of the  toes,  attended  with  hypertrophy  of some  of  the
   papillae beneath ; the latter, which from the pressure acquire
   much hardness, are popularly believed to be  the roots  or
   core of  the corn.  They are regarded generally as  being
   produced by pressure, but although  they are kept up, and
   their growth increases by this mechanical cause, that they
   are originally occasioned thereby is, I think,  disproved by
   their constant occurrence in the  usual site on the feet of
   persons, who  have neArer worn  shoes  or other covering
   whereby pressure could be caused  on the parts : of this I
   have seen numerous  examples.  Their development  also
   between the toes,  on a portion of the integuments especialy
   protected from any undue  compression, affords an additional
   argument against this  view; that the extreme degree  of
   hardness, however, which they usually present, and to which
.   the  local sufferring they give  rise to is chiefly due, is de-
   pendent on pressure, is proved by their being comparatively
   unindurated when situated here, whence they are termed
   soft corns.
     Corns occasionally become the seat of active inflammation
   when irritated by any  cause, or when they have been  cut
   too freely, and afterwards subjected too soon to compression
   and friction by the shoes  in walking; purulent matter then
   often forms beneath them, and, from its being  firmly bound
   down by the hardened superincumbent  tissues, extreme
   suffering results, followed sometimes by inflammation of the
   lymphatics and the formation of buboes in the groins; they
   have thus ended  even fatally, from  the occurrence of ery-
   sipelas, and in some instances from tetanus comino- on.
     Although, as above remarked, corns are almost invariably 
callositates.               223
confined to the feet, they may also be developed on other
parts of the body, but they then partake more of the nature
of callosities; I  have in a  few cases seen  them  on  the
knuckles  of  the  fingers  of persons,  too,  in  whom  the
hands were not exposed to any manual labour that could
exert pressure on the parts affected.
  The treatment of these morbid growths consists in their
ablation, by  means  of the knife patiently and  gradually
employed, until all traces of  hardened tissue are removed,
and  afterwards protecting the  parts  for  some time from
pressure ; this is the only effectual remedy, and  is the one
always adopted by the self-styled chiropodists.  The appli-
cation of caustics never succeeds in destroying them com-
pletely, but is of use in enabling the  hardened surface  to
be pared off without  causing hemorrhage.  Corns, whether
hard or soft, may generally be kept in abeyance, as regards
troublesome symptoms, by removing the  superficial layers
with the knife from time  to time, according to the rapidity
of their growth, or by rasping them with  a file, the surface
having  been  previously softened by maceration in warm
water.  Most of the corn-plasters which are ordinarily sold
in the  shops contain carbonate of  potash,  the alkali  of
which dissolves partially the horny substance which consti-
tutes the outer layer of the growth, or, a round hole being
cut in the centre of  each piece, they act  by removing the
pressure from the most prominent point of the corn, which
is directed to be pared previously to their  application.

                     callositates.
  Callositates.—Callosities consist simply in thickening
of the  epidermis, which  becomes  of  more or less horny
consistence, produced by friction or  continued  pressure;
they are usually witnessed  on the palms of  the hands  or
on the  soles  of the  feet, when  their cause  is in  general
sufficiently evident.    Occasionally they are  attended with
some degree of inflammation of the derma over which they
are developed, which may result in the formation of pus,
or in the effusion of  a serous fluid beneath  the  hardened
integument.  They  are Avitnessed also over  inflamed and
enlarged bursae mucosae, especially on the metatarsal joint 
224              hypertrophie.
of the great  toe, where they are manifestly produced by
pressure from the boot or shoe,  and their presence tends
to aggravate and increase  the  original  disease.  Their
treatment in  the chronic stage should be the same as  that
for corns, but when inflammation is present, cataplasms
and soothing applications should be employed, and in all
cases  the exciting causes  should of course be removed.

                    condylomata.
   Condylomata.—Generally the result  of  the  syphilitic
poison, but at times developed in persons in  whom no  such
taint exists, these soft, fleshy tumours appear  on those parts
of the integument where the skin and mucous membrane
meet, at the verge of the  anus, on the prepuce, at the vulva,
and occasionally, though very rarely, on  the lips  and nos-
trils.   They are of a soft consistence and a reddish-white
colour, varying  in size from that of a pea to that  of a
marble, and  have usually a broad base, with a  flattened
or rounded apex.  They consist of numerous papillae  in a
highly vascular condition, though  apparently not much
hypertrophied, and the epidermic  covering  is unchanged,
except in being more  vascular than in its  healthy state.
Various  opinions have been propounded as to the  nature
of condylomata; Simon  and Rokitansky regard  them as
being a new formation, consisting chiefly of  areolar tissue,
while Lebert believes that they  are epidermic or  epithelial
growths.   They may be destroyed by the  application of
caustics,  or strangulated with a  ligature, which, by means
of a  needle, may be  passed through the  centre  of the
tumour,  and  then tied  firmly at either side around the
base.

                        NEVUS.

   Nevus.—(Mother mark).—Of  the several varieties of
this adventitious production which have been described, but
one only can  be regarded as a disease of  the skin, namely,
that which consists in a hypertrophied  condition  of the
capillaries of a  portion  of  the  cutaneous  structure; the
others, in which the vascular system of the  areolar tissue, 
NEVUS.
225
and sometimes even of the deeper-seated parts, is engaged,
are truly surgical diseases, requiring usually surgical inter-
ference for their removal, and are consequently treated of
in all works on  surgery.   All the forms are usually con-
genital, and are popularly believed to be occasioned by  the
effect of the mother's imagination upon the foetus in utero,
an opinion shared  in by the profession  even until modern
times, and not yet altogether  exploded.
  The variety of naevus to be described  here  is character-
ized by a permanent discolouration and slight elevation of
the part  affected, on which the minute  veins of the cutis
appear  dilated  and  slightly tortuous,  becoming  gorged
Avith blood from  any exciting cause, and thus the  colour
varies at different times, being dark red, or purplish, Avhen
the circulation is  hurried  or impeded.   They vary in size,
sometimes consisting of a  small  central point, from which
several  minute  vesicles ramify — a  form termed naevus
araneus,—in  other  cases covering a patch of  the surface
from the size of a shilling to that of the palm of the hand,
when they are usually irregularly circumscribed, but often
roundish.   They seldom  enlarge  much after birth, but,
occasionally affecting the  deeper  vascular structures, they
become converted into one of the other forms of the disease,
which consist of erectile tissues, when they acquire a greater
magnitude, and are not unfrequently attended with trouble-
some or even  dangerous symptoms.
  If the nasvus which  engages the cutaneous capillaries be
wounded,  copious hemorrhage, often  difficult  to check,
ensues,  but otherwise  they are of no importance, except
from the disfigurement which their presence occasions,  the
more especially  as they are usually situated  on  the face.
On this account attempts  have  been  at  times made to
remove them  by caustics and other  means, but  a greater
deformity is  thereby often occasioned;  unless, therefore,
they exhibit a tendency to spread much,  or to be converted
into one of the other forms  of the disease, they should not
be interfered with. 
226
HEMORRHAGIE.
                CHAPTER  VIII.

                    HEMORRHAGIE.

  The single disease which constitutes  the order Hemor-
rhages: might perhaps be  more  correctly regarded as an
affection of the system generally, but as its  chief charac-
teristic phenomena become apparent to the eye through
the medium of the skin, custom has  sanctioned its being
described as a lesion of that structure.   In  cutaneous he-
morrhages the blood does not  escape from the surface of
the body, but, being  bound  down by  the  epidermis, is
effused beneath it in variously sized and differently shaped
spots or patches.   At times, in certain  diseases, especially
fevers  characterized  by low  vital power, of  which this
constitutes  one of  the most important signs, the  hemor-
rhagic  effusion is in the form  of perfectly distinct, minute
dots, termed Petechia?.   In other cases, occurring alone or
complicating  the  former, it appears in  irregularly circum-
scribed  patches,  often of  large extent, the  blood escap-
ing chiefly  into  the  subcutaneous areolar  tissue, these
are denominated Vibices or Ecchymoses, the latter term
being  especially  applied to them when they  succeed a
blow or injury.   And in  a third  form, which constitutes
Purpura, the only one here to engage attention, the he-
morrhage is in perfectly circular spots :  intermingled with
them,  however,  are  usually  several patches—vibices  or
ecchymoses.

                       PURPURA.

   Purpura (The  Purples) is characterized by the appear-
ance on the integuments, generally over the Avhole body,
of small, perfectly circular spots of the colour of the blood,
attended with more. or less derangment of the vital func-
tions.   The spots vary in size  from that  of  the head of a
pin to  that  of a small pea ; on their first appearance the
colour is  bright  red, but  augmenting  slightly  in  extent, 
purpura.
227
still  preserving their circular form, they gradually acquire
a  deep purple  hue,  which,  as they  fade away,  passes
through the various shades of greenish-yellow discoloura-
tion  ordinarily  presented  by blood effused beneath  the
skin  from a bruise.  They are  generally  very numerous
on the cutaneous surface, and often  aggregated in masses
on certain regions,  yet 'perfectly distinct from  each other,
except in some parts which may be exposed to pressure,
Avhere, becoming  confluent, they constitute vibices  or ec-
chymoses.  Each individual spot of purpura runs its course
from  its first  appearance until it  fades away in from five
or six to ten or  twelve  days, a slight stain remaining for
some time to  mark  its  site ; but the disease may last for
many weeks, or  even months, its duration depending upon
the development of successive crops of the eruption, an
occurrence which takes place in the mildest cases.   The
spots or patches are not in the least degree elevated above
the  cutaneous  surface, their presence being caused by an
extravasation of blood into the derma  or  beneath the epi-
dermis from the capillaries of the skin.
   The appearance of purpura is most usually preceded by
slight febrile symptoms and general depression,—hot skin,
quick  yet  compressible pulse,  thirst, anorexia,  malaise,
and  headache ; but in some  cases no premonitory symp-
toms are noticed.  The circular spots are in the  majority
of instances present on the several  mucous membranes of
the body, and sometimes  also on  the serous, at the same
time that they exist on the skin;  the blood being in them
effused beneath  their epithelial  covering,  through  which,
structure, so much more delicate and fine than  the epider-
mis,  it commonly makes its  way,  and  hemorrhage, often
to a great extent,  takes  place, complicating the disease
and rendering it much more dangerous.
  Several varieties  of  purpura have been described by
dermatologists, all of which may, I think,  be conveniently
arranged in two  divisions :—
                   Purpura simplex.
                       ,,     hemorrhagica.
  Purpura simplex.—The spots  in this  form of the dis-
ease,  Avhich  may be regarded as  being chiefly character- 
228
H EMORRHAGIE.
ized by its mildness, appear for the most part on  the ex-
tremities,  and are developed very suddenly, often  in the
course of  a  single night, and usually without any  preced-
ing or accompanying constitutional  disturbance.   Vibices
or ecchymoses are seldom  intermingled with them, and
they are generally much dispersed  over the surface, not
aggregated in masses;   successive* crops, rarely, however,
more than two or three, appear in most cases with an in-
terval  of  from twenty-four to forty-eight hours between
each,  and some  spots then occur also on  various  regions
of the body, the shoulders, the  chest, the  face, &c,  but
they are  always most numerous on the extremities.  The
disease runs  its course  in from seven or eight  days to a
fortnight  or  three weeks, at  the end of which time the
stains it occasions have totally disappeared.
  In some cases the  extravasation of blood into the derma
or beneath the epidermis, instead of occurring in  distinct
circular spots, without any elevation of the surface, takes
place  in  raised Avheals, resembling exactly  in  form the
eruption of  urticaria, and accompanied  often by more or
less of a stinging and tingling sensation,  in consequence of
which  it has  been termed purpura urticans ;  the patches,
owing to their extent, are of a deeper purple colour than
in the  ordinary form of purpura simplex,  and their duration
is for the same reason prolonged  to five or six weeks,
although  they are almost invariably developed in a single
crop.   Purpura urticans  usually occurs  on the loAver ex-
tremities,  and most frequently in persons labouring under
some  organic disease, and in those Avho  have taken much
mercury ; it  also  appears at  times  in  females when the
menstrual function is deranged.
  Purpura simplex occurring in  old persons, especially of
the female sex, when it appears very much  intermingled
with large vibices and some ecchymoses, was  described by
Bateman as a distinct variety, under the name of purpura
senilis ; it is usaully confined to the arms and legs, is de-
veloped in a single crop, unattended with any constitutional
or local symptoms, and  is an  affection  of  but little dis-
turbance,  not impeding the usual avocations of life, and
running its  course in from a  week  to ten days or a fort-
night. 
PURPURA.
229
  When any of the varieties of simple purpura  noAv  de-
scribed  is accompanied by hemorrhage from  the mucous
membranes, it then constitutes  a form of  the second divi-
sion of the  disease.   Occasionally  purpura simplex  is
attended with some trifling febrile symptoms, rarely  ex-
ceeding slight heat of  skin, thirst, and  anorexia, yet by
some writers it has been described under  the name pur-
pura febrilis simplex.   The  duration of the simple form
of  the  disease, as has  been  above remarked, seldom  ex-
ceeds a few weeks,  but cases  occur  in  which successive
crops are developed for from eighteen months to tAvo years
or upwards.
  Purpura hemorrhagica  is especially characterized  by
the escape  of blood from some of the passages of  the body
which  are  lined  with  mucous  membrane; occasionally it
takes place from the serous membranes also, Avhen hemor-
rhage into  the shut sacs occurs.  The spots on the integu-
ments  are  usually  much more numerous, and  generally
acquire a larger size than in the former variety, and vibices
and ecchymoses are more frequent;  they appear  on every
region of the body, being most  generally witnessed first on
the neck and shoulders, the face, and the upper extremities ;
they also occur on the conjunctiva,  on the gums, the tongue,
and the inside of the cheeks, and  are found after death to
be as thickly dispersed over the mucous membrane of  the
entire digestive tract as on the  external integuments.
   The  disease is ushered in usually by much constitutional
perturbation, the  chief symptoms  being those of general
oppression ; in from twenty-four to  forty-eight  hours  the
spots begin to appear  on the cutaneous surface, at first of
a bright red colour, but assuming a deep purple hue in
about tAvelve hours; they are very numerous in most cases,
and are rapidly developed ; whatever region of the body is
exposed to  pressure, there large hemorrhagic patches  are
developed  beneath the  epidermis, and  if the  surface is
scratched or torn, copious bleeding takes place from them;
in  some cases the slightest pressure, even that  caused by
feeling the  pulse,  will produce an ecchymosed spot.
   Hemorrhage from the mucous membranes takes place
often from  the very commencement of the disease, some-
times it precedes  the appearance  of  the  spots of purpura
                          20 
230
HEMORRHAGIE.
on the  integuments, but more frequently  does not occur
for several days after they are visible.   Its most usual and
most manageable form is that of epistaxis, but the bleeding
is also  very  common from the lungs,  when  it constitutes
hemoptysis, and from the stomach and boAvels, Avhence it is
rejected by vomiting, or escapes  by stool.   In some  cases
of purpura hemorrhagica, the  blood exudes  from the  gums
in great quantity, apparently by  a sort of oozing, Avhich it
is almost impossible to check, and not  unfrequently proves
fatal.   The  hemorrhage  may take place  also from the
kidneys, the  bladder, the uretha, the  vagina, &c.  These
losses of blood are  usually very great, and recurring con-
stantly  produce extreme depression and prostration, with a
marked pallor or anemic condition of the entire surface of
the body, that throws out into marked  relief the purple
spots and stains which are thickly scattered over it.
  The  duration of  this form of purpura is  very variable  ;
the local hemorrhages may be checked in seven or eight  days,
but they are  very apt to recur, and  thus the disease is  often
prolonged  for  several months,  the cutaneous  spots and
patches continuing to be developed in constant, successive
crops.  When it has lasted for any time, the vital  powers
become extremely depressed, dropsical effusion takes  place
into the lower extremities, and uncontrolable bloody diarrhoea
not unfrequently sets in.
  When the  constitutional symptoms attendant on purpura
hemorrhagica assume a more febrile character than has
been above described,—a general redness of the surface,
with burning heat, preceding the appearance of the purple
spots,—the disease has  been  specially noticed under the
denomination of ipx\rpura,febrilis hemorrhagica. This variety
is  chiefly remarkable from its not  unfrequently appearing
as an epidemic, especially where many persons are crowded
together, as in gaols, poor-houses, &c.
  In  many cases of purpura, the  cutaneous phenomena are
so trifling as to be scarcely noticeable, Avhile the hemorrhages
from the mucous surfaces are excessive ; these constitute, in
my experience, the most dangerous and  uncontrollable cases,
and death often occurs  in them from extravasion of  blood
into some of  the serous  cavities.   Dr. Graves described a
form of  the  disease  resembling  this,  in  which, however, 
PURPURA.
231
there was an exanthematous rash on the skin, resembling
the  red  efflorescence so often seen in maculated  typhus
fever ; in consequence of its presence he proposed to term
the affection Exanthema hcemorrhagicum. x
  Erasmus Wilson describes as a form of purpura, under
the  designation of purpura cachectica, the occurrence of
patechiae and ecchymoses on the skin, " as the consequence
of a reduced  and debilitated state of the  system,  from
whatever cause the latter may arise."   We frequently see
instances  of this kind during the latter stage of various
diseases, as of dropsies, or whenever the venous circulation
is obstructed.   The  pupura contagiosa of  Bateman cor-
responds with the petechial eruption of typhus fever.
  Purpura may occur at any age, but is very rarely wit-
nessed in infants or  very young children;  it affects both
sexes also, but females are more prone to the disease than
males.   The  hemorrhagic form is  more frequent in the
young, and  in those in the prime of life, while the simple
variety appears  generally in old  age.   Persons  of the
sanguineo-lymphatic  temperament  constitute unquestion-
ably the majority of those affected with  purpura, yet it
is seen in all constitutions, in  the strong  and  robust as
well as in the weak  and debilitated.   The  causes of the
disease are consequently  very obscure;  it was formerly
believed to be always dependent  on and to be a sign of
general constitutional weakness—a view which  influenced
the  exclusive  plan of treatment recommended  by Willan
and his folloAvers ; but it is now admitted to be often con-
nected with plethora and  sanguineous congestion.   That
low, ill-ventilated habitations, with deficient or unwholesome
food, are occasionally predisposing  causes of  purpura
amongst the poor is undoubted, but inasmuch as it usually
attacks only a single member of  a family, some  peculiar
state of the constitution, the nature of which we are unaware
of, is manifestly requisite  to enable these  causes  to  act.
An exclusively meat diet, or an  insufficiency of vegetables
and  milk, either  of which produces the peculiar affection
known as scurvy, does not seem  to  exert  any influence
in the causation of purpura ; in the year 1847, when scurvy
  1 Clinical Lectures on the Practice of Medicine, Second Edition, vol. ii.
p. 362. 
232
HEMORRHAGIE.
was  so general in this  country, in consequence  of the
failure of the potato crop, purpura Avas not as prevalent as
usual.   In some cases of the disease which I have  seen,
a hereditary tendency to it could be traced, but this is not
of so decided  a character or so general  as in the singular
instances of  the hemorrhagic  diathesis, occasionally Avit-
nessed, in Avhich the slightest  injury causes often  uncon-
trollable bleeding, death sometimes, in consequence of it,
resulting from the extraction of a tooth,  or  even from the
Avound produced by the scratch of  a pin.  The proximate
cause of purpura is manifestly atony in the capillary system
of blood-vessels, combined with an abnormal fluidity of the
blood.
   Diagnosis.—This disease is  so well marked by the visi-
ble phenomena that  it can  scarcely be  confounded with
any other ; but it  is  necessary to  distinguish the  occur-
rence of purpura  in the course of fever, or as a complica-
tion of any other  affection, from its existence as an indi-
vidual disease.  The diagnosis between  it and scurvy is
unattended with difficulty, the characteristic  condition of
the gums, the extensive  brown and purple discolouration
of the integuments, and the absence of the round purpuric
stains in the latter, are sufficiently distinctive marks.  The
spots  of purpura  are distinguished from flea-bites, with
Avhich  a careless observer might confound them,  by the
presence of a  central punctum in the  latter,  and  their
almost  total disappearance  on firm pressure  being made
with the finger, the marks  of  purpura  being thereby un-
affected.
   Prognosis.—Even cases of purpura that, in  their com-
mencement, do not  present symptoms of severity,  are not
altogether  free from  danger, for the simple  form of the
disease not  unfrequently  becomes  converted  into  the
hemorrhagic,  and Avhenever bleeding from the  mucous sur-
faces  takes places  in this  affection, the prognosis  must
be cautious.  When death  occurs, it is  either directly or
indirectly consequent  on the loss of blood : in the  former
case  it may  be sudden,  as  when  apoplexy results from
hemorrhage into the substance of the brain or from its mem-
branes, and, in the latter, it is generally less immediate,
the patient dying  with the symptoms usually caused  by 
PURPURA.
233
repeated losses of blood.  The hemorrhage  being profuse,
or continuing unchecked  by treatment, is always an  un-
favourable sign, and until it ceases completely, and fresh
spots no longer appear on the cutaneous or mucous surfaces,
the patient cannot be regarded as safe.   Bleeding from
the gums, particularly  when  at all excessive,  is,  in  my
experience,  one  of the  gravest  symptoms of the disease,
even although  there  may be but little eruption  on  the
integuments ;  I have rarely seen a case of purpura recover
in which it was present  to any extent.
   Occurring in the young, the strong, and the robust, and
in the old, the weak, and  the feeble, it is difficult to arrive
at any  correct view of the pathology  of purpura.   The
precise condition  of the circulatory apparatus, and  of  the
blood itself, in which  that fluid escapes from the vessels
most remote  from the centre, has not been  sufficiently
investigated  as yet, to enable  correct deductions  to  be
drawn as to the real nature of the disease.   It is true, that
the blood in purpura has been chemically analyzed and
microscopically examined, but the results afford no further
information than what had  been previously gained  by the
unaided  senses,—that it is deficient? in  solid constituents,
in consequence of which it is in most cases extremely fluid,
and  does not coagulate after  its exudation through  the
mucous membranes, or  should it be drawn from a vein ;
yet,  as shown by  the analysis of Frick, of Garrod, and of
Parkes, the  fibrine may be in excess, and the property of
coagulation  not deficient in purpuric blood.  The appear-
ances in  the internal organs  found after death are,  the
presence of purpuric spots and vibices on  the mucous, and
occasionally on the serous membranes, and  in some  cases
hemorrhage into one or  more of the shut cavities.
   Treatment.—The treatment  of  purpura has been much
influenced by the different opinions which have prevailed
as to its true nature ; many,  adopting the views propounded
by Willan as to the disease  being nearly allied to scurvy,
and consequentially being essentially one of debility,  agree
also with him, " that the treatment is simple, and may be
comprised in a very few words : a generous diet, the  use
of wine,  Peruvian bark,  and acids ;" others, regarding  the
doctrine of Parry,  " that it is always of inflammatory ori- 
234
HEMORRHAGIE.
gin," as correct, recommend early and  free venesection as
holding  out  the  only hope  of successful treatment.  In
very  few  cases of the disease,  hoAvever, is the decided
antiphlogistic treatment here  recommended  either needed
or beneficial, and in still  fewer will the employment  of
tonics and acids be necessary or advantageous.  Instances
unquestionably occur in which the abstraction of blood  to
a small extent in the very commencement of the  disease
will at once stop its progress ; these are cases of  purpura
simplex, affecting plethoric  young  persons of a sangui-
neous  temperament; but the  bleeding should  always be
used with  caution, and is  rarely if  ever  admissible when
hemorrhage occurs spontaneously to any extent from the
mucous membranes.  In that  form  of  the  disease  which
has been described as appearing on the lower extremities
of old  persons, whatever tends to strengthen the constitu-
tion  generally should not be  omitted  in the treatment;
but if preparations of bark, or other  tonics, be adminis-
tered  too  freely,  and without the simultaneous  employ-
ment of remedies calculated  to  remove  the hemorrhagic
tendency,  the symptoms  are often  suddenly aggravated,
purpuric spots are developed over the body generally, and
bleeding takes  place  from  the mucous  cavities,  the simple
form of the disease being converted into the hemorrhagic.
  Some years since I published an essay1 on the treatment
of purpura by large doses of oil of turpentine, and  illus-
trated  the  efficacy of this remedy,  when thus adminis-
tered,  by a report of several cases in which it proved singu-
larly successful.  Since then I have continued to employ it
both in the simple and hemorrhagic  forms of the  disease,
and  my additional experience is fully confirmatory of the
views then  propounded.  It must be given  in  doses suffi-
ciently large to act as a purgative,—from one to two ounces,
according to the age and strength of the patient,  for adults,
and a proportionate dose for children; to  insure its purgative
action, I was at first in the habit of giving it in combination
with castor oil, but this, so far from being necessary, inter-
feres, I think, more or less with the special effect  of the tur-

  1 Dublin Journal of Medical Science, First Series', vol. xxviii. p. 189. 
                     PURPURA.                  235

pentine, and therefore I now prescribe it combined simply
with mucilage, as in the following form:—

       R  Olei Terebinthinae,   .....  fl ^j.
          Mucilaginis,.......fl 3j.
          Aquae Menthae Piperitae,    .   .   .  fl j§iss.

                 Misce.   Fiat haustus.

   This draught may be taken once or twice daily, according
to the degree of its action on the bowels, and should  there
be much  hemorrhage from the intestinal  canal, or  the
stomach reject the draught, the same or a larger  quantity
of the oil  of turpentine, suspended by means of the yolk of
egg in decoction of barley, may be administered as an enema.
The beneficial action of  the  turpentine  in this disease is
twofold: first, it is a diffusible stimulant and styptic, Avhich,
when  conveyed into the  circulation through the  digestive
organs, is exhaled from the system  by means chiefly of the
mucous surface, as is manifested by  the odour of the breath,
and of the various secretions and excretions ; it is thus con-
sequently brought directly into contact with the capillary cir-
cultion, from which in this disease the hemorrhage  takes
place; and, second, the free employment of purgatives  in the
treatment of purpura having long  since been proved  to be
attended  with most successful results, the administration of
oil of turpentine  to fulfil this  indication  is especially
serviceable  in consequenee  of its not being a debilitant.
   In cases  in which  from any cause—excessive debility or
tendency to diarrhoea, &c.—purgatives are contra-indicated,
the turpentine may be given in smaller doses, and repeated
at shorter intervals ; thus from twenty or thirty minims to
a drachm may be prescribed every third or fourth hour, or
three  times a day,  according  to the amount of hemorrhage
Avhich accompanies the disease.  Should there be extreme
debility present,  preparations  of  iron—those  Avhich are
astringent being preferred—or other tonics, may  be  admi-
nistered  conjointly with the turpentine;  but  on  the  other
hand, when there is much vascular  excitement or general
plethora, bleeding or other evacuants should be had recourse
to at the  same time that  it is prescribed. 
236
HEMORRHAGIE.
   The  employment of numerous  other astringents  and
styptics has been recommended for the treatment of purpura;
in cases attended with much hemorrhage from the stomach
and intestines, or from the lungs, acetate of lead combined
with opium often proves useful;  the combination may be
given  in pill,—two grains of the former with  a fourth of
a grain of the latter every  fourth  or sixth hour.  But of
all of this class of medicines which have been used not one
has proved so beneficial as gallic acid;  it is especially of
service in  cases attended with profuse  bleeding from the
mucous surface, and may then be given in alternate doses
with the oil of turpentine.  Thus, a pill containing five
grains of gallic acid made with sufficient mucilage or con-
serve of roses, should be administered every fourth hour,
the turpentine draughts being given two hours  before and
after each  pill.
   When excessive hemorrhage takes place from the mucous
membrane  of the gums and the inside of the mouth, it is as
before  remarked, a most  dangerous symptom,  and the
bleeding is extremely difficult to check,—the most active
styptics applied directly often failing to diminish it in the
slightest degree.   I have in such cases tried unavailingly
nitrate of siver, saturated solutions of alum, of sulphate of
iron, of gallic acid, &c, Rusbini's styptic, nitric acid, and
even the actual cautery:  pieces of lint dipped in oil of
turpentine  seems to  have  the most effect, but the general
treatment above recommended can alone be then relied on.
   Sponging the surface of the body repeatedly during the
day with cooling lotions,—such as equal parts of vinegar
and water, with the addition  of a  sixth part  of rectified
spirit,  should there be much febrile heat,—is an adjunct,
too  often neglected, of much value in  the  treatment of
purpura. Acidulated drinks—lemonade,  raspberry vinegar
and water  should be always freely allowed, and the  diet,
though rather small as regards quantity,  ought to be nutri-
tious and tonic, but easy of digestion, consisting chiefly of
milk, farinaceous food,  and strong beef  tea: all food and
drink being taken rather cold than Avarm. 
MACULE.
237
                CHAPTER  IX.

                       MACULE.

  The group of cutaneous  affections classed in the order
Macule is characterized by a morbid condition of the colour
of the skin dependent on some deranged state of the secre-
tion of the pigment cells of the derma.  The change  may
consist in either an  augmentation or a diminution of the
natural colour,  or it may be  altered  in  hue  or  totally
absent; in some instances it affects the entire surface of
the body, but more usually occurs in spots or patches that
vary much in shape and extent:  in either  case there  is no
sensible elevation or depression of the surface.  The several
affections belonging to the order may be congenital, or they
may be developed  at any period of life : in the former case
they usually consist in the total absence of colouring mat-
ter, constituting what has been  denominated, Albinoismus,
—individuals  born so being termed Albinoes,—or there
may be  only  a deficiency  of  colouring  matter in large
patches, a condition  which is  rare, but  most frequently
witnessed in the children of negroes, who are thus piebald
at birth.   In certain diseases, as in jaundice, in chlorosis,
in malignant  and in most  chronic affections, a  peculiar
alteration  in colour of the tegumentary  membrane takes
place, and Avhich is regarded usually as one of the  most
important  signs of the  special  diathesis  or  constitutional
derangement which  characterizes or accompanies  the  dis-
ease ; but  it is readily recognizable, and   cannot  be  con-
founded with the pigmentary alterations of the  cutaneous
structure here to be  considered, which do  not influence in
any way the general health, and are  therefere to be re-
garded  solely  in  consequence of the disfigurement which
they occasion, in many instances a cause of greater annoy-
ance than a real disease.  These changes in colour may be
conveniently described in  two divisions, the one,  that at- 
238
MACULE.
tended  with  deficiency  of  colouring  matter—Vitiligo,
including albinoismus ;  and the other,  marked by augmen-
tation and alteration of the natural pigment—Ephelis.

                       VITILIGO.

   Vitiligo consists in a deficiency or total absence of the
natural colouring matter of  the  skin, in consequence of
which it presents a white and sometimes glistening aspect;
the term, which was adopted by Willan from Celsus, is con-
jectured to have been derived from the resemblance which
the integuments thus affected bear to the flesh of calves—
 Vituli; and being sanctioned by usage and sufficiently ex-
pressive, I have been unwilling to change it for  Leucopa-
thia, an appellation more strictly correct, perhaps, which is
employed by many modern dermatologists.  The  decoloura-
tion may be limited to certain regions of the body, occurring
in patches, or may be general when the absence of pigment
is witnessed in the hair, the eyes, &c.   In the former case,
the peculiar condition of the skin is often congenital, but
it may be  developed  at any period  of life ;  it constitutes
the Achroma vitiligo of Alibert;  the latter, the Achroma
congenitale of the same author, is  always congenital;  it is
denominated,  as before  remarked, Albinoismus.   Albi-
noismus cannot be regarded as a disease, and  therefore,
not coming within the  scope of  this  work,  need not be
described  here  ; it moreover is not  within the  sphere of
medical art, being altogether an  unalterable, and conse-
quently an incurable affection.
   What then may be termed true vitiligo, when not  con-
genital, is developed in the form of rounded spots or patches,
few or  many, on some special region  of the body, or on
several parts at the same time;  the spots are at first usually
small, not more  than  a few lines in  diameter, and  nearly
circular, but they gradually augment in size—often acqui-
ring the magnitude of the palm of the hand,  and become
irregular in shape.   It  appears  most  frequently on  the
chest, the back, the  scalp, and about  the genital organs,
but it  may  occur on  any part of  the  integuments.   The
portions of skin affected present simply a white  aspect, in
some cases  dull, in others bright  and  glistening, without 
VITILIGO.
239
any sensible elevation or depression of the surface ;  if hairs
grow naturally on the part they also become perfectly white,
no matter of  what colour they may have been previously,
and not unfrequently fall out after a short time, leaving a
bald, colourless  patch.   When the  hairy scalp  is thus
affected, attention is at first usually attracted  to  it by a
single lock of the hair, generally  on the back part of the
head or the temples, turning white, this gradually becomes
larger, and at length the hairs, which have lost their colour,
fall out, and  one  of the forms of  alopecia, or  what has
been termed a variety of porrigo deealvans, is thus consti-
tuted.
  The causes  of this singular affection of the skin are per-
fectly unknown :  it occurs at all ages, and is most frequent
in the  prime of  life, especially  when it  appears  on the
head, but  it is  developed on the genital region usually in old
persons ;  it is witnessed, too, in individuals of all tempera-
ments, yet I think it is more common on the scalp of those
who have dark than of those who have light hair; it is also,
in my experience, more  usual on the head in females, and
on other  parts of the body in males.   Congenital  vitiligo
is rare  in the white races, occurring with a much  greater
degree of frequency in negroes, infants at birth sometimes
presenting a completely pied appearance.
  The diagnosis of  vitiligo is  unattended with  difficulty;
the longitudinal white furrows on  the abdomen of  females
who have borne children, or of those who have had ascites,
and on the breasts  of nurses,  might, by a superficial observer,
be confounded with  it, but their site and the history of the
individual case are in all cases sufficient to prevent such a
mistake.  A  form of  lupus, to be  hereafter  described, is
stated by Erasmus Wilson to be incorrectly regarded as
vitiligo, and he consequently introduces this term amongst
the synonymes of Lupus non-exedens, but, as will be shown
in the next Chapter, the diseases  are essentially different,
and cannot be confounded.
   Prognosis.—An affection of the most trifling importance,
as regards the general health, and accompanied by not the
slightest local sign or symptom of irritation in its develop-
ment or  progress, vitiligo is,  nevertheless, attended Avith
the most  serious mental suffering, especially to  young per- 
240
M A C U -L E.
sons, when it appears on the face or the hairy scalp, owing to
the disfigurement which  it there occasions.   It is often
most rebellious to treatment, and always extremely slow in
exhibiting  any  signs  of amendment,  yet, by  continued
attention, a cure is usually effected in time.
   Treatment.—Constitutional remedies should not  be  ne-
glected in the treatment of vitiligo, but those  required are
simply such as will  restore  a healthy tone and  vigour to
the system:  consequently, preparations of iron or of bark
combined with iodine,  cod-liver  oil  in scrofulous  habits,
cold salt-water bathing, general or local, in  the form of
the shower-bath  or  of the  douche, and, above all,  mental
quietude,.are the most  essential.  Topical  applications,
however, are chiefly  to be relied on,  and of these various
stimulating remedies especially are employed Avith bene-
fit ; tannic acid ointment, in the following form, has  proved
of more service than any other in my hands :—

     R. Acidi Tannici,......gr. xl.
        Adipis praeparati,.....      5j.
        Glycerinae,.......fl 3ss.
        Olei Rosmarini,......m. viij. Misce.

   A portion of this ointment should be  rubbed forcibly into
the parts affected three  times a day, the  surface having,
previously to each  application, been Avashed  well  with  a
saturated  solution  of  common  salt in water.   In very
chronic or obstinate cases, blisters may be applied to  the
affected parts, in order  to excite a new action in them, or
tincture of cantharides  made  into an unguent, in the pro-
portion of a drachm to  the ounce of white wax  ointment,
rubbed in twice daily.   Sulphuret of potassium,  and other
preparations of sulphur, in the form of lotion or ointment,
employed locally, sometimes succeed when  other remedies
fail; but  next  to tannic  acid I have found oil of turpen-
tine prove most  useful as  a local application:  a pomade
may be prepared with it as follows :—

     R. Olei Terebinthinae,
        Sevi,   ....
        Balsami Tolutani,
A 3 ij-

  3ij. 
E P H E L I S.
241
Simul liquefac lento igne, dein adde,

        Olei Rosmarini,.......m. xx.
        Olei  Amygdalae Amarae,  ....  m. v.

  A small portion of this pomade should be rubbed into the
affected spots twice or three times a  day with a piece of
flannel, the part having been previously well Avashed  with
an  alkaline wash—a  drachm  of carbonate of potash  to
eight ounces of distilled water.


                        EPHELIS.
  Ephelis.—This  term, as  its  derivation (tut, *j*«>s, the
sun) indicates,  was originally employed to designate  all
discolourations of the skin caused by the direct action of
the solar rays, but latterly it has acquired a more extended
signification, and may, I think,  noAV be understood to in-
clude all those affections in Avhich the natural pigmenthue
of the skin is augmented or altered.  Some of these changes
being  congential and unalterable need not  be described
here, Avhile others are due and can often be traced to specific
causes.   Ephelis may be conveniently considered  as  con-
sisting of three  varieties :—

                   Ephelis  lenticularis.
                      ,,    hepatica.
                      ,,    violacea.

  Ephelis lenticularis (Freckles).—This discolouration of
the  skin is too Avell known to need description; in many
persons the  buff-coloured  or  reddish-yellows spots which
constitute it are congenital, Avhen they are beyond the reach
of medical art; but in others they are developed on those
regions of the body Avhich  are uncovered, by exposure to
the weather, but especially  to the direct action of the  sun's
rays.  They are seldom Avitnessed except in those who have
a very fine and  fair skin and are of the sanguine tempera-
ment!   Appearing usually for these reasons on the  skin of
young persons of the female sex, and on those parts of the
surface Avhich are most exposed to observation,  freckles
                           21 
242
MACULE.
cause very serious annoyance, and a host of applications
have  been employed  for  their removal, which  is often a
matter of some difficulty; persons who are liable to them
should therefore  protect  themselves  as  much as possible
from the causes by which they are produced.   The various
empirical lotions  which are sold for the  removal of these
spots, are composed chiefly of corrosive sublimate, or of the
solution of the subacetate of lead in bitter almond emulsion,
in the  proportion of a fourth of a grain of the  former, or
six minims of the latter, to each ounce of either of them ;
they are often very useful.  Erasmus Wilson  recommends
the application of a liniment, "composed of equal parts of
lime-water and olive oil," to which, if the  heat of  the
surface is considerable, he adds " liquor plumbi in the pro-
portion of twenty minims to the ounce."   I have found the
following lotion of much service :—

    R.  Liquoris Sodae Chlorinatae,   .   .   . fl  31'j.
       Aquae Florum Sambuci,  .   .   .   . fl  ^vij.
       Aquae Lauro-Cerasi,.....fl  5vj.  Misce.

And the application at night of  a pomade, consisting of
equal parts of cold  cream and cucumber cerate, to every
ounce of which half-a-drachm of the solution of chlorinated
soda is added.
   Ephelis  hepatica is characterized by the appearance of
one or more patches,  of tolerable extent, on some portion
of the cutaneous surface; they are of a dull-yellow or buff
colour, occasionally of a bronze hue ; at first distinct from
each other; when more than one occurs,  they gradually
enlarge,  and coalescing often acquire a considerable size,
so that in  some cases the neck, the  face, the upper part
of the trunk and the hands, being the parts usually affected,
acquire a dark brown colour.  On the first appearance of
the patches they are not unfrequently attended with some
itching  and tingling, and a  fine  mealy  desquamation,
increased by scratching or rubbing the surface, takes place ;
but there is no sensible elevation or depression of the skin
where  affected.   The  colouration varies  much in different
cases, through all the shades of gray, yellow, and  brown,
being  often evidently dependent  on the natural colour of 
EPHELIS.
243
the individual; at times, when it is very extensive, the con-
trast is so remarkable that the unaffected parts of the skin
appear as if they were the seat of vitiligo.
  Ephelis hepatica is a very chronic affection, in most cases
lasting for many months or even for years, but  it is occa-
sionally of short duration, and even evanescent, disappear-
ing suddenly a few hours after its development.  In the
latter case the discoloured patch or patches generally appear
in females just before the coming on  of  the menstrual dis-
charge, and fade away  when it commences.  It  is a more
frequent affection in all its forms in the female than in the
male  sex, being a not uncommon attendant on  pregnancy
and on  various uterine derangements, in both sexes it  is
rarely witnessed except in the prime of life,  occurring,
however,  with  greater frequency in  old  than  in  young
persons.   A large  patch of  ephelis hepatica is sometimes
developed on the neck or the side of the face, by  the action
of the rays of the sun; and  a discolouration of the skin
resembling  it in hue—but differing  from its occurring  in
large, irregularly-shaped rings, surrounding  comparatively
healthy skin—appears  on the lower  extremities generally
of old persons who  expose their legs uncovered to the fire;
the latter has been specially  described by Rayer, as being
very common in Paris amongst the lower orders, especially
females, who sit over a charcoal fire,  and is termed-by him
Ephelides ignSahs ; in  Ireland, also,  it is common amongst
the poor, chiefly in  country districts where turf fires are
used, and is vulgarly called the Trouts.
   Diagnosis.—This affection is often confounded  with a
form  of pityriasis, and as'already remarked Avhen describing
that disease, Rayer and Wilson consider pityriasis versicolor
and pityriasis nigra as  being nothing more than discoloura-
tions  of the skin, and  therefore to be classed with ephelis:
my reasons  for differing with them have been there given.
The stains  of  ephelis  hepatica may be confounded with
those which are symptomatic of a syphilitic taint  in the
system, from which they are  chiefly to be diagnosed by the
history of each case,  and the concomitant symptoms.
   In  the treatment of  this affection  it is requisite, in the
first place, to direct attention to the general health, especially
the state of the digestive organs, with a deranged condition 
244
MACULE.
of which their presence  is often associated, and to use
remedies calculated to restore them, if requisite, to a healthy
tone; in females, moreover, should there exist any irregu-
larity of the menstrual  function, appropriate  means  to
correct  it must  be employed; but when the patches are
developed in the course of pregnancy, no treatment ought
to be had recourse to,  for they  usually disappear  after
delivery.  The local applications that prove most successful
are  those  which  have been  recommended for  the  last
described variety of ephelis ; when, however, the discoloura-
tion  of the surface is very extensive, hot baths  containing
the sulphuret of potassium, or  of  the  natural sulphureous
Avaters, will  be found of  service :  these mineral  waters also
should be used internally, and if drank at their sources  so
much the better.   When a single large  patch of ephelis
hepatica becomes chronic, repeated blisters  applied over it
will  sometimes remove the discolouration of the part.
  Ephelis violacea.—When the internal administration of
the nitrate of silver has been  continued  for a  lengthened
period without prolonged intermissions, the  derma becomes
chemically stained Avith  it, and the entire  surface  of the
body then presents a slate-coloured, bluish-grey, or  leaden
hue, causing a frightful  disfiguration, more especially  as
the face and  those  parts  constantly exposed to  the light
are most deeply tinged.   This discolouration is much less
frequently witnessed now than it was some years since,
when this medicine Avas so universally employed for the
treatment of  epilepsy and other  nervous and  convulsive
diseases.  The most certain way to prevent this result,—
one  of so grave a character  as almost to  counterbalance
any good effects which might be derived from the adminis-
tration of nitrate of silver, as a medicine,—is not to con-
tinue its use  for a  longer period than six weeks or two
months, and should it be  thought well to resume its employ-
ment again, to permit at least a  month  to elapse  before
doing so.
  This discolouration  Avhen once  produced is  permanent,
and  becomes even  deeper with time, nor  have  any means
hitherto tried  for its removal had  the slightest  effect over
it.   The iodide of potassium, Avhen  applied to the skin, even
some days after  it may have  been stained by the direct 
EPHELIS.
215
application of the nitrate of silver, effectually removes the
discolouration; its use in various ways  has therefore been
proposed for the general  staining of the cutaneous surface
above described.   Professor Melsens, of Brussels, has given
it  in enormous doses, half-a-drachm, or even  more, three
times daily, exposing the patient at the same time to a hot
vapour  bath: the iodine is  thus  brought  to the surface,
when it may be readily detected in the perspiration by the
ordinary tests.   He  continues this plan of treatment for
months, but in one case that I am cognizant of, which Avas
treated by himself,  the" discolouration was  not  in the
slightest degree removed.   This, I think, was to be antici-
pated, for it is as iodine, and not as iodide of potassium that
the preparation  is given off by the skin after its use has
been continued  for some time; I would, therfore, suggest
that the patient, while under the influence of the remedy,
should be placed during for from half-an-hour to an hour in
a Avarm bath containing carbonate of potash in solution, in-
stead of employing the hot vapour bath, as thus the iodide
of potassium might be brought into direct  contact with the
derma.
21* 
246
CANCRODES.
                  CHAPTER  X.

                       CANCRODES.

  The order Cancrodes includes two diseases of the skin,
which possess a certain degree  of malignancy, inferior to
that of  true cancerous affections, yet in  many of their
features  bearing much  resemblance  to  them, especially in
being usually characterized by a slow and insidious ulcera-
tive process,  often attended Avith severe stinging pain, and
by  a marked tendency to  return in  the  same or in some
other part of the skin, after they  have been apparently
cured, or even after the diseased portion of the integument
has been excised.  These diseases are by most dermatolo-
gists classed  amongst the Tubercula of Willan, but for the
reasons  already stated  in the introductory  remarks to the
seventh chapter I have omitted this  order  altogether, and
even were it to  be  retained,  the  affections now to be
described could not,  with  any pretension to accuracy, be
included in it.   The term Cancrodes, which  I have adopted
from Copland's classification of  diseases  of the skin,1 ex-
presses well  their peculiar features above referred to, and
is at the same time sufficiently distinctive for  all purposes
of  arrangement.  The  two diseases to be described in the
order are: Lupus, Kelis.

                         LUPUS.
  Lupus (Eating tetter) appears on the skin usually of the
face, but often  on the scalp, in  various forms: it is  gene-
rally developed  as an inflammatory affection, with more or
less hypertrophy of the integuments  attacked, soon termi-
nating in  ulceration, which may be either superficial or
deep-seated,  but is always painful, slow, and insidious,  and
especially characterized by a destructive tendency, whence
the name,—Lupus,  'lawolf,"—was originally applied to
1 Dictionary of Practical Medicine, vol. iii. p. 799. 
LUPUS.
247
the disease.   The  ulcerative process  may be confined to
the epidermis  and the superficial layers of the derma, may
extend  quite  through the cutaneous integument, or may
even affect the deeper-seated parts, destroying the areolar
tissue, muscles, cartilages,  and periosteum, laying bones
bare, and thereby causing caries in them.  The disease is
thus naturally divided into three forms, but in general two
only are described by writers on cutaneous affections: the
one, in  which the  ulcerative process  attacks the deeper-
seated tissues, being termed lupus exedens, and the other,
which affects  more superficial  structures only, being  for
contrast denominated lupus non-exedens ; in both, however,
a similar form of ulceration, although differing in degree,
occurs,  and this division is, therefore, not strictly accurate.
I  shall  describe the three forms, the  leading  features of
which have been noticed above, under the following specific
denominations:—
                  Lupus superficialis.
                     "   serpiginosus.
                     "   devorans.

   Lupus superficialis commences by  the development  of
a  slight thickening or elevation  of the skin,  not larger
than  a  small  pea, usually on the most prominent part  of
one cheek ; it presents a somewhat inflamed appearance, is
soft to the touch, rather painful if pressed firmly, and is of
a  very  indolent  nature.   A  thin, hard, brownish scab
appears on  its  surface  after  some time, often not_ for
months, but is seemingly not preceded by any ulceration;
when the scab is picked off with  the nails, as it almost in-
variably is by the individual himself, the part on which it
rested is seen to be superficially ulcerated, with thickened
and slightly elevated edges; it is soon reproduced, a little
more consistent than before, but still of  small  extent, and
increases very slowly in size, even when irritated by the
use of  stimulant applications  or by  other  local  causes.
Generally, after several months, the dry crust or scab falls
off that part  of the integument on which it first appeared,
while it is  spreading slowly to the neighbouring surface.
The  portion  of the skin on which it had existed is white
and seamed,  resembling much the condition  Avhich  results 
248
CANCRO.DES..
from destruction of the superficial layers of the cutaneous
structure  by a burn.   With  slow but steady progress the
disease advances over the cheek, usually in one direction
only, leaving its trace behind in the white seaming of the
skin; at times it becomes the seat of active  inflammation,
generally from being rubbed or torn with the nails, when
a small, painful ulcer results, but  the  local symptoms are
never very severe, the chief annoyance it causes being due
to the  unsightly deformity which it occasions on the face.
The progress  of this form of lupus is so slow  that the re-
sulting superficial cicatrix above described, which is some-
what circular, does not attain a larger size than that of a
shilling in from two to three years after the first appearance
of the disease,—at least  such was the case in two persons
affected with it whom I have had under my care.
   Lupus superficialis, as here described, is a rare affection,
and has escaped the notice of many writers on diseases of
the  skin; Dr. Copland  gives the best account of it that I
have met with, under  the appellation of Lupus superficialis
non-tuberculosus}   Its duration may be almost indefinitely
prolonged; when it terminates  in cure the scab falls off,
and is not  succeeded by another, but the  mark  on the
cutaneous surface is indelible.
   Lupus serpiginosus.—This variety of the disease—well
named by  Alibert,  Esthiomenos (from  toOta,  "I  eat,")
ambulans vel  serpiginosus — is  well marked  by highly
characteristic  phenomena, which  distinguish it from either
of the  other forms of lupus, but it  must be noticed that
the specific name " superficialis"  has  been applied to it by
some dermatologists who  do not appear to have met with
the  variety  of the disease  above described  under that
appellation.   It commences  by the development of one or
more small, livid, or dusky-red tumours,—the  tubercles of
most authors,—about  the  size and shape of a pea,  on some
portion  of the integuments,  usually on  the face  or the
scalp, but not  unfrequently appearing on different parts of
the body at  the same  time ; they feel thickened and some-
what hard to the touch,  with  an uncircumscribed, soft, and
slightly swollen base,  and are rather painful on pressure, a
sense of heat and itching also attending  them.   These
        ' Dictionary of Practical Medicine, vol. iii. p. 790. 
LUPUS.
249
tumours  are very indolent, often remaining stationary for
months, and scarcely increasing in size; interstitial absorp-
tion of the deep layers of the derma is, hoAvever, sloAvly
going on, and at length purulent matter makes its way to
the surface, generally at  the  most prominent  part of the
elevations ; ulceration then takes place,  and,  the pus es-
caping, it is found  that the surrounding  integuments are
more or less  undermined by  the  process  of  destructive
absorption which had been taking place. Additional tumors
are now  developed in the neighbourhood of those  which
first appeared, and  of a similar character in all respects to
them :  the intervening portion of integuments present an
cedematous aspect,  has a boggy feel, and, being first under-
minded  by the ulcerative interstitial absorption,  which
continues its  slow  progress, at length gives way, and an
unhealthy-looking,  open ulcer, extending quite  through the
skin, and covered  in parts by a hard, brown crust or scab,
is formed.
   The ulcers  constituted  in the manner above  described
heal slowly,  leaving  an uneven excavated  cicatrix  or pit
of a Avhite glistening colour, but the disease continues to
spread from  the circumference, creeping  on—whence the
specific name—almost invariably in the form of irregular
rings.   The interstitial ulceration in many cases re-attacks
the parts which have cicatrized, and they again may thus
become for a second or third time, or even oftener, the seat
of the disease, which runs the  same course as at first, but
each time the  surface heals, the resulting cicatrix is deeper
and more uneven.   It not uncommonly occurs  that two or
more patches  of the lupoid ulceration coalesce  in  conse-
quence of the disease spreading from the circumference of
each, and an  extended  portion of the integuments may
thereby be affected.
   Lupus  serpiginosus  occurs,  as already  remarked, with
greatest  frequency on the face and scalp, often extending,
too, from one to the other, and being confined to them, but
it is also witnessed on both the upper and lower  extremities,
and occasionally on the trunk of the body; it is usually
attended with  more or less local pain in all its stages, which
is much aggravated at times by attacks of acute inflamma-
tion, when it spreads more rapidly, but the constitution very 
250
CANCRODES.
rarely participates, those affected  Avith  the disease  being
often apparently in excellent health, even although it may
have lasted for years.  It is  always of  a chronic nature,
and  its duration is extremely  prolonged.   When it termi-
nates in cure, the intra-dermoid ulceration ceases to spread;
healthy granulations, at times rather exhuberant, form on
the surface, and cicatrization  of the  affected  part  takes
place ;  the annular edges being  elevated over the healthy
skin,  and of  course much more over the  cicatrized portion,
and  being of a  bright-red colour, which  they retain for a
long time, contrast remarkably with the shining white aspect
of the latter : much disfigurement consequently results.
   Lupus devorans (noli me tangere).—This  variety of the
disease commences in various ways, but no matter what
appearance it may present at first, it  is  in  its progress
characterized by destructive ulceration of the various  struc-
tures situated beneath the skin,—areolar and adipose tissues,
muscles, tendons, cartilages, and periosteum, being equally
destroyed; the  bones even do not escape,  for  where they
are laid bare caries attacks them.  It may be developed,
like  the last-described  form, by the  appearance of one or
more rounded, dusky-red elevations  of  the integument—
tubercles—on the alae  nasi, on the cheeks, or on the roof
of the mouth, which, however, run a somewhat more rapid
course than in lupus serpiginosus, are the seat of more active
inflammation, and are  attended  with a  more  destructive
ulcerative process, which extends to the deeper-seated struc-
tures.  In  other cases, one of the alae of the nostrils becomes
slightly swollen, painful to the  touch, and  of  a violet-red
colour; being attended with itching it  is  soon scratched
with  the  nails, a brownish   crust or hard scab  results,
which is surrounded  by an inflammatory oedematous base,
and, purulent matter forming  beneath it, ulceration of the
destructive character peculiar to  the disease commences.
In a third class  of cases the tip of the nose  swells, and pre-
sents a dead-white colour, gradually but slowly enlarging a
black crust forms  at the very apex, the mucous membrane
of the nostrils becomes  thickened, chiefly from effusion into
the areolar tissue beneath it, and at length ulceration takes
place.  And, lastly, the thickening and  subsequent ulcera-
tion first appear in the soft palate or posterior nares, and, 
LUPUS.
251
proceeding from within outwards, eventually attack  the
septum naris, and the other cartilages of the nose.
  In  whichever  way the disease  may commence, the re-
sulting ulceration presents much the same characters; its
tendency is to  spread  from the surface inwards,  not  un-
frequently  undermining in its progress the healthy integu-
ments before it attacks them,  and being attended with a
foul, unhealthy, purulent, often ichorous, discharge.   The
parts first  affected usually cicatrize  in the course of the
disease, when  the cicatrices present  a similar appearance
to what is Avitnessed in lupus serpiginosus, but  indicate a
greater loss of substance  beneath.   This is especially re-
markable  on the nose, the most usual seat of this variety
of lupus,  this  feature  assuming then  a peculiar  pinched
appearance, from a deficiency of  some of its natural pro-
portions.   The amount of destruction caused  by the  ulcer-
ative  process  varies  much in different  cases,  in  some
removing only  a small portion  of the cartilages of the alae
nasi,  while in others the entire soft  part of the nose, the
alae and septum naris, and the  soft palate,  are  destroyed,
frightful deformity  being  thereby occasioned.  As in the
other forms of lupus, parts  that have been cicatrized  not
unfrequently again become  the seat of  fresh ulceration,
which runs a similar course to what it did  at first,  being
then, however,  more difficult to check.
   Lupus  devorans  most  generally  runs a  very chronic
course, its  progress being slow, years often elapsing before
it causes much destruction of  the  part it appears on ;  but
cases  occur—happily very  rarely—in which it destroys
Avith  extreme rapidity those portions of the integuments
and  of the neighbouring structure it attacks;  thus, in from
a month to six weeks the  entire of the nose may be  eaten
a\vay: this variety of the  disease has been appropriately
enough termed lupus vorax.
   In some cases lupus devorans  attacks the lower  eyelid
first, commencing by the development of a single rounded
elevation of the skin, of a  livid aspect;  its progress  is ex-
tremely slow, but in the course of years it eats  away all
the structures around  the  eyeballs, laying the orbit almost
completely bare, but sparing the eye itself, which  appears
just  as if it had been dissected out  by the ulceration.   This
variety of  the disease was  first  accurately described by 
252
CANCRODES.
Professor Jacob, who, however, regarded it as a malignant
ulcer and  not as a form of lupus, and  it has been ever
since known  to the profession in this country by the name
of "Jacob's  ulcer."  Rayer, who  also  gives  an accurate
account  of it, believed it to be  lupus, and  Avith him my
experience, derived from  the  prolonged  observation  of
several cases, compels me to agree.   The folloAving graphic
account  of this lupoid  ulceration is given by  Professor
Jacob :*  " The edges are elevated, smooth, and glossy, with
a serpentine  outline, and are  occasionally formed  into  a
range of small  tubercles or  elevations: the  skin  in the
vicinity is  not thickened or discoloured.   The part within
the edges  is  in  some  places a perfectly smooth, vascular,
secreting surface,  having veins of  considerable size rami-
fying over it, Avhich veins occasionally  give way,  causing
slight  hemorrhage ; in  other  places the surface  appears
covered  by florid, healthy-looking granulations, firm  in
texture,  and  remaining  unchanged in size and  form for a
great length of time.   The surface sometimes  heals over
in patches, which  are  hard, smooth,  and  marked with
venous ramifications."    " The discharge  from the surface
is  not of the  description called  by surgeons  unhealthy or
sanious,  but yelloAv and  of proper consistence; neither is
there more fetor than from the healthiest sore, if the parts
be kept perfectly clean, and be dressed frequently."   It is
surprising how little suffering, either local or constitutional,
attends this frightful affection, the duration of which may
extend from early life to an advanced old age.
  Lupus in all its forms is a disease of youth  and of the
prime  of life, being rare before the  age of 10,  and- very
seldom developed  for the first time in old age.  As regards
its causes, there  is abundant  evidence to show that it is
intimately connected Avith  the scrofulous  diathesis, espe-
cially when it is hereditary, and  many cases seem to prove
that a constitutional syphilitic taint also is a  frequent pre-
disposing  cause of it.   In  the majority  of  instances it
appears  at or soon after  puberty, without any manifest
exciting cause, but in some it follows  an injury or some
other local irritant.  It is  on  the whole rather  a rare
' Dublin Hospital Reports, vol. iv. p. 232. 
LUPUS.
253
disease, and is perhaps someAvhat more frequent in females
than in males.
  Diagnosis.—The  differential diagnosis of the various
forms of lupus now described is unattended with difficulty,
but some of them may be mistaken for  other  diseases of
the skin.  Lupus superficialis  is of such very rare  occur-
rence  that it is often not recognized when met Avith, yet
its phenomena are highly characteristic, and it is of import-
ance, with reference both to prognosis and treatment, that
it should be diagnosed; the peculiar cicatrization or seam-
ing of the surface over which it has passed  is  its especial
mark :  a similar result  is not met with in any  other cuta-
neous  affection.  Lupus  serpiginosus  may be confounded
with  impetigo, from which  it  is distinguished  by the  de-
structive  ulceration which attends  it, by its  spreading in
rings  and undermining the integuments as it  creeps  on-
wards : pseudo-pustules are constantly developed on those
parts of the skin which it attacks, but they differ from  the
pustules of impetigo in being flattened, more or less uncir-
cumscribed, and presenting from the first a comparatively
large quantity of purulent matter, with a very thin covering.
This variety of lupus is in general described by dermatolo-
gists  as being  with  difficulty  diagnosed from scrofulous
ulceration of the integuments ;  but this is a matter of little
import, for it rarely occurs except in persons of a well-
marked  scrofulous  diathesis, and by many  it- is  termed
Esthiomanic scrofula.   A somewhat similar form of ulcera-
tion constitutes at times one of the phenomena of secondary
syphilis, but  it is not of the same indolent and  destructive
character, is attended with other symptoms which mark  the
presence of this poison in the  system, and is always more
or less amenable to  specific treatment.  Lupus devorans
may, in its early stages, be mistaken for acne indurata, but
the distinctive signs have been already pointed out in the
description of  that disease (see  page  122).  From the
syphilitic affections which  occur  on the face it is  distin-
guished, by its  malignancy, by its  slow  progress, and  by
its not directly implicating the bony structures, but in many
cases  the diagnosis is  made with  extreme  difficulty, and
then the results of  treatment—more  especially when the
22 
251
CAN CR 0 DE S.
 history of  the individual case  cannot be  satisfactorily
 obtained—afford much aid in arriving at a conclusion.
   The  form of lupus described above  under the name of
 " Jacob's ulcer" is regarded by many as being nealy allied
 to, if not a variety of, cutaneous cancer;  by most surgical
 writers the latter view is taken, and Copland regards it as
 a connecting  link betAveen the two diseases.  But its chief
 characteristic phenomena, especially its tedious but omvard
 ulcerative  progress, not  implicating the bony  tissues,  the
 freedom from pain which marks its course, the non-contami-
 nation of the constitution generally, and the absence  of  the
 hypertrophied  condition  so  characteristic  of  cutaneous
 cancer, sufficiently identify it, in my opinion, with the other
 lupoid affections.
   Prognosis.—In every form of lupus, the prognosis, though
 favourable as regards the general health, must be more or
 less unfavourable Avith respect to the local disease, the latter
 being  by  many regarded as  altogether incurable; yet,
 although most tedious and obstinate, in the majority of cases
 resisting  even judiciously applied and  appropriate  treat-
 ment for years, it not unfrequently eventually yields, the
 destructive process of ulceration is arrested, and  the affected
 parts heal.  The  superficial  variety of lupus is  the least
 important in all respects, but even it is most rebellious, and
 the diseased  surface rarely takes  on a healthy action until
 after several months of treatment, and after  apparent cure
 it is very  apt to  re-appear in the  old  cicatrix.   Lupus
 serpiginosus, when of small extent, is in some cases very
 amenable to treatment, but  when it affects an  extended
 portion of the  integuments  is rarely  cured in a shorter
 period than from a year to a year and a half  or two  years,
 and often after the disease is apparently perfectly removed, it
 breaks out afresh in one or two of the spots which had healed,
 when it lingers obstinately for months.   Lupus  devorans is
 both the most severe and the most obstinate of  the several
 varieties of  the disease, its  destructive  progress, unless
 Avhen submitted to treatment  at a very early period after
it commences, is scarcely to be arrested, nor does it seem ever
to tend to spontaneous cure: the form denominated "Jacob's
ulcer" is in my experience, perfectly incurable in all  its
stages.  Like most other cutaneous diseases, the longer the 
LUPUS.
255
duration of lupus, the more difficult is it to treat success-
fully.
  As regards the pathology of lupus, it is manifestly nearly
allied to cancer, especially by its  malignancy, and the ap-
pellation for the group of diseases of the skin in which it is
here placed has, I think, been therefore happily chosen by
Dr.  Copland; yet  they differ  remarkably, in the latter
being almost invariably marked  by a general contamination
of the system, which is never witnessed in the former ; this
is well evidenced by the glandular system in the neighbour-
hood of the disease  not becoming affected in  the course of
lupus, even when it  has existed  for years.
   Treatment.—The administration of constitutional reme-
dies, in the  treatment of  lupus, is  regarded by  many as
being useless, and the employment of local applications is
solely relied on, but I agree with those who consider both
to be requisite, and it is only from a prolonged perseverance
in remedial measures, judiciously selected, that good results
can  be  expected to  follow in this obstinate and malignant
affection.  The intimate connexion that exists between the
disease and scrofula being  an  admitted  fact, the general
treatment  should consist in the use of those remedies which
are  calculated to correct  that vitiated  condition of the
system, and the avoidance of all  medicines Avhich experience
has  proved disagree with scrofulous  individuals, or aggra-
vate any local derangement under which  they may labour.
The preparations of iodine and of iron, cod-liver oil, and the
vegetable  tonics, are therefore  especially indicated in the
treatment  of the different  forms of  lupus,  and  general
hygienic measures, calculated to invigorate the constitution
and  to  remove  its  vitiated condition,  should never  be
neglected.
   Iodine in some form, given in combination Avith tonics or
alteratives, according to  individual circumstances^ is the
remedy which, in  my experience,  is most  to  be relied on;
for  the majority of cases  the  iodide of  potassium is the
preparation best adapted, but, as I  have already remarked
in  a previous part  of this work, its beneficial effects are
more certainly obtained  by being administered in rather
small doses, continued for a long time, than if it be pre-
scribed  in large  quantity at first—a  practice which has 
256
CANCRODES.
been recently much followed in the treatment especially of
secondary  syphilitic diseases.  In persons in Avhom  the
constitution is unimpaired, and the muscular and adipose
tissues Avell developed, it may be  prescribed in somewhat
the following form :—

     R. Iodidi Potassii,......gr. xij.
        Infusi Cascarillae,.....fl I xij.
        Liquoris Taraxaci,.....fl 3\j.   Misce.

   " Two table-spoonfuls to be taken three times a day."

   The quantity of the iodide of potassium should be increased
by the addition of a grain to the  mixture each time it is
renewed, until it contains twenty-four grains, when it should
be omitted for a few weeks, and again recommenced in the
small dose.  For weakly persons, or those of a broken-down
habit of  body, the iodide of iron should be substituted for
the iodide of potassium, and it may be given in decoction
of fresh  elm-bark; when the scrofulous diathesis is very
well marked, and the lupoid ulceration extensive, threaten-
ing to engage  the  deeper seated  structures,  iodine itself
will be advantageously combined with the iodide of  potas-
sium or iodide of iron :  if with the former, it may be pre-
scribed according to the formula at page 185, the arsenical
solution being omitted.
   Cod-liver oil   also  proves an excellent remedy in the
treatment of lupus, especially when the disease occurs at
an early age; from my own experience of its effects I do
not think it is attended with so much advantage Avhen given
in the enormous doses  recommended  by some, as when'
administered in smaller quantity, and its use persevered in
for a very long lime:  a teaspoonful three times a day, and
increased so gradually that at the end of six months two
table-spoonfuls,  as frequently given, will be  the amount
arrived at, a dose which need not be exceeded, is the manner
of administering the medicine that I have seen proved
eminently successful  in  lupus.  By some of  the French
dermatologists,  however, many of whom speak in  rather
extravagant terms  of  its efficacy in  this  disease, the
dose  is increased as rapidly as  the stomach will  admit, 
LUPUS.
257
until from a pint and a half to two pints are taken in the
twenty-four hours.
   Arsenic alone, or combined with iodine, has been highly
recommended by  many practitioners  for  the treatment of
lupus ;  the late  Dr. Anthony  Todd  Thomson was in the
habit of relying  chiefly on it in the form  of the iodide of
arsenic; I have found this preparation very useful in  the
form described above as constituting lupus superficialis, but
in the other varieties of the disease it has not proved so
beneficial in my hands as iodine and the iodide of potassium.
The  liquor arsenici  et hydrargyri hydriodatis  proves of
especial service in those cases in Avhich there may  exist in
the system an hereditary or acquired syphilitic taint.
   So many other medicines have been at different times,
and still  are, proposed for the  treatment of lupus, that it
would be almost impossible even to enumerate them ; a few,
however, require to be shortly noticed.  The animal oil of
Dippel—obtained in  the  dry  distillation  of hartshorn
shavings  in close vessels—has acquired some character on
the Continent; it is  given in doses of five or six drops, at
first, gradually increased  to twenty  or  twenty-five.   The
chloride of barium and chloride of calcium have both been
much used; that they possess some efficacy, due certainly
to their anti-scrofulous powTers, has been proved by the pub-
lication of several cases in which a cure resulted from their
administration.  Various preparations of mercury have also
been tried for the treatment of lupus, and the red iodide is
especially recommended by M.  Rayer for those cases  in
Avhich there is much hypertrophy of the  integuments; but
in consequence of the injurious effects so often occasioned
by the administration of  mercurials to  persons  of  the
scrofulous diathesis, I cannot agree with those Avho advocate
their use in this disease.
   The general hygienic measures to be adopted  require
merely to be alluded to ; they consist, of course, in attention
to every circumstance  which  can fortify the  constitution,
and remove the depraved condition on which the presence
of the local disease depends : the chief of these  are,  breath-
ing a dry, pure  air, the use of nourishing, unstimulating
diet, residence on the  sea-shore,  and when the strength
admits,  cold salt-water bathing.
                        22* 
258
CANCRODES.
  The local treatment of lupus has at all times attracted
more  attention than the constitutional, and, as before re-
marked, many consider that the disease can by it alone be
cured.  It may be considered under two  heads : first, the
ablation of the affected portion of the integuments by the
knife,  or  its  destruction by caustics; and,  second, the
employment of astringents or other medicinal agents, calcu-
lated  to promote cicatrization, or excite a new action in the
parts.   In the superfical variety of lupus, the chief  object
being to prevent disfigurement  by arresting the  progress
of the disease, the use of the  knife is not • admissible, for,
were  its employment  even certain  to effect  a  cure, the
resulting eschar would occasion as much, if  not greater,
deformity; for the serpiginous form it is not applicable, nor
has it been recommended,  except by a few  surgeons, to
remove the hypertrophied edges: and, therefore, it is only
in lupus devorans that excision holds out any prospect of
being  useful.    An  almost  insurmountable difficulty, as
regards its application, however, is experienced in all cases
in which the disease has existed for any time, owing to the
manner in which the ulceration spreads,  and the consequent
impossibility of removing the entire of the parts affected;
when it  is  but of short  duration, and the deeper-seated
structures are not involved, the  operation has occasionally
proved  useful,  especially  in "Jacob's ulcer;"  but the
employment of the constitutional  treatment above recom-
mended should not be neglected at the same time, as thereby
alone can it be expected that the return of  the disease will
be prevented.
   The stronger caustics, from being more easy of applica-
tion,  and more certain than the knife in their effects  on the
uneven, penetrating ulceration which characterizes this form
of  lupus, have  been  more  generally  employed.   Those
chiefly used are the  nitric and hydrochloric acids, the acid
nitrate of mercury, caustic ammonia, chloride of zinc, chlo-
ride of gold, caustic potash, solution of the terchloride of
antimony,  and arsenical pastes or powders.  The chloride
of  zinc has many advocates, and where the edges of the
ulcer are ragged and unhealthy, and the surface discharging
a sanious pus, it in many cases proves useful by  exciting a
new action; as much of the surface as it is wished to destroy 
LUPUS.
259
should be touched lightly with the solid salt, and the appli-
cation reneAved every alternate day until  the desired effect
is produced: the stronger acids may also  be applied, in the
same  manner.   I have generally known the employment of
caustic applications prove injurious in lupis serpiginosus,
yet they are highly praised by several writers, nitrate of
silver being usually preferred to any other;  in many cases
that I have seen them used, the  parts to which  they were
immediately applied healed up temporarily, but the serpigi-
nous ulceration from the circumference continued to spread
unchecked,  undermining  the surrounding  integuments,
generally with increased rapidity.  In lupus superficialis,
caustics,  if effectually applied, cause a worse disfigurement
than  the  original disease, which, moreover, they do not
check.
   Under the second  division of local applications may be
noticed, first, those which, though not actually caustic, are
highly stimulant  and resolvent, such as  the dilute  acids,
Donovan's  solution, the  animal oil of Dippel,  lotions or
ointments containing the chloride of zinc, nitrate of silver,
caustic potash,  &c.   The  oil of  Dippel is  employed very
extensively on the Continent, and, it is said, with excellent
effect, especially when  the nose is the part affected, as a
modifier  of the  diseased  action; it is applied by means of
a  camel's-hair  pencil,  the surface  being lightly touched
with  it, and the application repeated several times.  The
solution  of the  hydriodate  of  arsenic and mercury also
proves most useful as a lotion in many cases  of the disease ;
it is  especially of service in the  superficial form of the
affection, the crusts having been removed  by poulticing pre-
viously.
   M. Cazenave has recently published his experience of the
effects of the red iodide of  mercury as a local application,
from  which it  would appear to produce  most beneficial
results, especially in  those cases attended with much hyper-
trophy.   " Under the influence," says he, " of the applica-
tion  of the binoide of mercury frequently repeated, I have
seen  after the disappearance of the sharp but fleeting local
inflammation produced by it, and as a consequence probably
of its general  action,  the hypertrophied  points become
resolved, the tubercles  to disappear, and soft, superficial, 
260
CANCRODES.
smooth cicatrices, on a level with the rest of the skin, form;
in short, I  have  seen the most  frightful cases of  lupus
cured without leaving any other traces than an apparently
thinned  skin,  with  white or red  spots  here and there,
according to the length of time which had elapsed from the
formation of the cicatrices."1   M. Cazenave applies a thin
layer of the powder,  undiluted, to  a  portion  only of the
diseased surface at a time; it causes severe pain  and much
inflammation,  the former lasting for six or eight hours, and
the latter for three or four days ; a thick crust is left, which
falls off at the end of six, eight, or ten days, when, should
there be occasion,  the application may be renewed.
  The topical remedy which I have found most useful in
the treatment of lupus serpiginosus  is the acetate of zinc ;
the ulcerated surfaces should be touched with the solid salt—
care being taken to use a crystal which has not effloresced—
tAvice a day,  daily or  every second or third day, accord-
ing to the degree of activity of the local  inflammation, and
a lotion containing from three  to  five grains to the ounce
of distilled  water  should  be used, lint  wet  with it being
applied, and the parts  covered with oiled silk when practi-
cable.   In this form, as well as in lupus devorans, the local
inflammation,  of  which  from time  to time rather smart
attacks occur, should  be checked  by the application  of
leeches as near the affected parts as possible, but sufficiently
distant to prevent  the  bites from becoming involved in the
disease, and emollient poultices should  be used occasionally
with the same intention,  and to remove the  hard crusts
which form.
  No matter  what  local  treatment be employed in the
treatment of lupus, attention must be especially paid, when
the nose or mouth is  the seat of the disease, to prevent
the natural outlets from becoming  obstructed  during the
progress of  cicatrization.
  In conclusion, I may again repeat that, as the result of
considerable experience in the treatment of this obstinate
and  serious disease, I  regard  the employment  of topical
agents as altogether secondary;  they are unquestionably
useful  in modifying the diseased process that is going on,
and  in  exciting a new action  in  the parts, but  they must
 1 Annales des Maladies de la Peau et de la Syphilis, torn. iii. p. 69. 1851. 
K E L 0 i S.
261
be regarded as only auxiliary to the constitutional treat-
ment, which should engage the chief attention of the prac-
titioner, the fact being always kept prominently in view,
that it is alone by the prolonged use of remedies, and dili-
gent attention to general hygienic measures, that a favour-
able result can be expected.

                        KELOlS.

  Kelois (Chelo'd tumour) is an extremely  rare disease
of the skin, which was  first  noticed  in the latter end of
the last  century by  Retz, and was soon afterwards fully
described by Alibert, who applied this name to it from a
fancied resemblance which he thought it bore to the claw
of a crab (znXri, "forfex cancrorum"): for a similar reason
he first denominated it Cancroide, and also  because this
latter term expressed the analogy which he believed to exist
between  the disease and cancer;  it is  for the latter reason
that I have included it with lupus, in the order Cancrodes.
It consists in the development on the  cutaneous surface of
an irregular-shaped, or somewhat oval, hard, and prominent
excrescence, slightly  depressed and uneven in the centre,
the edges  being  raised and thickened; the surface has a
polished, shining aspect, of a  rose or reddish-white colour,
marked with bright-red and white lines, and corrugated so
as to present nearly the appearance of an old, much hyper-
trophied cicatrix. When pressed with the finger  it is  some-
what resilient, and the part pressed upon becomes momen-
tarily colourless.   The morbid growth, which varies in size
from a fewlines4;o an inch or more in diameter, is extremely
adherent  to the  integuments, roots projecting from it into
the deeper layers of the skin.  It first appears in the form
of one or more small, hard, wartlike tumours, accompanied
by itching and some pain;  as it  increases in size the pain
becomes  much augmented, being of a severe stinging cha-
racter, and in some  cases has been  described  as  being
almost unbearable.
  The cheloid tumour is most generally solitary, being, in
the majority of cases which have been reported, developed
on the anterior surface  of  the  thorax, either  below  the
clavicle on either side, or on the  sternum, but in  a  few 
262
CANCRODES.
instances  several of them have been witnessed to exist at
the same time on different regions of the body:  its groAvth
is comparatively slow, it does not ulcerate, nor is it painful
to the touch, and may continue indolent for years, but in a
few cases it has  been reported to have become gradually
smaller by interstitial absorption, until it finally disappeared
altogether, its site being marked by a white cicatrix.
  The causes of this disease are very obscure; in one or
two instances it  has  been stated to have  followed  local
injury, and  some cases have been published in which the
tumour was  developed  on the  old  cicatrix  of  a burn  or
wound, but many have with sufficient reason questioned the
fact of these being  examples  of true kelois.   No  proof
exists of its  being hereditary, or of its occurring in persons
whose  parents had been affected with cancer or scrofula,
nor does  it appear to be connected with any special tem-
perament or diathesis.   It would seem to affect both  sexes
nearly alike,  but it has not been observed in  early life,
those who labour under  it being  individuals  usually  of
mature age.  The  extreme rarity  of  the disease is very
remarkable,  and  consequently its nature, history, and
characteristics are not well understood, from want  of suffi-
cient  opportunity for their being  studied:  Wilson states
that the total number  of cases recorded amounts only to
24, of which  he  himself  has seen  7; but it has been wit-
nessed also in Ireland, casts and drawings of it  existing in
the Museum of the Richmond Hospital in this city, although
the cases  have not, as far as I am aAvare, been published.
  Diagnosis.—The  only affection  with which kelo'is is  •
likely  to be confounded is cancer;, it is distinguished from
it  by its  indolent nature, its indisposition to ulcerate, the
absence of contamination of  the grandular system, and its
peculiar site.
  Prognosis.—Were  it not for the extremely painful sen-
sations  Avhich usually attend this  affection, it Avould be of
little  moment, there  being no risk of  life, nor  local dan-
gerous  symptoms likely to be occasioned by its presence.
The duration of the disease is almost invariably  prolonged;
years elapsing in those cases  in Avhich it has disappeared
spontaneously, before absorption had commenced.
   Treatment.—Excision  of  the chelo'id tumor has been 
K E L 0 1 S.
263
proposed and practised,  but such course seems  to  have
been  invariably unattended with successful results; the
wound made was difficult to heal, and the disease returned
after some time either in the cicatrix or in the integuments
of some  other region of the body.  The spontaneous cure
of the affection by absorption having occurred in, compara-
tively speaking, many cases, should inculcate the propriety
of abstaining from meddlesome interference, and teach that
reliance  ought to  be placed chiefly on constitutional treat-
ment by means of alteratives and corrigents where neces-
sary, and the local  use of mild stimulants or sedatives to
allay pain.   With  the latter view I would suggest the
employment of an ointment containing the iodide of potas-
sium  and chloroform.  Cazenave recommends the sulphur
douche;  Wilson, the application of collodion and the tinc-
ture  of iodine;  and Rayer, that firm and  constant  com-
pression should be made on the tumour when its situation
permits. 
264
DERMATOPHYTE.
                  CHAPTER  XL    *

                     DERMATOPHYTE.

   The general application within the last few years of the
use of the microscope in investigating diseased conditions
of  animal structures, has  afforded  most  important and
valuable assistance to the morbid anatomist and pathologist,
by throwing new light upon much that was before obscure;
our knoAvledge of cutaneous affections has, along with other
subjects in practical medicine, been advanced thereby, and
chiefly by the discovery that in certain of them a vegetable
production—a cryptogamic plant—is present on the surface
of the skin.   It is in consequence of this discovery that a
necessity has arisen for constituting the present group or
order of diseases of the skin, and which is termed Derma-
tophytes—from fop^a, " the skin," and $vtov, " a plant:"—
it includes, then, those cutaneous affections which are depen-
dent on, or are characterized by the presence of parasitic
plants on  the diseased  surface of  the  integuments.   By
some the existence of these vegetable growths is altogether
denied, while others, who  admit their  existence, regard
them as being accidental productions,  a consequence and
not a  cause  of the  disease which  they accompany;  the
investigations, however,  of Dr.  Hughes Bennett, of Edin-
burgh, and of Robin, Gruby, Lebert,  and others, on  the
Continent, in my opinion, place beyond doubt.not only that
these parasites are developed in certain diseases of the skin,
but that they constitute their essential nature.  In addition
to the two affections, Porrigo  and Sycosis, which I shall
include in this order, the presence  of a cryptogamic plant
has also  been recently ascertained in Pityriasis versicolor
(Chloasma), but I agree with Dr. Bennett, in the opinion
that " although this disease  frequently presents  epiphytes
among the scales, it OAves none  of its essential  characters
to this circumstance." 
P 0 R R I G 0.
265
                        P0RRIG0.

  Porrigo  (Favus;  Tinea;  Scall-Head).   This peculiar
affection, which, from its appearing most frequently on the
scalp, is generally described as being peculiar to that region
of the body, is characterized by phenomena so distinct from
those of all the other  eruptive diseases which  are apt to
occur there, that it cannot possibly be mistaken for any of
them.   It is developed  in  the form of small, elevated,  dry
spots, about the size of a pin's head, of a bright yellow
colour, seated  on the surface of the skin, which is depressed
slightly by them; each  spot is distinct,  hemispherical,
slightly concave or cup-shaped  on  its  free surface,  and
convex beneath, where  it is  adherent  to the skin.   On
removing the  small, diseased mass, that portion  of  the
scalp on which it was seated  is found to  be  somewhat
depressed, smooth, and shining.   A single crust  of  the
disease, or favus,—as it has been termed, from its resem-
blance both in colour and central depression to the super-
ficial surface of a honeycomb,—is often traversed by one,
and sometimes by two hairs, which  appear to grow, as it
were, from the very centre or most depressed portion;  this
has given rise to the  notion that  the disease is one of the
bulbs of the hair, but the fact  of its appearance on other
parts of the body which are quite free from hair  affords a
sufficient refutation of this opinion.   The eruption spreads
by additions  to the  outer edge or  circumference of  each
crust, which thus retains its hemispherical  character,  until
it acquires  a  diameter  of  two or  three lines, or sometimes
more;  some of the favi on the trunk at  times attain  fully
half  an inch in  diameter;  on  the head,  however,_  they
rarely  exceed the size  above mentioned.   The adjacent
favi,  as they  increase, unite with  each other,  and  form
large, irregularly-shaped  masses, in  Avhich the  original
circular form of the individual crust is in a great degree
lost; the centre also of  each  is changed in appearance,
and,  instead of the cup-shaped depression, the entire  sur-
face is covered Avith  alternate elevations and depressions,
or, so to speak, ridges and furrows, concentrically arranged.
The eruption thus increasing, the Avhole of the scalp, often, 
266
DERMATOPHYTE.
too, the forehead, the neck, and parts of the trunk, become
encased in  one large, yelloAv crust, at  the edges of Avhich
some  favi, of  the peculiar characteristic appearance,  are
invariably to be seen.
   The crusts of porrigo are of a pale sulphur-yellow colour;
they are hard  and dry, and break with a short fracture,
exhibiting within a mealy powder  of  a paler yellow than
the external surface.   They may  generally  be removed
with  facility from the scalp,  but  they bring away with
them  a thin layer of epidermis, which is firmly adherent to
their under  surface, through which small projections may
be  seen with a moderate  lens, sometimes with the  naked
eye.  These projections, or processes, pass into the dermis
beneath, and when the crusts are torn forcibly away, blood
issues from the small orifices into which they were inserted.
From  the very commencement of  the eruption the hair
becomes altered; much of it falls out,  and  the straggling
hairs  that  remain are  thin, broken,  weak,  whitish,  and
readily removable  with  the crusts of the disease, in Avhich
they are firmly imbedded.  When  this affection has con-
tinued for any length of time, bald patches  are left after
cure,  on which  the hair does not  again grow; and even
where it has been cured at an earlier stage, the hair seldom
regains its proper character, being often weak, thin, and of
a  diseased  appearance, and  of a  whitish-yellow colour.
Porrigo, in  its  first stage, does not give rise  to either heat
of  scalp or  itching,  and, consequently,  is  very  rarely
noticed until it is fully developed.   It usually commences
on  the forehead,  at  the edge of  the hairy scalp, but it
spreads rapidly over  the head, soon involving nearly  the
entire surface, the healthy patches  which are left between
the diseased spots being but very feAv, and small in extent.
The eruption is also met with on various parts of the body,
the trunk or extremities ; but I have  very  rarely seen it
there  except when  it existed at the same time on the scalp.
As the disease  advances, much irritation of the surface is
produced; small pustules form here and there in spots as
yet unaffected with the eruption:  the tingling and heat  are
so unbearable as to compel the patient to tear the surface
with his nails, even to such a degree as  to cause ulceration;
innumerable pediculi are engendered; the favus crusts emit 
PORRIGO.
267
an  abominable  odour, resembling  that  of mice;  and  a
copious offensive discharge is secreted by the pustules and
ulcerated spots: in short, an individual  affected with this
disease in its aggravated form becomes a loathsome and
disgusting object.
  I have already referred to the vegetable nature of this
eruption; it is in the spongy, friable contents of the favi
that its characters  are best seen.   " Reduced to  powder,
and placed under the microscope, it presents," says Robin,
" a mixture—1. of  tortuous, branching tubes,  without par-
titions, empty,  or  containing  a  feAv  molecular granules
(mycelium);  2. straight or crooked, but not tortuous tubes,
sometimes, but  rarely, branched,  containing  granules or
small,  rounded cellules, or elongated cellules, placed end to
end, so as to represent partitioned tubes, with  or without
jointed articulations  (receptacles or sporangia, in  various
states of development ?); 3. finally,  sporules, free, or united
into  bead-like  strings.  The mycelium  is very abundant
near the inner surface of  the external  layer, to which it
adheres.  The spongy, friable mass of the centre of each
favus  is principally formed of  sporules  and the different
tubes containing mycelium already described (sporangia, or
receptacles?).  We often find mixed with them mycelium
tubes,  but in small  quantity.  All these  elements pass
insensibly into each other:  empty tubes (mycelium); tubes
containing small, round corpuscules;  tubes with  corpus-
cules as large as the smaller sporules;  sporules placed end
to end, so as to resemble a hollow partitioned cylinder, with
a tendency  to separate at the joints; and free sporules.
Bennett has giA^en  a good drawing of  this arrangement."1
M.  Robin gives  a  minute description of the various parts
of which the fungus is composed, as Avell  as  faithful and
Avell  executed illustrations  of this vegetable parasite, the
correctness  of which I have had various opportunities of
verifying Avithin  the  last few years, and  recently with the
assistance of  Dr. Lyons, Avho has  devoted so much time
and  talent to promote microscopical medical investigations

  1 Des Vegetaux, qui croissent sur l'l-Ionime ct sur les Animaux Vivians,
par Ch.  Robin.  Paris,  1848. 
268
DERMATOPHYTE.
 in  Ireland.   The botanical  characters  of the plant are
 appended in a note.1
   This is a rather rare affection, appearing, however, from
 the observations of those who have written  specially upon
 it,  to be more  common  on the Continent  and in Ireland
 than in England.  When I first wrote on  this disease in
 1848,2 my experience was drawn from a limited number of
 cases;  since then, however, I have had under my care  a
 comparatively large number of examples—twenty-three.
   It  may appear at any time of life, but is  very seldom
 met with except in childhood, from the age  of 3 to 12 ; it
 may be developed on almost  every part  of the body, but,
 as  already remarked,  occurs with by much the greatest
 frequency on the scalp, and next to it on the back of the
 trunk.   When it appears on  those portions of the integu-
 ment which are not  covered with hair, the favus crusts
 acquire a larger size, and increase more rapidly than when
 it is seated on the scalp, but  it presents precisely similar
 characters.
   Great confusion long existed amongst  dermatologists as
 to what special  disease was understood by the term, " Por-
 rigo;"  the  many eruptions which have  their  seat  on the
 scalp  were at one time described as being  merely varieties
 of a single genus, which was  indiscriminately denominated
 Favus,  Tinea,  or  Porrigo;  this confusion  has,  however,
 been lately  much removed, and the latter appellation—the
 others being synonymous with it—is  now strictly confined
 to the cutaneous affection above described,  and which cor-
 responds with the Porrigo lupinosa of Willan.  Cazenave
 divides  it into  two  species characterized by the form in
 Avhich the crusts are developed, the  one  he terms Favus
 dissemine, and the other  Favus  en cercles ;  this is, I think,
 an  unnecessary  refinement, tending  to complication, and
 presenting no advantage  in practice.   Wilson, who denies

  '_ " Achobion Schonleinii.   Remak.  Orbiculare, flavum,  coriaceum,
 cuti humanse presertim capitis  insidens  ; rbizopodion  niolle, pellucidum,
floccosum, floccis tenuissimis, vix articulatis, ramossissimis, anastomoti-
cis(?).  Mycelium floccis crassioribus subramosis,  distinct^  articulatis,
 articulis  inaaqualibus, irregularibus, in sporidia  abeuntibus; sporida
rotunda, ovaliavel irregularia, in uno vel pluribus lateribus germinantia "
  2 Eruptive Diseases of the Scalp.  Dublin, 1848, 12mo. 
PORRIGO.
269
the vegetable nature of the morbid production on the scalp,
describes favus, which is the name he adopts, as being  a
disease of the hair-follicles.
   The causes of porrigo have given rise to much difference
of  opinion,  especially Avith  reference  to  its  contagious
nature;  the  correctness of  my  adhesion to the  vieAvs of
those who hold  that it is  so, Avhich I  avowed some years
ago in  the  little work already referred to, has been  con-
firmed by almost every day's experience since, for I have
seen numerous instances of the propagation of the disease
from individual  to individual, by  direct  contact,  in  the
majority of cases from children to children, but sometimes
even from  children  to adults.   The  mode  in  which  I
believe  the contagion to be conveyed is by the propagation
of the vegetable parasite, by means of the mycelia.  But
its contagious character has been  denied by many on the
grounds of the rarity of the disease, and the failure to
produce it  by inoculation, as tried by  Gruby and others ;
the former of Avhotn produced the disease only once out of
seventy-six trials on vegetables, and not at all on animals.
But Remak succeeded  in inoculating his OAvn arm  in
August, 1842 j1 and Bennett, who had previously failed
in his own person after  repeated  trials,  succeeded com-
pletely  in 1845, in producing the disease in one of his class
by  inoculation  and  close contact of the  favus  crusts,
obtained from the head of a boy at that time in the Royal
Infirmary.   An  account of his  experiment,  and also of
Remak's, will be found in  the Northern Journal of Medi-
cine for  September, 1845,  p. 202.   Now in all these trials
to generate the plant, one important  fact  connected with
the natural history of parasitical fungi has been overlooked
by all,  namely, that they  require for their  growth  a
peculiar soil; thus we find one genus is found only on snow,
another  on  cheese,  another in  yeast, different  varieties
on  different  decaying  vegetable matters,  and individual
genera and  species on various living animals and plants;
nay, even  different sorts  on different  parts of the same
animal.  This  holds  true  Avith the  Achorion Schonleinii;
it requires for its reproduction to be planted in  a peculiar
soil, that is, on an individual Avhose system is in a peculiar
                1 Medicinische Zeitung, for 1842.
                          23* 
270
DERMATOPHYTE.
cachetic  condition; and until it is  ascertained what this
exact constitution is,  a single instance of its propagation
by contact—and such instances  are  not uncommon—must
be held as sufficient proof of its contagious character.
  Some have held that this eruption occurs in scrofulous
persons only; others, that  it is an hereditary disease; but
neither statements  are consistent with the observation of
the cases Avhich  I  have seen.   It  appears to have some
connexion with, though I cannot say that it is caused by,
poverty,  filth, wretchedness, and a weak  development of
the mental  faculties.   Unquestionably where  the disease
has long existed, the  mind is weak, and the  countenance
presents  a somewhat idiotic expression.
  Diagnosis.—With no other disease of the skin can por-
rigo be confounded, it is so distinctly characterized by the
dry, yelloAv, favus crusts, and the total absence of discharge
or scaly desquamation in  any  of its stages; occasionally
pustules  form, it  is true, on  the surrounding integuments,
but they are evidently due to  the  irriftitive inflammation,
caused by the morbid growth on the cutaneous surface, or
the application of acrid or stimulating unguents, lotions, &c.
In its very early  stage, when seated on the scalp, porrigo
might be mistaken for the commencement of an attack of
impetigo, but the rapid development of the pustules in the
latter soon renders the diagnosis simple;  and  it does not
present any features  in common Avith the other eruptive
diseases of  the scalp.  Should  a doubtful case, however,
occur,  any difficulty that may exist will be at once cleared
up by  a microscopic examination.
  Prognosis.—A disease  of great gravity,  and   always
regarded with extreme abhorrence  in  consequence of the
disagreeable symptoms Avith Avhich  it  is attended,  its un-
sightly aspect, and its contagious nature, porrigo neverthe-
less in no respect tends to shorten life, or even to injure the
general health, unless in so far  that it  almost  necessitates
strict confinement to  the house  and isolation.   The  fatuity
which is  so commonly witnessed to accompany its advanced
stages is certainly to a great extent a  consequence of its
existence, for it is not seen in  any remarkable degree  in
individuals  in whom the affection has  been of short dura-
tion.   The  effect caused on the growth of the hair must 
PORRIGO.
271
also  be taken into account in forming a  prognosis, as its
loss is  often regarded  as one  of the  most grievous conse-
quences  of the  disease; when  the crusts  cover the head
completely, and their duration has been at all  prolonged,
the pressure produced by them causes absorption of the
superficial layers of the derma, and consequent destruction
of the  hair-follicles,  permanent baldness  then necessarily
results; but when the morbid growth is removed  at an early
stage,  although  the hair is most usually  deteriorated and
its subsequent  growth  injured, no ill consequences to  it
follows in some  cases.   As regards the eruptive disease of
the scalp, porrigo is the most obstinate and most rebellious
to treatment  of  them  all; by many dermatologists  it has
been regarded as being almost incurable, and, consequently
the most violent remedies have been proposed for its treat-
ment,  but I have never failed in curing it permanently by
the simple method to benoAV described.
   Treatment.—There is probably no disease of the  skin
Avhich  has been subjected to a greater variety of plans of
treatment, some of them of the most painful  character,
than this, chiefly in  consequence of its extreme  obstinacy,
and the opposing views which  have been and are even still
held as to its nature : before proceeding to speak of the
remedies used by others, I shall first describe the  method
Avhich  has invariably succeeded in my hands, and  the efficacy
of which has been uoav for so many  years proved  by the
testimony  of  others.   It consists  in the  simultaneous
employment  of constitutional  remedies and  local applica-
tions : the former, used Avith the intention of correcting or
altering that vitiated condition of the system generally, to
to the existence of  Avhich is  due the development of the
morbid growth on a congenial soil; and the latter, to remove
the  diseased mass constituted by the peculiar vegetable
parasite, and to prevent its reproduction.
   A combination of the tAvo  alteratives which  experience
has proved to be the most poAverful in the removal  of cuta-
neous  diseases—arsenic and iodine—has,  in my  experience,
effectually fulfilled the requirements of the constitutional
treatment.   They may be given in the fluid form, as  already
recommended  for  the squamous  eruptions, combined, if
requisite, with vegetable tonics, or in the solid  state, as in 
272
DERM ATO PHYTE.
 the  following  prescription,  the dose  ordered being  that
 adapted for a child ten years' old:—

        R. Arsenici Iodidi,......gr. j.
          Mannae durae,.......gr. vj.

   Mucilaginis quantum sufficit ut fiant pilulae  duodecim.

          " One to be taken three times a day."

   This is the preparation which  I usually prescribe in the
 treatment of porrigo; in some cases, after it has been taken
 daily for five or six weeks,  headache and  dryness of the
 mouth and fauces are complained of, which quickly disap-
 pear, however, on intermitting its use for a few days.   As
 in the other cutaneous affections, for which these medicines
 prove so valuable a remedy, their administration must be
 persevered in for a long period, and the dose increased very
 gradually and slowly; they must also be  given for some
 time after all traces of the local affection have disappeared.
 In decidedly scrofulous children, the administration of cod-
 liver oil simultaneously with  that of the iodide of  arsenic
 is attended with the best effects, and in cases in which from
 any cause arsenic may  disagree, iodine  may be given
 dissolved in the cod-liver oil, in the proportion of the twelfth
 of a grain in each fluid drachm.  The following is an outline
 of the  local treatment: when the disease is  situated on
 the scalp "the hair is to be cut,  not  shaved, as closely as
 possible, and a large linseed-meal poultice applied and kept
 on for twelve hours, so as to soften the crusts, and repeated
 for a second  or third  time if  necessary.  As  soon as  the
 poultice is removed, the head is well  Avashed with a strong
 carbonate of potash lotion,—a drachm to a pint of distilled
 water,—and  slightly brushed  with a soft hair-brush or  roll
 of lint; the scalp is then covered with the carbonate of pot-
 ash ointment—a drachm to one ounce of prepared lard  and
 a fluid drachm of glycerine—spread on lint, and  over  it a
 closely-fitting oil-silk cap is placed: the ointment is renewed
 tAvice daily.   By the use of these applications the crusts of
the eruption  are generally completely removed  in from  two
to three days.   The carbonate of potash ointment is at the 
PORRIGO.
273
expiration  of this  time replaced by one  containing the
iodide of lead, in the portion of half-a-drachm of the iodide
to an  ounce of  prepared lard,  which  is  to be  renewed
morning and evening,  the head being well washed with the
carbonate of potash wash every time before the  ointment is
re-applied.  In some cases it will  be found  that the iodide
of lead ointment excites a certain degree of  inflammation
of the surface of  the scalp  after it has been used  for some
days ; when such occurs it should not be applied for a day
or two, and the lotion employed alone three  or four times
daily.   After this first attack of  inflammation  disappears
it rarely recurs again,  although the use of the ointment be
persisted in for  months.  The strength of the ointment
should be increased after  a  fortnight, and if the disease
again appear, even to  double that above indicated.   The
oil-silk  cap should  be kept on  the  head  until a cure  is
effected; the advantage derived from it  is twofold; in the
first stage of treatment, by keeping  the hard and firmly-
planted crusts of the disease  in a constant atmosphere of
Avarm moisture,  it  softens, and thus  renders them more
easily removable; and in the after-treatment the mucedinous
vegetable being  retained by it in the closest  contact with
the iodide of lead and the emanations arising  therefrom,  is
more certainly destroyed, and its reproduction prevented.
   After continuing this treatment for at least three weeks
or a month, all  external applications should be  stopped,
and the hair allowed  to groAV, so as to ascertain if the
fungus will be reproduced; for it  often  lies dormant, and
suddenly shoots forth, increasing  rapidly when no  longer
subject to the action of the iodide of lead.   Should it again
return,  the local  applications must be had  recourse to as
before,  immediately on its appearance.  The administra-
tion of  the  iodide of arsenic  should be  continued until we
are quite satisfied that the  cure is  complete.
   During the entire progress of treatment, the patient
must be kept on  a  strictly milk and  farinacious diet, and
the bowels regulated by the administration of  mild mercu-
rial alteratives  and saline cathartics—especially the saline
mineral waters—Avhen  necessary.
  A most cruel, almost barbarous, method of  treating  por-
rigo, when it occurs on the  scalp, originally proposed in 
274
DERMATOPHYTE.
the ancient days of medicine, is still followed  to a great
extent on the Continent.  It consists in the application to
the hairy surface—the crusts of morbid growth having
been previously removed as much as  possible by poulticing,
&c.—of some adhesive plaster, such as Burgundy or common
pitch,  or  ammoniacum  spread on strips of stout calico,
Avhich, being caused  to adhere  firmly,  and  left  on for
several days, are torn off  in a direction opposite to that in
which the hair grows, so as to  remove as much of the latter
as possible; and  they are  applied again and  again until
the entire of the scalp is completely deprived of hair. The
sufferings occasioned by this proceeding are, as may readily
be imagined, something horrible, and the Brothers Mahon,
who strongly advocated its  employment in a  somewhat
modified form, mention that even death has resulted  from
it.  As a remedial measure, it originated  in the false idea
that the disease was an affection of  the  hairs  solely, and
that by their total ablation it would  of necessity  be cured,
and in modern  days it has been continued chiefly from a
theory which found many supporters, that the production
of perfect baldness would  suspend the morbid action suffi-
ciently long to allow the  diseased  surface to return to a
normal state.
   A host of powerful topical applications has been used in
the treatment of porrigo:—the strongest caustics ; blisters;
ointments  containing quick-lime, the sulphuret of  lime,
tartar  emetic, arsenic,  pepper,  &c.;  lotions of  corrosive
sublimate, and of other irritants and stimulants;  but inas-
much as the method of  treatment  which I have recom-
mended  above, has proved  invariably successful  in my
experience,  this simple enumeration of them will suffice
here.
   No matter on  Avhat part of the cutaneous  surface por-
rigo may be developed, the constitutional and topical reme-
dies to be employed are the same.

                        SYCOSIS.

   Sycosis.—It is conjectured that  this  term, Avhich is of
very ancient origin in medicine, Avas applied to  designate
the cutaneous  affection which  is now understood  by it, 
sycosis.
275
or one nearly allied thereto,  from a fancied resemblance
which the  eruption bears to  the rough exterior of a fig
(wxov); from the special seat of the  eruption  it  has by
many modern writers  been denominated mentagra, which
must therefore be regarded as synonymous.   By Bateman
the disease Avas classed in Willan's order of the Tubercula,
from which it  has been removed, together with Acne, to
the order Pustulae, by  those dermatologists of the  French
School who have adopted an artificial arrangement of dis-
eases of the skin.  Erasmus Wilson also regards it as being
nearly allied to Acne, and  consequently describes it with
that affection in his group of  " Diseases of the Sebiparous
Glands."   As  regards the  appearance  of  the eruption, in
one of its  stages  it certainly bears much resemblance to
acne in being more or  less pustular, but the pustules which
are present are, in my opinion,  the  result  of irritative
inflammation, caused by the existence of  a parasitic vege-
table  production, first  described by Gruby, and, since  the
publication of his observations in 1842, by other observers
also.   As the result of repeated microscopic examination I
fully coincide with M. Gruby and Dr.  Hughes Bennett as
to the  existence  of  this parasitic  cryptogamic plant in
sycosis ; I have therefore  placed it with Porrigo in  the
group of cutaneous diseases to  which the term  Dermato-
phytae has been applied.
   This affection, the site of Avhich is limited to that portion
of the face on which the beard grows,—the chin, the cheeks,
and the upper lip, rarely extending to the integuments im-
mediately adjacent,—is developed at first by the  appear-
ance, around the roots of  the hairs, of slightly inflamed-
looking  elevations, on which  a  dry, greyish scurf  soon
appears;  this  increases pretty■ quickly, and its  presence
exciting inflammation, which is much  augmented by the
use of the  razor in shaving, conical pustules soon form, and
mask much the original character of the disease.  The
eruption escaping notice  in most  cases  in its early stage,
has caused  it to be described as  being pustular from the
first,  but careful  observation has  convinced me that the
pustules are secondary, and that  they originate from the
irritation  caused  by  the vegetable parasite, which must
therefore be regarded  as the essential characteristic of this 
276
DERM AT 0 PH YTE.
affection.   The crust or  scurf  increases  very slowly in
extent, but, the attendant inflammation attacking the sub-
cutaneous structures, is accompanied by much heat, pain,
swelling, and tension, which are  further augmented by the
formation of the pustules ;  these pustules maturate slowly,
and when they at length  burst, a dry, hard,  brown scab
forms, which  is very persistent,  and if its  removal  be
attempted, the surface  to  which it  adheres bleeds  freely
and is very painful.
  In the commencement of the disease a small portion only
of the skin is affected, and the attack is often of short dura-
tion, the crusts and scabs falling off and the surface pre-
senting a  tolerably  healthy appearance,  reddish  stains
marking the previous site of  the morbid growth ; but most
usually the eruption  returns after a short time,  when  it
spreads more  rapidly and engages  a much larger  extent
of surface,  the  local symptoms also being more severe.
After  repeated outbreaks  thus  characterized, the integu-
ments of the  chin become generally much  hypertrophied,
of a  dusky-red colour, hard, and covered, in  patches of
a greater or less extent, with a thick, greyish crust pierced
by the hair of the beard, with hard, dry, brown scabs, from
beneath which pus exudes here and there, and with conical,
elevated pustules, many of which, in consequence of their
being developed over the site of a  hair-follicle, are perfo-
rated  by hairs.  The inflammatory action, when sycosis
presents these aggravated symptoms, is usually very severe,
small abscesses sometimes form in  the subcutaneous areolar
tissue, and, engaging the  hair-follicles, the  beard falls out
in patches, and permanent bald spots on  the face  result.
Although the disease is in the  majority of instances con-
fined  to that portion of the chin on which the beard grows,
in very severe cases  the upper lip  and the  surface covered
by  the whiskers are  also  engaged,  and occasionally it is
confined to these parts  alone.
  In  1842,  M.  Gruby first announced  to   the  French
Academy of Sciences, his  discovery of the existence of a
cryptogamic plant surrounding the roots of the hair of the
beard in sycosis, and he believed that its presence  consti-
tuted a previously undescribed variety of the disease, Avhich
he proposed to term Mentagra contagiosum.  This parasitic 
SYCOSIS.
277
vegetable does  not appear above the surface of the integu-
ments, and  thus  differs  altogether from that of Porrigo.
" On examining the crusts or scabs under the microscope,"
writes  M. Gruby, 'rthey are seen to be  composed of epi-
dermic  cells; but  a  microscopic examination of the  hair
demonstrates that  the entire of that  part of it which is
inserted in the  skin, is surrounded by cryptogamic plants,
which form a layer between the sheath  of the hair and the
hair itself, so that the hair is placed,  as it were, in a cryp-
togamic sheath, just as a finger  in  a glove.  But it  is a
remarkable  fact  that the  parasitic growths  never extend
above  the surface  of the  cutaneous epidermis; they have
their origin in the matrix of the hair, and in the cellules of
Avhich  its sheath  is composed,  and they increase so as to
envelop the portion of the hair  inserted in  the skin.   The
sporules are almost innumerable  in every part of the sheath,
and are firmly adherent both to  it and to the hair itself,  so
that it  is difficult to separate  them without  tearing the
sheath."1  The stems of the plant are granulated in the
interior, and are  bifurcated at angles of from 40° to  80°.
M. Gruby has  given  a  table of the distinctive characters
between the parasitic cryptogamic of porrigo and of sycosis ;
but Vogel, who corroborates his views as to the  existence
of the  vegetable growths,—the correctness of which has
been denied by many,—regards them as  being only varie-
ties of the same species.
   Sycosis is a rather  rare affection, and its causes are  con-
sequently obscure, the only manifest one  being contagion,
the disease being propagated, as in porrigo, by the mycelia
of the parasitic vegetable; of this an example is recorded
by M. Foville,  who witnessed the  transmission of sycosis
to several individuals  by means  of a razor which  had been
used in shaving a person  affected with  it.  To enable the
disease  to be communicated by contagion, we must, how-
ever, believe in  the pre-existence of a peculiar constitutional
state  of the  system, as in porrigo.  It,  of course, affects
adults and persons of  the male sex only; one or two instan-
ces have  been  recorded of its  having been  witnessed  in
females, but it  is probable some other  cutaneous  eruption
was confounded with it.   The irritation produced  by shav-
1 Comptes rendus des Stances de l'Academie des Sciences. 1842. p. 512. 
278
DERMATOPHYTE.
ing, and the use of acrid shaA'ing  soaps  in  persons  of a
delicate  skin, are usually enumerated amongst the causes
of sycosis, but although they must be regarded as a means
of keeping up and of aggravating the disease when once it
is developed, I do not consider  that it can be thus origi-
nated ; they unquestionably often cause other affections of
this region of the skin, which are very often  mistaken for
this disease.
   Diagnosis. — Acne,   impetigo,  ecthyma, furunculi, and
syphilitic eruptions on  the face, when they appear on the
chin  or the  lips, are  not unfrequently confounded  with
sycosis, especially when they  become chronic, and indeed,
by some dermatologists, all pustular eruptions, when seated
on that part of the face on Avhich the beard grows, are de-
nominated sycosis;  this term, however, should,  I think,
be restricted  to designate the  disease above  described, as
being characterized by grey and yellow crusts  or scales and
a  thickened and indurated condition of the  integuments,
and attended with the development of conoidal  pustules,
terminating in  dry, brown, adherent  scabs; in doubtful
cases, a  microscopic examination of the roots of the hairs
will aid the diagnosis.
   Prognosis. — Although  seemingly not  injurious to the
general  health, sycosis is  a  cutaneous disease of  much
gravity in consequence  of its extreme obstinacy, the great
suffering it occasions, and the repulsive appearance which
it gives to the face  of those Avho suffer from it.   If sub-
mitted to treatment  in  its  early  stages,  it is in most cases
readily cured, but it  is extremely apt to return, and almost
invariably in  a more severe form than at first; when  once
it has become chronic it usually resists every plan of treat-
ment for years, and sometimes lasts  for  life, or, if removed,
leaves  its disfiguring traces behind, in  the form of hyper-
trophied livid-red patches  on the parts which had  been
affected,  and often in  the  existence of  irregularly-shaped,
uneven, bald spots, on  Avhich the beard  is  not reproduced.
Such being the  character of sycosis, as regards its dura-
tion  and ultimate  results,  it is of the  utmost importance
that the disease should be carefully diagnosed before a
prognosis be formed.
   Treatment.—The  first point to be attended to in  the 
SYCOSIS.
279
treatment of  sycosis is  the state  of  the general health,
which will be  found more or less deranged in most persons
affected with the disease; and the condition of the  digestive
organs especially demands attention.  To regulate it, mild
mercurials, purgatives, alteratives, or tonics should be pre-
scribed, according  to  the indications in each  case ;  and
when the eruption has been of long standing, and engages
an  extended  portion of  the  integument, preparations  of
iodine with the vegetable tonics and diaphoretics should  be
administered.   As  regards the  local  treatment,  the  first
indication is to counteract, as far as possible, the irritation
caused by the growth of the beard ; with this view the use
of the razor  should from the first be  altogether omitted,
and the hair  kept cut as close as practicable with a sharp
pair of scissors during the entire progress of the treatment.
The application of three or four leeches beneath the jaw or
behind the ears, once or  twice a week, during the inflamma-
tory stages  of the  disease, or whenever the affected parts
present a  swollen  or irritated appearance, is  productive
of especial benefit; in the more chronic stages, or when it
has been of long duration, they should be used with caution*
and their  application repeated  not oftener than  twice a
month.   Numerous  topical  remedies  have been  recom-
mended  for the  treatment of sycosis; that which  I have
found most  useful is a cerate containing calomel and chloro-
form,  as  in  the following  formula, applied three times
daily:—

     R. Calomelanos,......5SS-
        Cerati Galeni,......3j.
        Chloroformi,......m.xij.   Misce.

But in very  obstinate cases, or  those which resist the use
of  this combination, the iodide of lead ointment, as recom-
mended for the treatment of porrigo, with the  addition of
the quantity of chloroform above prescribed, will  be found
of  much service.  Whichever be  employed, the   diseased
surface should be well sponged previously to each applica-
tion with equal parts of  new milk and the weak alkaline or
lead-wash.  The ointment of the  iodide of sulphur,  also,
has been highly recommended by many for the treatment 
280
DERMATOPHYTE.
of this  disease, and in some very  obstinate cases I have
found it of service.  Attention to diet and regimen is par-
ticularly demanded in all cases, the use of spirituous liquors,
and of all rich or heating articles  of food, being carefully
eschewed. 
THE  SYPHILIDES.
281
                CHAPTER  XII.

                    THE SYPHILIDES.

  As a consequence of the absorption of the syphilitic
poison into the system during the existence of the primary
or immediate  symptoms of the venereal  disease, several
secondary affections  are in  most cases developed in a space
of time, the exact limits of which experience has not yet
enabled us to define, but  which  usually  varies from six
weeks  or two months  to  from  six to  twelve  months;
amongst  these, cutaneous eruptions hold a prominent posi-
tion, chiefly in consequence  of their extreme frequency, and
their  disfiguring effects. The  diseases  of the  skin  which
owe their origin  to this  cause present the same elementary
characters as  those  which  are not so produced, and may
assume in different cases the form of nearly every variety
of eruption which has been  described in  the preceding
pages; but they have certain specific features by which they
are readily distinguished, and the treatment  by which their
removal is to be  effected consists in the employent of reme-
dies calculated to eradicate from the system, or counteract
the effects of the constitutional taint to which their  exist-
ence is due.   It is  for these  reasons  that most  modern
dermatologists have thought it necessary to describe  the
syphilitic eruptions  as  constitutiug a  distinct group  of
cutaneous diseases.
  Secondary  syphilitic symptoms, more  especially  those
which affect the  skin, may  also be developed in individuals
who have never had the  primary disease, the venereal
virus being transmissible  from parent to  child; thus,  a
cutaneous  eruption  is  not uncommonly  witnessed  soon
after birth, the origin of which may be traced to the pre-
vious occurrence of syphilis, whether primary or secondary,
in either parent, it may have been even many months pre-
viously.   Secondary symptoms are also by many  practi-
tioners, chiefly those of the English school, believed to be
directly communicable by contagion, as in the case of the 
282
THE  SYPHILIDES.
breast of a nurse being affected by suckling an infant Avho
has  a venereal eruption on  the mouth,  by the  act  of
kissing, &c, but the truth of this vieAv, one so difficult to
be proven, has been ably impugned by M.  Ricord,—an
analysis  of whose  observations has been given  in  the
twelfth and thirteenth  volumes of the Dublin  Quarterly
Journal  of Medical  Science,—and his arguments, fully
corroborated by my own experience,  incline me to agree
witn  the  opinion that  secondary symptoms are not con-
tagious.
   Syphilitic cutaneous  eruptions have certain features in
common,  by which they are specially  characterized, and
distinguished from other diseases of the skin; these it will
be well  to consider shortly before speaking  of the indi-
vidual varieties.
   Since  they were first recognized  as being  dependent on
a  special cause,  it  has been  noticed  that  although  the
syphilides may differ in the elementary form which they
assume,  they invariably present a  peculiar dull  tint of a
brownish or coppery hue,  which is more  or less evident
in all their stages,  and also that they are rarely accom-
panied by the  active, local inflammatory symptoms which
so often attend other cutaneous eruptions.  The shade of
colour by which they are marked varies in different cases
from  pale brown to a dull copper, the difference depending
both on the natural  colour of the complexion and  on  the
degree to which it is affected by the syphilitic  cachexia;
thus, when the secondary eruptions appear in a short space
of time after the occurrence of the primary symptoms, the
hue of the diseased surface is of a less dull tint than when
they  are  not  developed for several months, the venereal
virus affecting the system more, and consequently producing
a more decided constitutional  effect, the longer it has lain
dormant in the system.  For  the  same reason  the more
acute forms  of syphilitic  eruptions,  or those which  are
occasionally attended with  some degree of local inflamma-
tory action, occur  either when  the  primary symptoms  are
still present, or shortly  after they have disappeared.
  Another remarkable feature which the syphilides possess
in common is a tendency for the eruption, no matter where
situated  or of what form, to assume a circular or annular 
TnE  SYPHILIDES.
283
shape as regards its distribution, and to spread over the
surface of the body in rings or crescentic-shaped patches;
this is especially remarkable when they are of the papular,
the squamous, and  the hypertrophic types, and least mani-
fest in the syphilitic maculae and pustulae.
  They are also characterized by their more general occur-
rence on the  exposed regions of the skin, especially on the
scalp, the forehead, the cheeks, and the  alae nasi, than on
those parts which  are  ordinarily  covered; the  eruption,
too,  is more  thickly disseminated  there.  They  appear,
however, more frequently on  the trunk of the  body than
on the extremities,  being especially developed on the back
and the shoulders.
  Lastly, syphilitic eruptions  engage  the more  deeply-
seated  cutaneous structures to a greater extent than the
non-specific diseases of the skin, as is evident by the greater
hypertrophy of the integuments that attends them, the firm,
indurated feel by which they are  characterized, and the
greater elevation over the surface of those Avhich are papular
or pustular.  They are moreover, essentially chronic in their
nature; the stains  which remain on  the skin after they
have been cured are usually  very permanent;  and  they
are even more apt to return than the other cutaneous erup-
tions, Avhich  are complicated  by rio special constitutional
taint.
  The  development of the secondary symptoms of syphilis,
in the form of a disease of the skin, is  almost invariably
preceded and accompanied  by well-marked signs  of de-
rangement of  the system generally.  The individual about
to be affected may have recovered in all respects from the
immediate consequences of the primary attack, and even
a considerable period  of  time may have elapsed, during
which he seems to  be  and feels in the enjoyment of his
ordinary health, when, without any manifest exciting cause,
a degree of cachexy is established :—the complexion be-
comes  sallow and  earthy-looking, unwillingness  to take
part in any active  exertion, whether of mind or  body, is
experienced,  the  appetite fails,  thirst  becomes  constant,
often extreme, pains in the muscles and bones, much ex-
acerbated at night, are complained of, and venereal peri-
ostitis and sore throat in some cases precede and m others 
284
THE  SYPHILIDES.
accompany the cutaneous eruption which now  appears,—
the outbreak being in general immediately preceded by a
pretty smart feverish attack.   To a certain degree the sy-
philides resemble the eruptive fevers, and by many writers
the analogy  between them has been  made 'a subject of
special observation: the similarity consists in both having
a stage of incubation following the contagion, a period of
febrile oppression  preceding the  eruption,  and  a charac-
teristic fever  attending its  development, which  ceases to a
greater or less  extent when the eruption appears fully on
the surface.
  As the scope of this work does not admit of any account
being given of the other secondary symptoms of the vene-
real disease which usually accompany  the syphilitic cuta-
neous affections, and  which in many  cases aid  much in
arriving at a correct diagnosis between them and  the non-
specific affections of the skin, I shall now proceed to speak
of the special characteristics of the individual eruptions,—
describing them in the order of classification  which I have
adopted, as they present the symptoms of the groups therein
contained.

               SYPHILITIC EXANTHEMATA.

  The Syphilitic Exanthemata may present the apparent
phenomena of Erythema, of Urticaria,  or of Roseola.
  Syphilitic Erythema is characterized by the  occurrence
in an individual Avhose  system has  been tainted Avith  the
venereal poison of irregularly-shaped, dingy-red, or copper-
coloured patches, more or less circular, but uncircumscribed,
intermingled  with which generally  are  numerous small,
rounded elevations of  a  darker shade;  the eruption in  the
majority of cases thus resembles erythema papulatum, from
which it is chiefly distinguished by its  peculiar colour,  and
the other concomitant  secondary symptoms which are almost
invariably present.  The patches of eruption are permanent,
not fugacious, and  although they fade someAvhat, do  not
disappear, even  on  firm  pressure ; they are  most usually
witnessed on the forehead  or some other part of the face,
and on  the chest and shoulders; in some cases  they  are
confined altogether to the palms  of the hands,  when they 
         SYPHILITIC  EXANTHEMATA.      285

are extremely  obstinate, recurring again and  again, even
after  they have  apparently yielded to treatment.  This
eruption is at  times ushered in  by rather smart febrile
symptoms, but  in general it is not attended with any well-
marked disturbance of the system, nor is it accompanied
by  local pain,  heat,  or itching.   It is rather  a  frequent
form of syphilitic cutaneous  disease, and not uncommonly
complicates many of the other varieties.
  Syphilitic Urticaria is especially marked by being attend-
ed with the characteristic  burning and tingling sensations
of the ordinary disease ; it resembles in shape and mode
of  development urticaria  tuberosa, and  like  it is seated
chiefly on the extremities,  but it  differs in being of a dull
red or violaceous tint, the centre of each  elevation being
of a coppery hue ; it appears, too, generally during the
night, when the local annoyance it*produces is also most
troublesome, but it  does not fade away, although  it is less
prominent, during the day.  It is an uncommon form of
syphilitic  eruption, but when it  does occur is extremely
obstinate.  By some dermatologists it is stated that syphi-
litic urticaria is not unfrequently developed on the skin as
a symptom  of the  primary disease, in  consequence of its
appearing while a blennorrhagic  discharge is present; but
when an eruption of urticaria is witnessed in such cases, it
most  probably  always depends on  the  administration of
copabia, which has  been before noticed  as being a cause of
the disease.
  Syphilitic Roseola.—This is the most common of the
secondary eruptions belonging to  the group;  it generally
appears in from four to six weeks after the apparent  cure
of the primary symptoms, but sometimes months even elapse
before its outbreak.   Cazenave and Wilson both describe
it as occurring on the skin while  chancres still  exist on the
genital organs, and also as a frequent concomitant of blen-
norrhagia;  but Ricord, with whose views  my experience
coincides, regards its causation in  such  cases to be rather
referrible to  a previous venereal  attack; at all events, all
must admit the almost total impossibility of arriving at a
true history of the precedent occurrences in  individuals
labouring under  any  of the symptoms of  syphilis.   The
eruption  is developed usually on the  forehead,  and the 
286             THE  SYPHILIDES.
upper part of the face, but sometimes on the trunk  and
extremities also,  in  the form  of small circular  patches,
scarcely elevated above the surface of the skin ;  they are
of a dull rose-red or  bronze hue, and  fade but slightly on
pressure.   The individual rings do not at first exceed the
size  of  a shilling, but, gradually increasing, two  or more
coalesce, so as to form large uncircumscribed patches, the
borders of which, however, still retain an  annular charac-
ter.   The  outbreak of the eruption is in general preceded
by some slight  febrile  symptoms; it comes  out  rather
rapidly on  the skin, being often fully developed in tAventy-
four hours; and  it runs a more acute course than most of
the  other  syphilitic  cutaneous  affections.  Occasionally
slight  itching  attends  it, but this soon  disappears  with
some superficial  epidermic  desquamation:  in  all  cases
copper-coloured stains for some time mark the  site of the
eruption after it  has disappeared.   As in ordinary roseola,
a  similar eruption on the throat very frequently is present
in the specific form, independently of the usual secondary
venereal affection of that part.  Syphilitic roseola occurs
not  unfrequently in  infants as  one  of the symptoms  of
congenital  syphilis.

                  SYPHILITIC  VESICULE;

   The  Syphilitic Vesicule may  appear in  the  form
either of Eczema, of Pemphigus,  or  of Rupia;  by some
Avriters it  is stated  that a  secondary venereal  eruption,
agreeing in its local phenomena with  Herpes, also occurs,
but this I  have never witnessed, and the descriptions  of it
which have been given' are,  I think,  more applicable  to
Eczema.
   Syphilitic Eczema is a rare variety of seconday symp-
toms, but well-marked cases of it from time  to time occur,
and of these I have a most characteristic example at present
under my  care.  The eruption appears chiefly on  the face,
the scalp,  the ears, the trunk of the body, and  the region
of the genital organs, rarely extending to  the extremities ;
the vesicles  are  developed tolerably numerous on small,
nearly  round, patches of  skin, of a reddish copper colour;
these patches gradually enlarge, and additional vesicles are 
SYPHILITIC  VESICULE.         287
developed on them, but no matter Avhat size they may attain
by coalescing, the outer border still  retains more  or  less
of a circular character, and the disease spreads in an annu-
lar form, distinct rings sometimes  appearing at  the edges.
The  vesicles  maturate  slowly, and are  accompanied  by
comparatively slight serous discharge ; the stains, attended
with some epidermic exfoliation, remain  on the  surface of
the skin for a considerable period, and fresh crops of vesi-
cles are from time to time developed on  them;  the integu-
ments, however, do not become thickened and fissured, as
in non-specific eczema.   In  some cases, when the eruption
has existed for a long time, or is attended with more active
inflammation than usual, it presents many of the characters
of eczema impetiginodes, but the crusts or scabs which form
are dark brown or blackish, hard, dry, and very persistent.
Syphilitic eczema is generally late in being developed after
the disappearance of  the primary  symptoms, several years
not uncommoly elapsing, so that if we were to  reckon, as
some  do, from time, and not  according to order  of occur-
rence, it might be classed in most cases  as  a tertiary and
not a secondary affection.
  Syphilitic Pemphigus is  a very rare form of venereal
eruption, which  occurs  more frequently, however, in new-
born  children than in adults.  It is  not preceded by any
apparent  constitutional disturbance:  several moderately
sized  bullae are simultaneously developed generally on the
palms of the hands and the  soles of the feet, but I have
seen them on the buttocks also ;  each bulla is  surrounded
by an areola of a dull  violent  tint; the contained  fluid is
turbid from  the first,  does  not  completely distend the
epidermis under which it is contained, and is rather slowly
absorbed, the  dark stain remaining.   After the  absorption
of the  effused  serum,  the spot on which  the  bulla  was
situated most generally becomes the  seat of an unhealthy
ulcer, and then the disease almost invariably proves fatal.
  Syphilitic  Rupia presents nearly the same characters as
the prominent variety of the  non-specific eruption.   The
vesicles which are rather large and  flattened,  are deve-
loped in successive crops, especially affecting the face, but
appearing also on nearly every region of the body, being
most rare on the hands and feet.   Each bulla is surrounded 
288
THE  SYPHILIDES.
at first by a tolerably broad margin of a dull-red or copper
colour, over which, as in ordinary rupia, the characteristic
crust gradually extends.   The  crust is  large, remarkably
prominent, extremely hard, and very  adherent to the in-
teguments:  and Avhen removed from the surface it leaves a
deep, unevenly  ulcerated pit, sIoav to heal, and on which
a similar crust, but usually of a larger size, is rapidly
developed.  This form of secondary eruption is rarely wit-
nessed for a long  time, often not for several  years, after
the cure of the primary symptoms, and is of most frequent
occurrence in persons advanced in life, or in those Avith a
broken-down habit of  body; it is therefore attended with
much constitutional derangement,  the result of  the satura-
tion of the system Avith the syphilitic poison.   In extreme
cases the symptoms are of a grave character :—the greater
portion of the  cutaneous surface is thickly  set  with the
black, prominent,  horny-looking crusts, giving a  frightful
appearance to the  countenance ; the throat is  deeply ulce-
rated, and periostitic nodes exist over the bones of the legs
and on the cranium ; severe nocturnal pains  are present,
and the individual not uncommonly dies, a victim  to syphi-
litic cachexia;  or, should recovery take place, the cure is
most protracted.  Cazenave speaks of  syphilitic rupia as
being very rare, but in my experience it is a rather frequent
form of secondary venereal eruption.

                  SYPHILITIC PUSTULE.

  The Syphilitic Pustule may  occur in any of the three
forms which  characterize this group, viz., as Acne, as Im-
petigo, or as Ecthyma, and are amongst the most frequent
of the venereal secondary eruptions.
  Syphilitic Acne, which is the most common of the three,
occurs usually on the ordinary sites Avhich the disease, when
not  specific, occupies, being especially witnessed on  the
forehead.  The pustules  appear distinct from each other,
and are  very rarely surrounded at first  by any change of
colour in the skin: they arejjeveloped in the form of hard,
inflammatory-looking papular elevations, about the  size of
a small  pea, and of  a livid red colour; on the second or
third day after their appearance, purulent matter forms at 
SYPHILITIC  PUSTULE.
289
their  apex,  which  is somewhat flattened, this gradually
increases  in quantity, extending into the substance of the
derma, and at length the pustule giving way  at its summit,
pus is effused, which concretes quickly into a hard, dry,
broAvn scab or crust. During the progress of these changes
the low form of inflammation that is present  spreads to the
integuments  around the base of  each pustule, Avhich con-
sequently become hard and thickened, and  assume a dull
violaceous or copper colour.  After  several days' duration
the crusts become  detached, leaving a small, rather exca-
vated  ulcer,   Avhich,  hoAvever, soon heals;   the  peculiar
syphilitic stain of the surface  remains for a considerable
time,  and when it  fades  aAvay, a superficial wThite stain,
somewhat resembling the pit of small-pox, but smaller, is
witnessed on  the site  of the  pustule,—this  is permanent.
The pustules  appear in successive crops,  and thus, when
the disease has existed for any time, they are Avitnessed on
the surface  in their various stages of  development, inter-
mingled  with copper-coloured  stains or blotches, and the
superficial pits marking the former  site of those which have
disappeared.   AVhen the  eruption is situated on the trunk
or  the extremities, the individual pustules often acquire a
considerable  magnitude,  equalling in size a small bean;
they  are, however, less  prominent than  on  the  face, and
contain only  a minute quantity of pus,  surrounded  by  a
hardened, copper coloured base, which does not undergo
resolution usually for a considerable time, the induration
remaining long after the disease has been apparently cured.
Syphilitic acne may be developed at almost any period after
the disappearance of the primary symptoms, but is gener-
ally of early occurrence;  it  is witnessed much more fre-
quently in adults than in children, and its duration is usually
prolonged for some months.
   Syphilitic  Impetigo is the  least frequently met Avith  of
the three forms of the  pustular  syphilides; it may,  as
regards  development,  assume  the  characters of the non-
specific impetigo figurata or sparsa; in either  case a reddish
copper-coloured or  violet-tinted patch appears on some part
of the integuments, most usually of the face, on which the
psydracious pustules are developed on the second or  third
day.   These  maturate pretty quickly, and, giving way, 
290
THE  SYPHILIDES.
become covered  with a  dark,  greenish-yellow  crust  or
scab, of more firm consistence than in ordinary impetigo,
and not  presenting  the same pelucid  aspect;  these crusts
are tolerably adherent, in the majority of cases not falling
off for  from ten days to a fortnight, when superficial ulcera-
tions are left, which  in healing leave a cicatrix often perma-
nent.   An  outbreak of syphilitic impetigo  is generally
preceded by some slight febrile disturbance, and the surface
on which  it is about to appear, is the seat  of a somewhat
tingling and itchy  sensation,  which  is  alleviated on  the
coming out of the eruption.   Its duration is seldom much
prolonged, and  it is witnessed  in children  rather  more
frequently than in adults.
   Syphilitic Ecthyma is a very common form of secondary
cutaneous  affection, and  almost  invariably  indicates an
extreme  degree  of contamination of  the system  with the
venereal poison.   The phlyzacious pustules which charac-
terize it are generally few in number, and are developed in-
dividually on scattered spots or stains, of a livid red colour,
and about the size of a sixpence, or somewhat  larger; these
appear distinctly separated from  each other, chiefly on the
extremities, but they also  occur on the shoulders,  the front
of the chest, the face, and occasionally on the lower part of
the abdomen and on the scrotum.  On the second  day after
the appearance of the stains, the epidermis in  their entire
extent is slightly raised by a sero-purulent effusion; the pus-
tule thus formed acquires its full  development very slowly,
and becomes surrounded  by a dull copper-coloured border,
which  enlarges gradually until the entire surface acquires
nearly the size of a half-croAvn.   After some days the pus-
tule bursts, and the contained matter, exuding, dries  into
a  hard,  dark-brown, or  blackish circular crust,  which is
very persistent;  when it falls off, or is removed, a slightly
excavated, indolent ulcer is left, which exhibits an extremely
slow tendency to heal, the characteristic crust of the disease
re-forming on it again and again; when eventually it  does
heal, a permanent, uneven cicatrix, of a  dull red  colour at
first, but gradually becoming white, marks the  part which
had been affected.  Little or no constitutional  derangement
immediately attends  the outbreak of syphilitic ecthyma, and
the local symptoms Avhich precede amount merely to slight 
SYPHILITIC  PAPULE.
291
itching, there being neither heat nor pain.  It is one of the
most  frequent of the syphilitic eruptions in infants and
young children, and is  witnessed  more commonly  in old
persons than in those in  the prime  of life.

                   SYPHILITIC  PAPULE.

  The Syphilitic Papule  are developed always  in the
form of the non-specific  Lichen simplex or Lichen  agrius;
they constitute a  very common secondary cutaneous erup-
tion, and  occur usually  at an early period after the con-
tamination of the system with the venereal poison, being
often present on the skin while the primary symptoms still
exist, or  being developed in  a few weeks  after they have
disappeared.   In the former case the affection runs a much
more acute course than in the latter.
  Lichen symphiliticum is usually  preceded by some fever
and general heat of the skin  ;  the eruption comes out very
quickly, the entire cutaneous surface of the body, including
the face and  the extremities,  being  sometimes covered with
innumerable, minute papulae, in from twenty-four to forty-
eight hours.   They are  placed so  close together, often  in
patches or groups of a  circular form, as  to  coalesce and
present the appearance  of large elevations, which require
the aid of a lens to prove  that they are  made up of the
minute papulae which are so characteristic  of this eruption.
At other times they are scattered over the surface perfectly
distinct from each other, Avhen, however, though less nume-
rous, they are individually of larger size : in  either case
they present a bright copper  colour.  The papulae generally
disappear in  a few weeks, Avith slight epidermic desquama-
tion, as in the ordinary forms of the disease, but the surface
remains spotted with dull coppery  stains, Avhich fade away
very  slowly;  and  not uncommonly a  second outbreak  of
eruption takes  place shortly  after  the first has  commenced
to decline.   In some persons, especially  those of a full
habit of body, and in infants, syphilitic  lichen  assumes
more of the character of lichen agrius, the  papules ulcerate
at their  apex, and a serous  exudation  takes place, which
dries into thin, broAvnish-yelloAV scales; much itching and
well-marked constitutional disturbance attend this form of 
292
THE SYPHILIDES.
the eruption, which is also more persistent.  When either
variety becomes chronic, which, hoAvever is rarely the case,
psydracious pustules and copper-coloured blotches are min-
gled with and complicate the papular eruption.   Syphilitic
lichen is  witnessed both in infants soon  after birth, and in
adults, and  is amongst the  mildest  of the  syphilitic cuta-
neous affections.   It is regarded by some Avriters as being
occasionally a primary sympton, and as being not unfre-
quently a complication of blennorrhagia.

                  SYPHILITIC SQUAME.

   The Syphilitic Squame constitute  rather  a frequent
variety of secondary eruption, rarely making their appear-
ance for a considerable time after the removal of the primary
symptoms, and consequently indicating much saturation of
the system with the venereal poison.  The  scaly affection
of the skin is, in many cases, preceded by a roseolous rash,
which exists for some time before the scales are developed
on it.  It may present the form of any  of the non-specific
varieties  of the eruption, Psoriasis guttata, Psoriasis aggre-
gata, and Psoriasis lepraeformis; and, consequently, a syphi-
litic psoriasis and  a syphilitic lepra  are  described  by most
writers as distinct affections.
   Syphilitic  Psoriasis is not ushered  in  by any decided
constitutional  disturbance,  nor is it  attended Avith local
irritation, but  the usual  general  symptoms of secondary
syphilis ahvays accompany  it, and serve much to aid  the
diagnosis.   The scales, Avhich  are of a dull gray colour,
are developed in distinct spots  or  small  patches, as in  the
ordinary form of the disease,  but  when the  eruption is
about to  assume the aggregrate or leproid  character, they
increase  in extent pretty  quickly.  The disease usually
comes out first on the  extremities, to  which,  however, it
is not confined, soon  appearing  on  the  face,  the scalp,
and  the  entire  trunk, especially  affecting  the chest  and
shoulders ; the surface of the skin on which the squamous
eruption is seated is  of a dull  violet or dark  coppery-red
colour, and is elevated somewhat aboAre the  surrounding
integuments.   In the leproid form, the edges of the circu-
lar patches are much raised, and the centres, which  are 
SYPHILITIC  SQUAME.          293
always  of a  more  dingy hue, depressed and free  from
scales, or with a  few thin  scattered scales  on them.  In
the aggregated variety, the outer border of the patches
assumes more or less of an annular character, and, as Biett
has remarked, it is separated in the majority of cases from
the surrounding  non-affected  integument  by a  narrow
white rim; the  central portions are much more  elevated
than the edges, and the scales on them are thicker, and of
a dull gray colour.   Syphilitic psoriasis  differs especially
from  the non-specific disease, in not being more  thickly
developed around the joints  than elsewhere on the extremi-
ties.  In some cases, when the eruption has been of long
persistence, it presents the tessellated pavement character
described at  page 174 ; but fissures  do not form in the
scales, nor is it attended with an ichorous discharge or the
symptoms of local irritation Avhich characterize the invete-
rate variety   of the ordinary disease.   Syphilitic  scaly
eruptions are of extreme obstinacy, and their  duration is
invariably much prolonged ;  when they begin to disappear,
the desquamation—which, hoAvever, is never in such quantity
as in the non-specific squamae—gradually diminishes, the
elevated surface becomes flatter, until it at length sinks to
the level of the surrounding integument, but still  retains
its  peculiar copper colour, which disappears very  slowly,
years often elapsing  before it fades away completely.
  Syphilitic psoriasis is in some cases confined to a single
region of the body, especially the palms  of  the hands,
when it presents most of the  phenomena characteristic of
ordinary psoriasis palmaris, but the scales are  thicker, of
a duller  hue,  more persistent, and the portion of  integu-
ment  on which they  are developed is  more elevated, drier,
and  of a copper colour; the general  appearance  of the
palm  of the hand Avhen affected with the eruption  is such
that Biett termed it horny, the affection constituting the
Syphilide squameuse cornee of that dermatologist.
  The squamous syphilides are very rarely seen in children,
and are still more rarely developed for the first time in old
persons, being an  affection of individuals in the prime of
life, liable to accompany either the so-called secondary or
tertiary venereal symptoms. 
294
THE  SYPHILIDES.
               SYPHILITIC  HYPERTROPHIE.

  In the Syphilitic Hypertrophie a form of cutaneous
affection occurs which  has  no parallel among the non-spe-
cific diseases of the skin; custom has so completely sanc-
tioned the application of the term tubercle to its different
varieties, that it is almost hopeless now to think of chang-
ing this denomination, and for  this reason, notwithstand-
ing the great  objections, so frequently referred to in the
preceding pages, which exist to retaining this word in the
nomenclature of cutaneous  nosology, I shall not attempt to
substitute another for  it.  Condylomata, which belong to
this group of diseases of the skin, are, as already noticed,
most frequently of syphilitic  origin, but as, when of this
nature,  they fall  altogether within  the domain of  general
surgery, no  further description of them than what has been
given at page 224 is requisite here.   For the same reason
warts which result from a venereal source will not be no-
ticed.   The syphilitic tubercles will therefore alone engage
attention in considering this group of cutaneous diseases as
symptomatic of secondary  syphilis.
   Syphilitic tubercles are amongst the most frequent of the
secondary symptoms of the venereal poison which affect the
skin; they  may be developed in a  very short time after
the disappearance of the  primary disease, or their occur-
rence may  be deferred  for many months,  or even years.
The tubercles  vary much in size  and in  their apparent
phenomena, and thus constitute different varieties.  First,
they may occur in the form of large papulae, differing from
lichen chiefly  as  regards their  size, being about equal to
that of  a small pea ; they  are rounded, hard, and eleArated
above the level of the skin, appearing in small groups, most
usually of a circular shape, with healthy skin intervening,
and not unfrequently  forming  a centre  to  each  patch.
These groups  are irregularly disseminated over the surface
of  the face, the neck, the trunk, and the extremities, espe-
cially the first;  but are  often symmetrical  as regards the
tAvo sides of  the body.  The individual tubercles, which
are of a violaceous or dull  coppery hue, soon secrete a thin
scale at their summit, from beneath which, if rubbed off or 
syphilitic  hypertrophie.      295
torn with the nails, a slight watery exudation takes place;
this dries into a thin, reddish-brown, persistent scab, which
eventually falls off, leaving a characteristic syphilitic  stain
that for a long time marks the seat of the eruption.
  Second, the tubercles are of greater magnitude, varying
in size from that of  a nut to that of an olive, of an  ovoid
shape, hard, distinctly elevated, and disseminated over the
surface;  they may occur on  a single region of the body,
especially affecting the face and neck, or may be generally
distributed  over the  surface.   In some parts,  being  more
closely set together than in others, they sometimes coalesce
and form a  tolerably large tumour, uneven on the surface,
but  distinctly  circular  at  the margin.  The tubercles in
this variety are  of a deeper and duller shade of colour than
in that first described ; neither desquamation nor serous
exudation takes place from  them ;  they remain stationary
for a very  long time, not  unfrequently for  years, and at
length, being absorbed, often rather suddenly,  the  char-
acteristic stain,  slow to fade away, marks their  site.
   Third, a still larger tubercle than the last appears isolated
on some  portion of the integument, most generally of the
extremities, but sometimes of the body or face; it is rather
soft to the  touch, slightly painful, scarcely elevated above
the surrounding skin, of a dull violaceous tint, with a bronze
or copper-coloured margin.   It increases very slowly in size,
exhibiting an appearance as if about to suppurate, and the
margin assumes an  uncircumscribed erythematous blush.
At length the  most prominent  part ulcerates slightly,  a
thick, blackish,  adherent crust  forms on  it, which is very
gradually detached, usually not for Aveeks, Avhen the entire
tubercle  falls out, leaving an unhealthy, indolent ulcer, with
excavated edges, painful, and slow to heal.   At first rarely
more than  three  or four  tubercles of  this character are
developed on the body, but  they  come out in  successive
crops, so as at length to amount  to a considerable number.
When the  ulcer  which they leave heals, a  permanent
depressed cicatrix results, which for a long time exhibits  a
rather bright copper-red stain.  This variety of tubercle
rarely appears  for  years after the primary symptoms, is
generally met with in  old persons,  or those of  a broken- 
296
THE  SYPHILIDES.
 down habit of body, and in individuals in whom there exists
 extreme syphilitic cachexia.
   Fourth and last, several tubercles, about the size of a
 sixpence, but  little elevated  above the  surface and rather
 soft to the touch, are developed, distinct from each other,
 on some special region of the body,—usually on the scrotum
 in males, and the  pudendal region in females, on the face,
 particularly on the lips and nose, and around the arms;
 they are perfectly circular, and of a dull reddish tint. Small
 superficial ulcers soon form on them, appearing first at the
 outer margin, these gradually extend, so as to cover the
 entire  surface of  the tubercle, retaining,  however,  their
 superficial character, and  from them there exudes an ex-
 tremely fetid, sanious liquid, which irritates  and inflames
 the  neighbouring  integument  over  Avhich it  may  flow.
 Eventually  the discharge ceases,  copper-coloured  crusts
 form, and the parts heal Avithout any marked  cicatrix.  By
 many modern  writers,  particularly  of the French school,
 this form of syphilitic tubercle is regarded as constituting
 in some cases one  of the varieties of primary symptoms.

                   SYPHILITIC MACULE.
   Under the  head of Syphilitic  Macule  some of the
 forms of secondary roseola are not unfrequently described,
 but they should not be confounded with the  peculiar  pig-
 mentary alterations of the cutaneous structure which in
 many cases  accompany other secondary eruptions, and in
 some constitute the only affection of the skin present. They
 resemble most in their apparent phenomena ephelis hepatica,
 but differ from it in being developed in the majority of cases
 on the legs, or in the region of the genital organs, occurring
 only in  a few instances on the face or the trunk of the
 body.  They are also characterized by their colour, which
is  distinctly of  a  copper shade,  at times  approaching to
black, and in assuming from the first a well-marked circular
 form spreading from the circumference in ring-like patches.
 These morbid alterations of colour do not appear on the
 cutaneous surface  usually  until several months  or  even
years have elapsed after the cure of the primary symptoms ;
they are invariably attended with  well-marked  syphilitic
cachexia, and  are  extremely obstinate to treatment, some- 
SYPHILITIC  MACULE.           297
times remaining for life.   Syphilitic maculae occur at all
ages, both in persons in the prime of life and in old age,
and  are a not unfrequent result of congenital syphilis.

  Diagnosis.—Under this  head little remains  to be said
after the  observations Avhich have been  made in the com-
mencement of the chapter on the general characteristics of
the secondary eruptions.   The history of the individual case,
where  it  can  be arrived  at satisfactorily, which, hoAvever,
in the  majority  of instances is  quite impossible, is the aid
chiefly to be relied on;  in doubtful cases assistance is often
gained by an examination of the glans in  males, and the
external organs  of generation in females, when the cicatrix
or induration resulting from a chancre, if it had previously
existed, will afford satisfactory evidence; inspection of the
throat and back of the pharynx also should never be omitted,
the characteristic venereal ulceration existing there usually
in connexion Avith the eruption on the skin.
   The prognosis in secondary cutaneous  affections must be
guided much by the degree of syphilitic  cachexia  present,
by the length of time which  they may have previously
existed—for in proportion to their duration is their obstinacy,
—by the severity and extent of the concomitant symptoms
in other structures of the body, and by the nature of the
eruption  itself:  the latter  point  has been noticed in the
description of the individual forms.
   Treatment.—As in all other affections which ha\Te their
origin in the absorption of the syphilitic  poison into the
system,  the secondary eruptions of  the skin demand a spe-
cific mode of  treatment, directed  to the eradication of the
constitutional taint on which they depend.   Formerly it
Avas believed that this could alone be effected by the action
of mercurials, but the discovery of iodine  and of its medicinal
properties has wrought a complete  revolution in the thera-
peutics of the consecutive symptoms of the venereal disease.
This has in some respects,  hoAvever, been attended with an
evil result,  that of inducing many practitioners  to  discard
mercury altogether as a remedial agent in the treatment of
the  syphilides,  and to trust  to the employment  of such
simple measures as maybe  indicated by the local and gene-
ral  symptoms,  independently of their  specific character; 
298
THE  SYPHILIDES.
or to rely solely on the administration of preparations of
iodine to correct the constitutional contamination.  But as
in nearly  every other disease  to  which man is subject, it
should be  ahvays kept prominently in view that an exclu-
sive  system of treatment, cannot be expected  to be inva-
riably successful, for the same affection often requires  the
use of even the most opposite remedies in different indi-
viduals, or in the same person under different circumstances.
  The remedies to be employed in  the treatment of  the
syphilides  may  be conveniently considered under  three
heads: the general, the specific, and the topical.
  The gzneral treatment  consists in  the  employment of
means,  calculated  to meet the indications  dependent  on
the special  symptoms which may arise  or  be  present  in
individual cases.   Thus, Avhen the outbreak  of  an eruption
is attended with distinctly febrile symptoms or well-marked
local inflammatory action, the employment  of  antiphlogis-
tics is demanded before the administration of specifics can
be commenced.  Under such circumstances, in  young ple-
thoric persons, general bleeding will be resorted to with
advantage,  and topical abstraction  of blood by  means
of leeches  is almost invariably necessary.   Active saline
purgatives should be given  also, and in no case  should they
be omitted; with very few exceptions their effects are pro-
ductive of the most beneficial results in the  early stages of
every syphilitic eruption: the only instances in Avhichthey
occasionally prove injurious  are, when the syphilitic  ca-
chexia is  extreme in very old persons  or individuals of a
broken-down habit of body.   They seem to act chiefly  by
determining to  the intestinal mucous tract, and thereby
diminishing excessive cutaneous action, the  quantity of  the
eruption,  and  consequently the local  inflammation,  being
thus checked ;  but they  also  lessen  the  general  febrile
symptoms.  The neutral purgative salts are best adapted
to fulfil these  intentions, and  their administration  will be
advantageously preceded by a full dose of calomel or blue-
pill.
  On the  other hand, should the vital  powers be low, and
the depression of the system very manifest, the vegetable
tonics must be given ;  and if  there  are  deep-seated pains
present, especially the nocturnal pains so characteristic of 
SYPHILITIC  MACULE.
299
the disease, opiates in full doses should be prescribed in
combination, or if the suffering is extreme their  use may
precede the  employment  of  the  tonics.  No preparation
relieves the deep-seated pains which so frequently  accom-
pany secondary symptoms, whether of the skin or  not, as
crude opium : it may be given in  the dose of a grain, made
into a  pill,  three or four times  or  even oftener  in the
twenty-four hours,  according to  circumstances.   Of the
vegetable  tonics, those which determine to the skin, such
as the elm bark, are especially useful, or cinchona bark or
quina may be combined with  the tonic or stimulating vege-
table  diaphoretics,—dulcamara,  mezereon,  sarsaparilla,
guaiacum, &c.;—the mineral  tonics, especially the stronger
acids, and iron and its preprations, are  also often  highly
serviceable in the syphilides,  Avhen the employment  of this
class of remedies is indicated.   The  former  were largely
given by Biett in the syphilitic exanthemoid and papular
secondary  eruptions, much reliance being placed by  him
on the nitric and sulphuric acids :  the latter are especially
indicated when much anemia  is present, and they  are often
usefully prescribed  in  combination with iodine, as  in the
chemical compound of  the iodide  of iron, or of the  iodide
of iron  and quina.  When a  specific eruption occurs in an
individual of  a  scrofulous diathesis,  or  with a  strumous
tendency,  cod-liver oil will be administered  with decided
benefit, and should the debility be extreme, preparations of
iron are usefully given at  the same time.
  The specific treatment  of  the syphilides consists  in the
employment of the preparations of  mercury, of gold, or of
silver, and of iodine alone or in  combination with  any of
them.   Mercurials  are unquestionably  the  remedies  on
which most reliance is to be placed, but the amount of
benefit to be derived from their use depends  much  on the
manner in which they are  administered, and the preparation
that is employed.  They  should not be given on the first
appearance of the eruption, the more especially if  its out-
break be connected with  general  febrile  symptoms,—these
must be previously removed by the  means already referred
to: and in all cases the  state of  the digestive organs re-
quires  special attention before their  employment is com-
menced.   The several forms of  the secondary  eruption 
300
THE  SYPHILIDES.
senre as indications  as to what preparation of mercury is
best suited, but it may be laid down as  a general rule that
those which  have the  property of  producing salivation
quickly or freely, such as blue-pill, calomel, and the allied
compounds, are rarely adapted for  these consequences  of
the venereal disease.
  For the  scaly and tubercular syphilides, corrosive  sub-
limate and the red iodide usually prove the best preparations
of the metal; either may be given  in  pill  with opium,  in
doses of from l-12th to l-8th of a grain, three times daily,
the quantity of opium being proportioned to the degree  of
the  characteristic venereal  pains  which may attend;  or
the former may be preferably prescribed in  some vegetable
decoction, such as that of dulcamara, of elm-bark,  of meze-
reon, of sarsaparilla, &c, as in the following formula:—

     R. Corrosivi Sublimati,........  gr. j.
       Decocti Dulcamarae,.........fl iiv.
       Decocti Mezerei,..........fl 3xij.
       Infusi Sassafras,..........fl Sviij. Misce.

     "A wine-glassful to be taken three times a day."

   When these or any other of the syphilitic eruptions be-
come chronic, or return frequently after  they have  been
apparently removed, it will be  necessary to have  recourse
to  the administration of arsenic, in  combination  with the
mercury and iodine, and under such circumstances Dono-
van's solution—the  liquor arsenici  et hydrargyric hydrio-
datis of the last Dublin  Pharmacopoeia—proves singularly
beneficial.   It  is for the chronic forms of secondary dis-
eases of the skin that this combination is especially adapted,
and in these cases its therapeutical efficacy is undoubted ;
indeed, in my hands, it  has  very rarely failed to effect a
permanent cure, but it must  be given in moderate doses,—
from ten to twenty minims three times daily,—the quantity
increased very gradually, and  its  use continued for a long
time, even after the disappearance of the eruption.   It may
be  administered in some of the vegetable  tonic or diapho-
retic decoctions, according to individual circumstances.
   For the pustular and papular syphilides the green iodide 
SYPHILITIC  MACULE.
301
of mercury of the Dublin—the iodide  of  the London—
Pharmacopoeia, has proved, in my experience, the best pre-
paration of the metal.  It may be given in  pill combined
Avith opium, should circumstances indicate the  use of that
drug, in the dose of from half-a-grain to  three grains three
times daily, but its effects must  be carefully watched, as it
is in some persons apt to produce salivation, even in small
doses, and  in the  treatment of any form of syphilitic erup-
tion it is most important to administer as little mercury as
possible, and to introduce it very gradually into the system ;
the precise quantity requisite can only be judged by watch-
ing the effect produced in each individuul  case, but the
mildest  action on the  mouth is  always an indication that
for the  time enough has been given.   An excellent Avay of
prescribing this preparation  for adults  is to substitute it
for the  calomel in Plummer's pill, and the vegetable decoc-
tions before referred to may be given at  the same  time.
   The  syphilitic  exanthemata do not require the employ-
ment of specific remedies  in their acute  stages, but should
they exhibit a tendency to  become chronic, the green iodide
of mercury is the preparation best adapted to them.  The
occurrence of maculae as  a secondary symptom indicates
the necessity for a prolonged administration of a mercurial,
and, therefore, either the bichloride or the red iodide should
be used.
   When any of the forms  of syphilitic eruption appear on
infants  at  the  breast, it is desirable, when practicable, to
introduce the specific medicine into the system of the child
by means of the  nurse's milk;  but as in the  majority of
cases it is essential to change the  nurse, and  it is, conse-
quently, often requisite to  wean the infant, the hydrargy-
rum cum magnesia, or hydrargyrum cum  creta, may be
given in doses of from one to two grains daily according
to the age, and with each  dose from a twelfth to an eighth
of a grain of the green iodide of mercury  may  be  com-
bined when the eruption is extenshre.
   The preparations of gold and of silver Avere  at  one time
proposed by the French  school  as  substitutes for those of
mercury, but they were found not to possess at all the  same
efficacy, and they have, consequently, fallen now into almost
complete disuse for the treatment of secondary symptoms. 
302
THE  SYPHILIDES.
The former Avere supposed to be especially adapted for per-
sons of a scrofulous  diathesis, Avith Avhom mercurials very
generally disagree, and their effects are highly spoken  of
by Legrand and  Chrestien, but they have not, that  I am
aware, been employed in this country.
  Iodine or its preparations should not be trusted to alone
with  the intention of producing a  specific action in the
treatment of the secondary eruptions ; from Avhat has been
already said it is evident that their combination with mer-
curials is of especial service, but unless thus prescribed, they
usually disappoint.   In scrofulous habits, their administra-
tion should  never be omitted—still, a mercurial must be
given with them, and the  more  decided the  evidences  of
scrofula are in any individual case,  so much the more must
the proportion of the iodine preparations predominate  in
the treatment.   The administration of iodide of potassium
is attended Avith the best results as soon as the preparation
of mercury which may have been given evidences its action
on  the  system by the mouth being affected, and it is also
most valuable  when given to nurses, with the vieAV of treat-
ing a venereal  eruption in  an infant at the breast; in the
latter case, it often suffices to cure the disease, whether the
nurse is at the same time affected Avith secondary venereal
symptoms or not.
  The  employment  of  topical remedies in the treatment
of the syphilides is  of much less importance  than in the
non-specific  eruptions;  little more being requisite, in the
majority of cases, than the use of the tepid bath every
second or third day  to allay any local irritation or inflam-
matory action  which may  arise, and also to restore the
healthy functions of the skin.   When ulceration occurs  in
the progress of -any  of  the secondary eruptions, the black-
wash is the best application which can be used, if it takes place
on the scalp, the trunk  or the extremities, but on the face,
an ointment containing a drachm of calomel to an ounce  of
simple cerate is more  easily applied, and is more efficacious.
In infants, the  local symptoms are usually more severe than
in adults, but   they are  easily  calmed by the  employment
of a dusting powder, containing tAventy grains of the carbo-
nate of lead, half-a-drachm of the oxide of zinc, and an ounce
of starch, reduced together to a state of the minutest divi- 
SYPHILITIC  MACULE.
303
sion; a tepid bath of fresh water, containing from tAvo to
four ounces of size, should be at the same time employed
every night, or  every second night,  according  to  circum-
stances.   The dispersion of the stains in syphilitic maculae
is  much  hastened  by inunction  with mercurial ointment
Avhile the constitutional treatment is being folloAved out.
  In all cases of secondary syphilitic eruptions, as soon as
the first inflammatory symptoms,  if any occur, are subdued,
the diet should be nutritious, and  wine and other stimulants
should be alloAved; if the syphilitic  cachexia be extreme,
and much debility present, the chief  points to be attended
to  are, to support the strength, and  at the same  time  to
allay both general  and local irritability.   Change of air,
especially to a dry and warm climate, is an aid to the treat-
ment of the utmost importance  in chronic  and obstinate
cases. 
304         DISEASES  OF  THE  HAIR.
               CHAPTER  XIII.

       DISEASES OF THE APPENDAGES OF THE SKIN.

  In this Chapter I shall describe affections of the hair and
of the nails.  They constitute  a  class of morbid changes,
concerning which  the regular medical practitioner is but
rarely consulted, and therefore  a short notice of them  must
here suffice, yet the former, especially, are not uncommonly
a cause of as much anxiety to those Avho suffer from them,
as a really grave cutaneous disease.

                 DISEASES OF THE HAIR.

  The Diseases of the Hair  consist in alterations of its
natural colour or characters, and in its partial or total loss.
Some few cases have  been recorded in which the hair has
undergone a sudden change of colour from a light to a  dark
hue, or the  reverse, Avithout  any apparent cause, or  after
some acute disease;  and not unfrequently, when it is re-
produced after it has been removed for some febrile or other
affection, it  grows of a much  darker  colour than  it had
been originally; this is usually the case when it has  been
kept cut close for any length of time in the treatment of any
of the eruptions of the scalp.  Loss of colour in the  hair,
—Canities,—is one of the natural results of old age, but
it often occurs at a comparatively early period of life, either
from constitutional causes, or  from extreme mental anxiety.
The effect of the latter is often well marked, and  some  cases
have been witnessed in which the hair has become perfectly
white in the space of a few hours, while an individual was
labouring under some violent emotion of the mind: these,
which have  often  furnbhed a theme for the poet and the
popular writer, demand no other notice here than  that of
a mere reference.  The most important of the constitutional
causes of canities is hereditary predisposition, and examples
of premature  grayness  of the hair  descending through
several generations in  several families  are very numerous. 
diseases  of  the  hair.        305
Blanching of the hair is sometimes associated with debility
of the vital poAvers, but that it is very rarely so, is evident
from  the  fact of its being so seldom witnessed in those
Avho die young of consumptive or other lingering diseases.
   Treatment, Avhether topical  or general, has in my opinion,
no effect over any of the forms of canities except that last
described, and in it the indications are manifestly to restore
the system to a state of  robust health, if practicable, by
the use of such remedies  as  may be appropriate for the
individual case.   But numerous local applications and other
means have been and still are  recommended, with the view
of preventing the hair from turning gray : should it be dry
and crisp, and the surface of the scalp appear bloodless,
any gently stimulating  pomade may be  used : cutting the
hair short, or removing it  altogether by shaving the scalp
occasionally,  proves useful.   The preparations which are
used  for  dying  the  hair are  very numerous, and  formulae
for them are given in all druggists' or perfumers' receipt-
books.
   The occurrence of white hair  in patches on the scalp has
been  already  described.   (See Vitiligo.)
   The only alteration in the character of the hair which
can be strictly regarded as a disease is that peculiar felting
and matting of  it together which constitutes  the singular
affection  that has been named Plica Polonica ; but inas-
much as  it  does not occur in this   country, and as, from
having ne\'er seen a case of  it, I can add nothing to the
account contained in the several works in which it has been
described, I shall not notice it farther here.
   Loss of hair, or baldness, termed " Alopecia'' by the ancient
writers on medicine, Avould appear  to have been of much
more frequent occurrence and to have attracted more atten-
tion  formerly than  at  present;  it  may be either  partial
or general on the hairy scalp, or on the^ other parts of the
body Avhich are naturally covered with hairs. In the former
case, it was termed Porrigo decalvans by Willan, but  then
it is  manifestly due to  the occurrence of Vitiligo on these
regions of the skin,  as before  described.   General baldness
is in many  persons the accompaniment of old age, being
usually associated with gray  hairs,  nor  can it be  regarded
as a disease  except when it  occurs in comparatively early
                           26* 
306         DISEASES  OF  THE  HAIR.

life: some few cases have been recorded as being congenital,
in which, however, it was due  to non-development of  the
hair follicles.  Permanent baldness, as has  been remarked
in the preceding pages, is also at times a result of the erup-
tive  diseases of the scalp, especially of Porrigo, and is then
a  consequence of  the inflammatory action  which may
exist extending  to the bulbs:  after most  diseases of  the
scalp, however, although the hair falls out, it is reproduced.
Loss of hair, partial or general, is also  a not unfrequent
sequence of feArers and acute inflammatory affections, and
of syphilis; in  the former  case it  generally grows  again,
but in the latter the baldness is usually permanent.   Loss
of hair from natural  causes at an early age is, like the pre-
mature change of its colour to  gray, hereditary  in  the
majority of instances, is also caused by violent emotions of
the  mind, or prolonged mental anxiety, and  is  connected
pathologically in some individuals with general debility, or
diminished vital  action.
   Congenital  and senile baldness are incurable, as is also
that  form of it Avhich is hereditary.  In  other cases, re-
peated shaving of  the head, or keeping any hair that may
remain constantly cut close, and the application of  stimu-
lating  spirituous washes, such  as  either of the  following,
sometimes prove useful:—

     R. Spiritus  Vini Rectificati,......fl |vj.
       Ammoniae Hydrochloratis,.....   gr. xxx.
       Olei Rosmarini,.  . .........fl 3SS-
       Infusi Armoraciae compositi, . .  .  . fl |vj.
Misce. Fiat lotio.

     R. Tincturae Cantharidis,  .
       Aquae  Florum Sambuci,
       Essentiae Rosmarini,. .
Misce. Fiat lotio.

   The turpentine pomade, as ordered at  page 240, not un-
frequently proves of service also, and each time  previously
to its application the scalp should be washed with an alka-
line  lotion,  containing a drachm  of carbonate  of  potash
to eleven  ounces  of  water, and  one  ounce  of rectified
A3y.
flgxj.
fl3vj. 
DISEASES  OF  THE  NAILS        307
spirit or of rum.   The following pomade, as recommended
by Dr.  Copland,  I  have  frequently used  with  excellent
effect:—

        R. Adipis praeparati,.....^ij.
           Cerae Albae,.......5ss.

Lento igne simul  liquefac, tunc ab igne  remove et ubi pri-
  mum lentescant,

      Balsami Peruviani veri,   ."....   3ij.
      Olei Lavandulae,.......m.xij.

adjice, et assidue  move donee refrixerint.

In all forms of alopecia the scalp should be kept warm, and
consequently wearing a wig  is often of service when the
hair  first begins to fall off.

                DISEASES OF THE NAILS.

  Most of the Diseases of the Nails are of such a nature
as to demand surgical interference, and are consequently
described  in  the works of  surgical writers.   Perhaps the
most important of them all is  that in which the nail of some
of the toes grows into the surrounding fleshy integuments,
and  by  the irritation it  thus occasions, gives rise to the
formation of a foul, unhealthy ulcer.  It would  not be in
accordance with the plan of this work to say anything here
of the surgical treatment requisite to cure this most obsti-
nate and painful  affection; but  I cannot avoid remarking
on the importance of preventing the ingrowing, as it is
termed, of the nails, by always cutting them straight across,
parallel  with the extremity of the toe, as  when they are cut
at the edges, the pressure of the boot or shoe not uncom-
monly gives  rise to this disease.  The  nails both of the
hands and feet are also  subject to inflammation attacking
their  matrix,  to hypertrophy, and to atrophy, and they
occasionally fall off completely,  and are not reproduced.
This last affection, which has been termed  by the French
writers Alopecia unguale, is sometimes congenital, children 
308        diseases  of  the  nails.
being born without nails, but such cases are extremely rare.
When the nails become hypertrophied, the application to
them of caustic potash, and the daily use of a strong lotion
of carbonate of potash is often useful; the nitrate of silver
is  the best application when the  nails, being brittle, split
and break readily; and it is also productive of much service
should a foul discharge continue from beneath the nail, as
a consequence of previous inflammation of the matrix.  As
has been remarked  already, the  nails at times become
engaged in some of the eruptive diseases of the skin, more
especially psoriasis and eczema, Avhen, hoAvever, they require
no further  treatment than that applicable  to the existing
affection. 
therapeutics.
309
                CHAPTER  XIV.

        therapeutics of  diseases of the skin.

   In describing the individual eruptions of the skin, I have
spoken  of the  treatment adapted for each, yet there are
some general points in therapeutics  specially  applicable to
this  class  of affections, which require a separate notice, and
to their consideration I propose to devote this chapter :  it
will,  therefore,  consist in  a review of the  remedies  most
generally  used in cutaneous diseases, and  the manner in
which they should be employed;  a few formulae which may
prove suggestive in prescribing will also be appended.   The
remedial measures ordinarily required  may for convenience
of description be considered in two divisions—the topical
and  the constitutional; it is true that  some  of them, baths
for example, produce their effects by acting both locally
and  on the system generally, but as their mode of applica-
tion  is external, they will be considered in the first division.
   Several objects are in general expected to be fulfilled by
the employment of topical medication in the treatment of
cutaneous eruptions.  It may be  used with the view simply
of cleansing the skin from the scales  or crusts which form
on  the surface, so as to permit  the  direct application of
remedies to the diseased parts:  for this purpose cataplasms,
baths, alkaline washes, and  soaps are  usually  had recourse
to.   It may be employed Avith  the intention of protecting
the affected portions of the integument from the action of
the air; or a directly therapeutical effect may be expected
from its application.  Some topical remedies fulfil only one
of these indications, while the benefit derived  from the use
of others depends on their mode of operation combining the
three.
  The treatment of diseases of the skin by the total exclu-
sion  of air has within the  last few years, more especially
since the  discovery of collodion,  been  much employed and
highly recommended by some  practitioners,  while in the
hands of  others it has completely failed.   The practice is 
310
THERAPEUTICS.
chiefly applicable to local eruptions, and to those which are
not attended  with  much  discharge.  Its employment in
erysipelas has been referred to Avhen speaking of the treat-
ment of that disease; but it has not as yet been sufficiently
tested by  experience  to  enable  a satisfactory  conclusion
as to its therapeutical  efficacy to be arrived  at.  So far as
regards the application of collodion to form an impermeable
coArering, it has been  productive  rather  of  injury than of
benefit in  any cutaneous  eruptions in which I  have used
it; this appeared to me to  depend chiefly on the uneven
compression  and  contraction  of the integument  which
is occasioned,  causing much local  irritation, and  some-
times even a degree of inflammation.  Such effects  being
due  principally to  the  rapidity of evaporation of the
ether in which the gun-cotton is dissolved, these  result-
ing  injurious  consequences  will probably  be  prevented
by the recent proposal of Dr. Graves1 to  employ a solution
of gutta percha in chloroform for this purpose.   Moreover,
the gutta percha  forms a  less brittle, firmer, and thicker,
though still transparent, covering to the skin, and exerts
an even  and more complete compression on the surface;
the latter  effect also being regarded by Dr.  Graves  as of
importance with reference to  its beneficial action.   In his
paper on the use of this substance referred to in the note,
Dr.  Graves  illustrates  its therapeutical efficacy by the
narration  of some  cases  in which  it proved remarkably
successful; but Avhether it will be of such general applica-
tion as he predicts, experience alone can  decide.
   The advantage to be  derived from the  application of
Bandages  to either the upper or lower  extremities, when
they are the seat of cutaneous eruptions, is too often over-
looked ; they  fulfil to a  certain  extent  the  indication of
excluding the action of the air, but  they also prove bene-
ficial  by exerting an  equable amount of compression  on
the overloaded  and congested vessels, as has been  already
noticed when speaking of erysipelas ; and  they afford in
addition  a useful means of applying medicated  lotions, as
referred to in describing the treatment of eczema.
   The various  remedies which are employed topically for

  1 Dr. Graves' paper on this subject, which I have had the  advantage of
reading in manuscript, is to appear in the number of the Dublin Quarterly
Journal of Medical Science for August, 1852. 
THERAPEUTICS.
311
the treatment of diseases of the skin may be applied to the
surface in  the form of baths, cataplasms,  caustics, lotions,
ointments, powders, and  soaps.   These will noAV  be con-
sidered in succession.
   Baths, both simple and medicated, have  at all times been
very extensively used as remedial agents in cutaneous erup-
tions, and have by many been supposed to be sufficient for
their  cure, without  the  administration of any internal
remedies.  To the reader of the foregoing  pages it must be
evident that I place but little reliance on their efficacy, and
that I recommend a  resort to their employment Avith the
intention of  acting, so to say, medically on the  disease in
but feAV cases: yet it cannot be denied that abundant testi-
mony exists  to prove  that persons  affected for years with
chronic eruptions, more particularly those of a scaly charac-
ter, have been cured  by the  prolonged use of medicated
vapour, steam, or Avater baths.  But they are not at present
employed to at all the same extent they were formerly, and
modern Avriters do not recommend baths in the same lauda-
tory terms as those Avho preceded them,—a proof that their
efficacy Avas,  to say the least, somewhat overrated.   As a
cleansing agent, and to promote the discharge of the healthy
functions of the skin, and a return  to  its normal state, the
fresh  water tepid and warm baths are of especial service in
many cutaneous eruptions, chiefly those in Avhich the surface
is dry and hard, as in  the exanthemata, the scaly diseases,
and icthyosis; and when these affections are local, they are
often  advantageously employed in the form of douche ; but
they seldom agree Avith those cases Avhich are attended with
a discharge, whether it be serous or purulent.  In addition to
their cleansing effects they also often prove useful, as anti-
phlogistics, in allaying local  irritation  and inflammation.
Vapour baths, being  slightly  stimulant, are not indicated
until  the chronic stages  of cutaneous  diseases are fully
established, when, in  consequence of their possessing this
property, they are frequently used  with advantage.   Salt
Avater bathing, in my  experience, proves injurious in most
diseases  of the skin, for although it often  appears at first
to produce a  beneficial action, the eruption usually returns
afterwards with greater obstinacy, and is much more rebel-
lious to  treatment; but usually, and always when the affec- 
312
THERAPEUTICS.
tion is  of an  inflammatory tendency,  it aggravates  the
disease : the only cases in which I have seen  it  almost
invariably  serviceable are  when maculae or stains  of  the
integument become persistent after  the  removal of  any of
the syphilitic eruptions.   The  following are formulae for
some of the medicated baths usually employed:

                     GELATINE BATH.

    R. Gelatinii (vulgo dicti " Size")......ft),  vj.
      Aquae,  (Caloris gradu, 75° ad 92° F.), C. xxx. Solve.

   This bath is employed with  excellent effect to allay local
irritation and itching, and is especially useful in the cuta-
neous diseases of children.  The temperature must be pro-
portioned to  the indications in each case.   The  above are
the quantities requisite for a bath for the entire body in the
case of adults.

                    ALKALINE BATHS.

R. Sodae Carbonatis,........^viij
 Aquae Pluviae, (Caloris gradu, 84° ad 96° F.), C.xxx. Solve.
R. Potassae Carbonatis,.......3vj.
 Aquae Pluviae, (Caloris gradu, 84° ad 96° F.), C. xxx. Solve.
R. Sodae Carbonatis,........3vj.
    Sodae Sub-boratis,........lij.
 Aquae Pluviae, (Caloris gradu, 75° ad 98° F.), C. xxx. Solve.

   These alkaline baths are  often  usefully employed as
detergents of  the surface when  it becomes covered with
thick crusts or adherent scales.   They should be used with
caution when any tendency to  inflammatory action exists
in the skin.  They are also of service in chronic scaly erup-
tions, especially pityriasis, and in icthyosis.

                      IODINE  BATHS.
R. Iodinii,...........3ss.
    Iodidi Potassii,.........Sss.
    Glycerinae,..........fl gij.
    Aquae, (Caloris gradu, 86° ad 94° F.)    C.  xxx. Solve. 
THERAPEUTICS.
313
 R. Iodinii,...........zj.
    Liquoris Potassae,.....fl Ij ad fl 5ij.
  Aquae Pluviae, (Caloris gradu, 86° ad 96° F.), C.xxx. Solve.

 R. Brominii,..........m. xx.
    Iodidi Potassii,........gij.
    Glycerinae,..........fl gj.
   Aquae, (Caloris gradu, 86° ad 94° F),  .  C. xxx. Solve.

   Iodine baths are used in very chronic cutaneous eruptions,
 when there is much hypertrophy of the integuments.  They
 may also be employed in aggravated cases of prurigo.

                    SULPHUR BATHS.

 R. Potassii Sulphureti,.......3iv.
   Aquae Pluviae, (Caloris gradu, 86° F.),    C. xxx. Solve.

 R. Potassii Sulphureti,
    Sodae Hyposulphitis,......aa. §ij.
    Aquae Pluviae, (Caloris gradu, 86° F.),  . C. xxx. Solve.

   Either of these baths  may be used in the treatment of
 chronic scaly diseases  of the skin, but their efficacy is much
 inferior to that of the natural sulphurous  mineral waters.

                    MERCURIAL BATHS.
   R.  Corrosivi Sublimati,.....     zjj.
      Glycerinae,........fl  §ij.
      Aquae Pluviae, (Caloris gradu, 96° F.),  C. xxx. Solve.

   R.  Iodidi Hydrargyri  rubri,   .   .   .  .   5j-
      Sodii Chloridi,........gij.
      Aquae, (Caloris gradu, 96° F.),   .   . C. xxx. Solve.

   Mercurial  baths  are  applicable  for  the  treatment  of
obstinate  syphilitic  cutaneous  diseases.   They have  also
been used in very  chronic scaly  eruptions.
   Cataplasms are employed  chiefly to remove  hardened
incrustations, for which purpose those prepared Avith linseed
meal and smeared over Avith fresh lard or olive oil are best
                           27 
314
THERAPEUTICS.
adapted.   But they are also very serviceable in allaying
local inflammation or irritation : when used with this inten-
tion they should consist of white bread steeped Avell  in hot
water, then squeazed dry, and moistened with some cooling
wash, as recommended before for the treatment of eczema
and of herpes.
   Caustics are used  principally with  the intention  of
destroying the affected integuments and arresting the morbid
process in lupus, and their use in it  has been spoken of in
the description of the treatment of that disease.  But many
practitioners  employ them also  in  the chronic stages of
several  cutaneous eruptions, Avith the view of exciting a new
action  in those portions of the skin on which they may be
seated:  caustics have been thus used, especially  in  the
treatment of the eruptive diseases'of the scalp and in squa-
mous affections ; my experience of their effects, however, is
not  in  accordance with the opinion of those who report
favourably of their  application.   Besides nitrate of silver
—which is the favourite caustic in skin  diseases—chloride
of zinc  and caustic potash, some practitioners use a strong
solution of iodine, which may be prepared as follows:—

     R. Iodinii,.........5SS>
        Aquae destillatae,......5V«
        Iodidi Potassii, quantum sufficit ut fiat solutio.

  The following formula for  a compound caustic solution is
contained in the Pharmacopoeia of the London Hospital for
Diseases of the Skin :—

     R. Zinc Chloridi........3iv.
        Antimonii Chloridi,.....3ij.
        Pulveris Amyli,......3j.
        Glycerinae, quantum sufficit.   Misce.

  Whether caustics be resorted to or not in the treatment
of diseases of the skin, they should  never  be used  to the
exclusion of other remedial measures.
  Lotions, were it not for  the difficulty of  applying them
effectually in  many cases  and on certain  regions  of the
body, constitute the best form for using topical medication 
THERAPEUTICS.
315
in the treatment of a great number of cutaneous eruptions.
Their special application has been described when treating
of the individual diseases in which they are to be used, and
several  formulae  for  their  prescription have been given.
They are most readily applied by means of bandages kept
constantly wet with them ; but as this method is applicable
for the  extremities only, when the eruption is situated  on
any other portion of  the integument, they may be applied
on a double fold of old linen or lint, covered  with a thin
sheet of gutta percha, which is  preferable for  this purpose
to oil-silk,  as it does not keep the surface so hot, in conse-
quence  of  its permitting a certain degree of evaporation.
In the  cases of spirituous or other  cooling lotions, neither
covering is at all admissible, and  then the linen  or lint must
be moistened with the wash as often as it becomes dry.
The addition of glycerine to lotions  is of especial service,
as  in   consequence of its  non-evaporating properties,  it
keeps the  part to which they are applied in a constant
state of moisture ; this is peculiarly useful as respects alka-
line lotions, which tend to render the surface harsh and dry,
—an evil  that in  many cases  would counterbalance the
good effects that  might result  from their employment.
Independently of their use with  the intention of producing
a direct medical action, lotions and washes are also employed
beneficially to  cleanse the  diseased  surface, previously to
the renewed application of  ointments, and for  this purpose
they are applied by means of a sponge ; or should the crusts
or scales that form be hard and  firmly adherent, a roll of
lint wet with the Avash may be brushed over the part.  When
the ordinary alkaline or  lead lotions which are used for
these purposes are  found too irritating  or astringent, they
will be  advantageously diluted by adding to them an equal
part of new milk/  In addition  to the formulae for lotions
Avhich are contained in the several preceding chapters, the
folloAving  may also  be employed for  the purposes indi-
cated :—
             STIMULATING ALKALINE LOTIONS.
     R. Liquoris  Ammoniae,.....A 3j._
        Glycerinae,........A  3yj.
        Spiritus Lavandulae,.....A  3VJ-
        Aquae destillatae,......A .?vj. Misce. 
316               THERAPEUTICS.
    R. Liquoris Ammoniae Carbonatis, .   .  fl .?x.
       Glycerinae,........fl oij.  Misce.

    R. Sodae Carbonatis,......gr.  xx.
       Spiritus Rosmarini,.....A  3j.
       Aquae Rosae,.......fl  svij. Misce.

  These  lotions are adapted  for  all eruptive  diseases in
which the external application  of alkalies  is  indicated;
when their chronic stages is attended with  atony of the
cutaneous surface.

               SEDATIVE ALKALINE LOTIONS.

     R. Sodae Sub-boratis,.....     5U;
        Aquae Florum Sambuci,   .  .   .  fl .?xj.
        Aquae Lauro-Cerasi,   .   .   .   .  fl 3j. Misce.

     R. Sodae Bicarbonatis,.....     gr. xxx.
        Aquae Florum Aurantii,  .  .  .  fl Bxj.
        Succi  Conii,.......fl Ij. Misce.

   Chiefly useful in eruptive diseases of a dry nature which
 are attended with much itching.
GLYCERINE WASH.
R. Glycerinae,........fl 3ij.
   Misturae Amygdalae,.....fl .^vj.
   Aquae Rosae,.......fl 3 viij.
Misce.
ASTRINGENT  LOTIONS.
R. Tincturae Acetatis Zinci,
   Aquae Rosae,    .   .

R. Acidi Tannici,  .   .
   Aceti Gallici,   .   .
   Aquae destillatae,

R. Creasoti,  ....
   Tincturae Krameriae,
   Acidi Hydrocyanici,
   Aquae destillatae,   .
fl £ix.
fl ~viiss. Misce.
  gr. xl.
fl 3ss.
fl gviiss. Misce.
  m. viij.
fl 3y-...
 m. viij.
fl 3iv. Misce. 
                  THERAPEUTICS.              317

  In  using this lotion, the bottle in which it  is contained
should be Avell shaken before it is applied to the surface.

                  SULPHUROUS LOTION.

  R.  Sodae Hypo-Sulphitis,.....     3ss.
      Potassii Sulphureti,.....     3j.
      Aquae destillatae,......fl gxiss.
      Aquae Lauro-Cerasi,.....fl gss.   Misce.

                   STIMULANT WASH.

  R.  Tincturae Nucis Vomicae,   .  .   .   fl 3ss.
      Essentiae  Camphorae,
      Essentiae  Carui,......aa fl zjj.
      Aquae destillatae,......fl 3*vij.   Misce!

  This last wash is sometimes a useful  application in the
chronic stages of lichen  simplex—when  the disease is very
obstinate, of  porrigo, and in  inveterate psoriasis, provided
there is no tendency to local inflammatory action.
  Ointments, under which appellation I include cerates and
pomades, are  more generally employed than any other form
for the application of topical remedies in  the treatment of
diseases of the  skin; this is OAving chiefly to the facility
Avith which they can be used,  and the readiness with which
their  strength  may  be increased  or  diminished ; —both
matters of great  practical  convenience and  utility: yet
they have  the  disadvantage  of being easily rubbed  off, of
affording but little protection to the diseased  surface, and
of soiling the clothing with Avhich  they may come in con-
tact.   In some cutaneous eruptions the  application of any
greasy matters  disagrees remarkably, but  this appears to
depend, in the majority  of cases, rather on some constitu-
tional cause in the individual  affected, than in a speciality of
the eruption Avhich may be present;  it also seems to be to a
certain degree influenced by the region of the skin on which
the disease is situated :  thus, I have seen  them prove inju-
rious  more frequently in the eruptions of the scalp than in
those of any  other part of the body.  With affections Avhich
are accompanied  by  excessive serous discharge, as in most 
318
THERAPEUTICS.
forms of eczema, they also, in my experience, generally dis-
agree more than with any others.  We can, however, seldom
ascertain the existence of this peculiarity except by direct
trial; but when it is once discovered to exist, the use of oint-
ments should then be carefully avoided.   Prepared axunge,
in consequence  of its greasy nature, does not, therefore, form
a good basis for ointments to be used in the treatment of
cutaneous  diseases,  except in cases attended  with much
hypertrophy of the integuments, as in icthyosis, and in the
chronic stages  of  some obstinate  eruptions Avhich  are not
accompanied by copious  discharges; and the  white wax
ointment—which is employed for the preparation of nearly
all the ointments contained in the last edition of the Dublin
Pharmacopoeia—is often not well  adapted for this purpose
in consequence  of its  firmness and consistency.   I have,
therefore,  latterly used in  almost every case  either cold
cream or  the cucumber pomade of the French pharmaceu-
tists, as  the  basis of whatever ointment I prescribe; the
latter preparation, as  already remarked when  speaking of
the treatment of intertrigo, is in itself a useful local appli-
cation, possessing calmative and  healing properties.  As
formulae  for  either of them are contained in but very few
English works on Materia Medica, it will be well, I think,
to give them here :—

            ceratum  galeni (Cold  Cream).1

         R. Olei Amygdalae,   .  .   .   .  fl  Ixvj.
           Cerae Albae,.....     3iv.
           Aquae Rosae,.....fl  3"xij.

   " Melt the wax in the oil with a gentle heat, in  an earthen
vessel; pour the mixture into a marble mortar, previously
heated, and stir it constantly until it is nearly cold : then,
by beating up the cerate briskly, incorporate  with it the
rose  water, added in small quantities at a time."

   Yellow Avax may  be substituted  for  the  white wax in
hospital practice.
' French Codex. 
THERAPEUTICS.
319
        ceratum  cucumis  (Cucumber Pomade).1

          R. Axungiae ........   .  .  ft>ij.
             Adipis Vituli, (Calf's Suet),  Ibss.
Liquefac simul, dein adde,
             Succi Cucumis Sativi,  .  fl  3*xxiv.

  " Mix and bruise them well Avith the hand; set aside for
twenty-four  hours; then pour off the juice  and replace it
by a similar quantity of fresh juice, and repeat this process
ten times, adding fresh juice each time.  As soon as the
pomade has  acquired a well-marked odour of the cucumber,
melt it in a water-bath,  and add an ounce of finely-powdered
starch, Avhich will  combine  with the water  and precipitate
it.  Allow the entire to settle, and then pour off the pomade
into  small vessels.  To render it more white and smooth
the French pharmaciens usually prepare it for use by melt-
ing again in a water-bath, and beating it for tAvo hours or
even longer  with a wooden spatula, but Avhen submitted to
this  treatment it  does  not  keep fresh for a  longer period
than a month ;  while in the former case it will  keep for a
year, or even longer, in a cool place."
  I shall now append  some formulae, in addition to those
contained in the preceding chapter, for ointments which are
ordinarily employed in the  treatment of diseases of the
skin.   And  first, I may mention that an excellent calma-
tive  ointment, especially useful in the cutaneous eruptions
of children which are attended with  heat and itching, may
be prepared  by substituting cherry-laurel water for rose
water in the above formula for cold cream.

                  SEDATIVE OINTMENTS.

  R. Chloroformi,.........m. vj.
     Cerati Cucumis,........3*j.   Misce.

  R. Carbonatis Plumbi,.......3ss.
     Cerati  Galeni,........3j.
     Chloroformi, .........m. iv. Misce.
                   ' Henry and Gnibourt. 
320               THERAPEUTICS.
   R.  Glycerinae,.........fl 3j-
     Unguenti Cerae albae,......3VU»
     Chloroformi,.........m. viij.
     Cyanidi Potassii,.......gr. iv. Misce.

   The great advantage derived from the  employment of
chloroform, alone  or  in  combination with other sedatives,
as an external application in the treatment  of  cutaneous
diseases, has  been frequently refered to in the foregoing
pages.  In the preparation of ointments it should always
be the last ingredient  added, in consequence of its  vola-
tility, and  for the  same reason the ointment should be dis-
pensed in bottles and not in boxes or pots.
ASTRINGENT  OINTMENTS.
R. Carbonatis Calcis praecipitati
   Cerati Galeni,    ....
   Extracti Belladonnoe,  .
   Glycerinae,   ....
R. Oxydi Zinci, .   .
   Cerati Galeni,   .
   Tincturae Myrrhae,
R. Creasoti,  .  .  .  .
   Adipis praeparati, .
   Pulveris Opii,  .  .

R. Carbonatis Plumbi,
   Acidi Tannici,  .
   Cerati Galeni,  .   .
•   3ij.
.   3ij.
.   gr. xx.
fl 3ij.  Misce.

.   gr. xx.

fl 3ss.  Misce.
  m. x.
  3-ij.
;r. viij. Misce.

  gr. xij.
  gr. viij.
  3j.   Misce.
R
R.
             CAMPHOR  OINTMENT.

Camphorae rasoe et redactae,   .   .   .   gr. viij.
Tincturae Conii (Ed. Ph.),   .   .  .   fl  3ij.
Unguenti Cerae albae,.....3*j.    Misce.

             HEMLOCK  OINTMENT.
Fructus Conii, in pulvere subtilissimo,   3SS.
Unguenti Sambuci,......Jij.
Glycerinae,........fl  zj.    Misce. 
THERAPEUTICS.               321
  A hemlock ointment thus prepared I have found very
useful  in  allaying the painful sensations which attend on
some forms of cutaneous eruptions.
   Powders  are  used externally,  chiefly in  cutaneous
diseases  attended Avith  copious serous discharge,  as in
eczema,  and  in  those  accompanied  by  marked  local
inflammatory  action,  as  in  erysipelas.  They are  ap-
plied  to  the surface by  being  shaken from a  small bag
made of fine muslin, and  should be  dusted  over it pretty
thickly.   Whenever  poAvders of different  specific  gravi-
ties are employed in  combination  for  this purpose, they
should be intimately mixed, and  well shaken up  each
time  before  they are applied.  Forms  for different com-
pound dusting poAvders have been  given in the preceding
chapters: the  following  will be  found  useful  when  an
active astringent  is  indicated, as in the superficial ulcera-
tions  Avhich  result  in some  cases  of  pemphigus  and of
ecthyma:

   R. Krameriae Pulveris,......Iss.
      Carbonatis Calcis praecipitati,  .   .  .  31J.
      Amyli,..........3x.   Misce.

   When dusting powders are employed, the affected parts
should be cleansed every day or every second day, by the
use of gelatine  or size baths, or by sponging the  surface
with  equal  parts  of a weak alkaline  wash and new milk
Avarmed.  This is not requisite in the treatment  of erysipe-
las or of erythema,  in which diseases their efficacy, as has
been  before remarked, is partly due to their effect in exclud-
ing the air.
   Soaps—The use of ordinary soaps, as detergents, is seldom
admissible in cutaneous  diseases  in consequence of their
irritant properties on the skin  when it is at all inflamed,
and they should, therefore, never  be  employed except in
the chronic stages of the non-inflammatory affections and
in Avhich  there is no breach of the surface, and even  then
their effects must be carefully watched.   In eruptions situa-
ted on the scalp, or  on other regions of the body which are
ordinarily covered with hair, I have almost invariably seen
them productive of injury, and,  moreover, in such cases the 
322
THERAPEUTICS.
incrustations and scales which form are more  easily and
more effectually removed by the application of Aveak alka-
line washes as already recommended.  The employment of
medicated soaps  in  the treatment of eruptive diseases  of
the skin was at one time much resorted to, particularly on
the Continent, and  latterly  their use has been revived by
Sir Henry Marsh, who  speaks in very high terms of their
efficacy, but I must confess that, in  the  feAv cases  in
which I tried them, they did not produce any good result;
nor is  it likely that a  soap should prove  a good form for
the application of  remedies in  the topical medication  of
cutaneous affections; for whatever substance constitutes the
active ingredient  of the  soap is left but a short time in con-
tact with  the  skin, being almost immediately Avashed off;
and it would be very difficult to regulate its strength,  as
this must vary with the amount of water used each time in
the application of the  remedy.  Sir  Henry Marsh has
recommended  four  different forms of soaps, which contain
respectively sulphur, Avhite precipitate, red precipitate, and
corrosive sublimate, the first two in the proportion  of a
drachm, the third of half-a-drachm, and the fourth of ten
grains to  the ounce.  The formula for  this preparation,
which originated  with Dr. W. D. Moore, of this city, con-
sists in beating up in a marble mortar, in the above propor-
tions, white Windsor soap and the active ingredient, Avith
half a  fluid drachm of rectified spirit, a few drops of oil of
roses being  added as a perfume.

   Those remedies which are administered internally in the
treatment of eruptions of the skin, with the view of acting
generally on the system, require but little notice here, as
they have been  so  fully described and several  formulae
given for their prescription, in the preceding chapters when
treating of  the individal diseases.   The chief point  to  be
kept in view in the constitutional  treatment  of cutaneous
eruptions, one  which has been before referred to, is, that
they require, in most cases, a prolonged administration of
the remedy which maybe employed, and that, consequently,
it should  be given at first in rather small doses, and  its
strength increased afterwards very gradually and slowly.
This is especially evident  with respect to those poAverful 
THERAPEUTICS.
323
alteratives,  arsenic  and  iodine, which  are such valuable
agents in these affections, yet which often produce injurious
consequences by exciting local irritation, and a tendency to
local inflammatory action  from being given at first in too
large  doses  ; the  same holds true of cod-liver oil  and of
many other  medicines which are of daily use in the thera-
peutics of diseases of the skin.   During the employment of
any  of  these  remedies,  their  administration should  be
occasionally omitted for a day  or two, whether they cause
constitutional manifestations of  their effects or not, and the
bowels freely  acted on  by purgatives,  those  of a saline
nature being preferred  if the patient's  strength  admit of
their use.
 _ The following formulae may, in addition to those already
given in the preceding  chapters, serve to aid the  practi-
tioner  in prescribing the medicines which are ordinarily
used in the treatment of this class of affections :—

                  DIAPHORETIC PILLS.

    R. Antimonii Oxydi,......gr. xc.
       Morphiae Muriatis,......gr. iss.
 Confectionis Rosae, quantum sufficit ut fiant pilulae xxiv.

          " Tavo to be taken every sixth hour."

    R. Antimonii Sulphureti praecipitati.
       Pulveris Ipecacuanhae compositi,   . aa 3J.
       Guaiaci Resinae,.......3ij.
 Theriacae,  quantum sufficit ut fiant pilulae sexaginta.

          "  One to be taken every sixth hour. "

                  ALKALINE MIXTURE.

       R. Liquoris Potassae,.....fl s"ss.
          Decocti Dulcamarae,   .   .   .   . fl 3"xj.
          Tincturae Chirettae,             . fl  3*ss.  Misce.

  " Two  table-spoonfuls to be taken three times a day." 
324
THERAPEUTICS.
             ALKALINE CATHARTIC  DRAUGHT.

  R. Solutionis Alkalinae (Brandish),   .   .   .   . fl  5j«
     Potassae Sulphatis cum Sulphure, (Ed.  Ph.)    3iss.
     Aquae destillatae,.........fl  3ij.
     Tincturae Aurantii,........n  3J*
Misce.  Fiat haustus.

     "To be taken in the morning before breakfast."

                DIAPHORETIC MIXTURES.

       R. Tincturae Guaiaei Ammoniatae,  .   fl  3ij-
          Mucilaginis Gummi Tragacanthae, fl  3vj«
          Misturae Amygdalae,   .   .   .   .  fl  3*iij. Misce.

   " Two table-spoonfuls to be taken every sixth hour."

      R. Sarsaparillae Radicis incisae,   .   .   .  oiss.
         Aquae destillatae ferventis, .   .   .   .  Oj.

per horas duodecim in vase clauso macera, subinde agitans,
  dein cola, et

          R. Hujus infusi,  .  .   .  . fl 3*xij.
             Infusi Sassafras,
             Decocti  mezeri,   .   .  aa fl s"iss.
            Syrupi Hemidesmi,    .   . fl  3j.     Misce.

 "A wine-glassful to be taken three or four  times a day."

                 ALTERATIVE MIXTURES.

       R. Hydrargyri Bromidi,   ...    gr. ss.
          Decocti Dulcamarae,    .  .  . fl  Jviij.  Misce.

  "Two table-spoonfuls to be taken three times a day."

  This preparation may be administered in  obstinate cases
of secondary syphilitic  eruptions ; in its action it is nearly
allied to the red iodide of mercury. 
THERAPEUTICS.               325
     R. Hydrargyri Iodidi Rubri, .  .  .   gr. v.
        Spiritus Vini rectificati,   .  .  .   fl   3j.

tere simul dein adde,

        Aquae destillatae,.....fl §iss.
        Iodidi Potassii,......3ij-
        Syrupi Aurantii,.....fl |ss.    Misce.

"Twenty drops to be taken  three times a clay in a wine-
            glassful of infusion of sassafras."

  This is a preferable form to that of pill  for  the adminis-
tration of the red iodide of mercury in venereal eruptions.

     R. Ferri Bromidi,......3j-
        Liquoris Arsenicalis,   ....    m. lx.
        Syrupi Florum Aurantii,  .   .   .  fl 3*ss.
        Aquae Florum Aurantii,   .   .   .  fl s"iss. Misce.

" A tea-spoonful to be taken three times  a day in a wine-
         glassful of decoction of fresh elm-bark."

  A useful form for the administration of arsenic in chronic
cutaneous eruptions, attended with enema  or much debility.
  Before concluding, a few words are requisite as to the
hygienic measures  best adapted for cutaneous diseases.
As  a general  rule, the diet must be, of course, regulated
according to the individual requirements of each case, but
as these  affections  are usually evidences  of constitutional
debiltiy,  though so  frequently attended with a tendency to
local  inflammatory or  irritative action, it  should be nutri-
tious but not stimulating.  Restriction to an almost  purely
milk and  farinaceous diet is attended with the best results
in the majority of instances, and should be almost invariably
enforced with infants and children.   Change of air to a dry,
elevated  position, is often of great service, but  extremes of
cold and heat should be avoided as much  as possible  For
the  latter reason, the surface of the body should be  kept
as far as can be of  an uniform temperature by attention to
the  clothing worn, which, however, should  never be such as
to check the insensible perspiration, or tend to condense it
on the integuments.  That worn next the skin should  be
                           28 
326
THERAPEUTICS.
soft  and unirritating,  and  therefore  woollen should  be
avoided, soft calico or silk being preferred for under-clothing.
In referring to change of air, I wish to  record  it  as  the
result of my experience, that a residence at the sea shore
usually proves injurious  in  cutaneous eruptions, the fine
saline particles which float about in the atmosphere appear-
ing to aggravate the disease by exciting local irritation : the
the climate of those  districts which are situated  a short
distance inland is however, well adapted for persons afflicted
with them
   Great objections are often raised to the  cure of cutaneous
eruptions, particularly  those which  are  attended with  a
copious secretion, more especially if they have been of long
existence, for fear of their sudden removal or the stoppage of
the discharge with which they may be attended causing some
grave internal disease; but I have never seen any ill conse-
quences result when  they were removed  by constitutional
treatment, not even in the case of infants or children who may
be teething;  on the contrary, I have  invariably witnessed
the general  health to be much improved  in  all respects
thereby ; but the sudden cure by the employment of topical
remedies only, such as caustics  or powerful astringents or
stimulants, is certainly not advisable unless the eruption is
of small extent and has been of short duration. 
INDEX.
Acarus folliculorum, 119.
      scabiei, 107.
Achorion Schonleinii, 268.
Achroma congenitale, 238.
      vitiligo, 238.
Acne, 117.
      indurata, 121.
      molluscoides, 209.
       punctata, 119.
       rosacea, 120.
       sebacea,  118, 213.
       simplex,  118.
       syphilitic, 288.
       varioliformis, 209.
Acrodynia, 34.
Albinoes, 237.
Albinoismus, 237.
Alibert's classification, 18.
Alkaline baths,  312.
       cathartic draught, 324.
       lotion, 56, 61.
         sedative, 316.
         stimulating, 315.
       mixtures, 323.
Alopecia, 305.
Alterative mixtures, 324.
Appendages of the skin, diseases of,
   304.
Artificial classifications, 16.
Arsenic, ioduretted solution of the
   iodide of potassium and,  185.
Asiatic pills, 186.
Astringent lotions, 316.
       ointments, 320.
Author's classification, 24.

Baker's itch, 153.
Baldness, 305.
Bandages, 310.
Barbadoes leg, 218.
Baths, 311.
      alkaline, 312.
      gelatine, 312.
      iodine, 312.
      mercurial, 313.
      sulphur, 313.
Bennett's classification, 22.
Bleb, 17,  63.
Brandy-face, 120.
Bulla, 17.
Bullae, 63.
Burnt holes, 97.

Callositates, 223.
Camphor ointment, 320.
Cancrodes, 28, 246.
Cancroi'de, 261.
Canities,  304.
Cantharides, tincture  of, in psori-
   asis, 188.
Carbonate of ammonia in psoriasis,
   187.
Carbuncled face, 120.
Cataplasms, 313.
Caustic of chloride of zinc, 314.
       of iodine,  314.
       solution,  compound, 314.
Caustics, 314.
Cazenave's classification, 20.
       treatment of lupus, 260.
Ceratum  cucumis, 319.
       galeni, 318.
Cheloi'd tumour,  261.
Chloasma, 192, 264.
Chloride  of zinc caustic, 314.
Classification, 13.
       artificial systems of, 16.
       author's, 24.
       Alibert's, 16, 18.
       Bennett's, 22. 
328                         INDEX.
Classification,
      Cazenave's, 20.
      Willan's, 17.
      Wilson's, 19.
      natural systems of, 19.
      regional system of, 17, 21.
Clavus,  222.
Cold cream, 318.
Collodion in skin  diseases, 309.
      use of, in erysipelas, 47.
Condylomata, 224.
      syphilitic,  294.
Corns, 222.
      soft, 222.
Corrosive sublimate soap, 1522.
Couperose, 120.
Cream,  cold, 318.
      cucumber, 319.
Crusted tetter, 126.
Cryptogamia of favus,  267.
      of sycosis, 275.
Cucumber cream, 319.

Dandriff, 193.
Dermatophytse, 28,  264.
Diaphoretic mixtures,  324.
      pills, 323.
Donovan's solution, 300.
Draught, alkaline cathartic, 324.
Dry scale, 169.
      tetter, 169.

Ear, herpes of, 80.
Eating hive, 97.
      tetter, 246.
Ecchymoses, 226,
Ecthyma, 139.
       acutum, 139.
       cachecticum, 141.
       chronicum, 140.
       infantile, 141.
       luridum,  141.
       syphilitic,- 290.
Eczema, 63.
       capitis, 68.
       chronicum, 66.
       faciei, 67.
       impetiginodes, 66, 133.
       mercuriale, 70.
       rubrum, 65.
       simplex, 64.
        solare, 70.
        syphilitic, 286.
       umbilicale, 69.
Elephantiasis. 217
Elephantiasis,
      Arabum, 218.
      Grrecorum, 217.
Ephelides ligneales, 243.
Ephelis, 241.
Ephelis, hepatica, 242.
      lenticularis, 241.
      syphilitic, 296.
      violacea, 244.
Epidemic of erythema, 34.
      of pemphigus, 97.
Erratic erysipelas, 40.
Erysipelas, 37.
      contagiousness of, 42.
      erratic, 40.
      gangrenous,  39.
      idiopathic, 38.
      metastatic, 40.
      phlegmonous, 39.
      symmetrical, 40.
      true, 38.
      traumatic, 40.
      treatment of, 44.
Erythema, 31.
      circinnatum, 32.
      fugax, 32.
      intertrigo, 32.
      lffive,  32.
      marginatum, 32.
      nodosum, 33.
      papulatum, 33.
      simplex, 31.
       syphilitic,  284.
      tuberculatum,  33.
Esthiomanic scrofula, 253.
Esthiomanos ambulans, 248.
       serpiginosis, 248.
Evanescent urticaria, 51.
Exanthema,  17.
       hemorrhagica, 231.
Exanthemata, 24, 30.
       syphilitic, 284.

Face, acne of, 120.
       eczema of, 67.
       impetigo of, 130.
Favus, 265.
       dissemin6, 268.
       en cercles, 268.
Fire, sacred, 81.
       St. Anthony's, 37.
Fish-skin disease, 200.
Flux, sebaceous, 212,
 Freckles, 241. 
INDEX.                        329
Galen's cerate, 318.
Gelatine baths, 3.2.
Glycerine wash, 316.
Graves  on  gutta percha  in skin
   diseases, 310.
Gray hair, 304.
Grocer's itch, 70,153.
Gruby on mentagra, 276.
Gum, 149.
       red, 149.
       white, 150.
Gutta percha in skin diseases, 310.
Gutta rosacea, 120.

Hair, diseases of,  304.
       falling out of,  305.
       grayness of, 304.
Hardi's treatment for the itch, 114.
Heat, prickly, 151.
Helmerick's itch ointment, 113.
Hemlock ointment, 320.
Hemorrhagise, 27, 226.
Herpes,  78.
       auricularis, 80.
       capitis, 84.
       circinnatus, 83.
       iris, 86.
       labialis, 80.
       phlyctenodes,  78.
       prseputialis, 80.
       pudendalis, 81.
       squamosus, 84.
       tonsurans, 84.
       zoster, 81.
Higginbottom's treatment  of erysi-
   pelas,  48.
Huile de cade, 76.
Humid tetter, 63.
Hydrargyria, 70.
Hypertrophioe, 27, 199.
      syphilitic, 294.

Icthyosis, 169, 200.
      cornea, 201.
      hysterix,  201.
      papillary, 202.
      scutellata, 201.
      simplex, 201.
      spinosa, 201.
      squamosa, 201.
Idiopathic  erysipelas, 38.
Ignis sacer, 81.
Impetigo, 126.
      capitis, 131.
                    28*
Impetigo,
       erysipelatodes, 129.
       figurata, 128.
       granulata, 131.
       larvalis, 131.
       lupiformis, 133.
       pilaris, 132.
       purifluens, 132.
       rodens,  132.
       scabida, 130.
       sparsa,  130.
       sycosiformis, 132.
       syphilitic, 289.
Impetiginous eczema, 72, 133.
Inflammatio folliculorum, 213.
Inflammatory blush, 31.
Intertrigo, 32.
Iodine baths, 312.
       caustic,  314.
Ioduretted solution of the iodide of
  potassium and arsenic, 185.
Itch, 106.
       baker's, 153.
       grocer's, 70, 153.
       insect, 107.
       washerwomen's, 70, 153.

Jacob's ulcer, 252.

Kelois,  261.

Leper hospitals, 218.
Lepra, 169, 175,  217.
      alphoides, 176.
      nigricans, 176.
      syphilitic, 292.
      vulgaris,  175.
Leprosy, 217.
Leucopathia, 238.
Lichen, 146.
      agrius, 150.
      circumscriptus, 148.
      gyratus, 148.
      lividus, 147.
      pilaris, 148.
      simplex, 146.
      solitarius, 148.
      strophulus, 149.
      syphilitic, 291.
      tropicus, 151.
Lips, herpes of, 80.
Lotion,  alkaline, 56, 61, 315.
      astringent, 316.
      glycerine, 316.
      stimulant, 317. 
330
INDEX.
Lotion,
      sulphurous, 317.
Lupoid impetigo, 132.
Lupus, 246.
      devorans, 250.
      exedens, 247.
      non-exedens, 247.
      serpiginosus, 248.
      superficialis, 247.
         non-tuberculosus, 248.

      vorax, 251.
Maclagan, Dr., on the urine in urti-
  caria, 54.
Maeula, 18.
Maculae,  27, 237.
      syphilitic, 296.
Mark, mother, 224.
Marsh's soaps, 322.
Melasma, 192.
Melitagra, 128.
Mentagra, 275.
      contagiosum, 276.
Mermaids, 203.
Mercurial baths, 313.
      eczema, 70.
Mixtures, alkaline, 323.
      alterative, 324.
      diaphoretic, 324.
Molluscum, 208.
      acutum, 209.
      chronicum, 210.
      contagiosum, 209.
      non-contagiosum, 209.
      pendulum, 210.
Mother-mark,  224.

Naevus,  224.
      araneus, 225.
Nails, diseases of, 307.
      ingrowing of, 307.
Natural systems  of classification, 19.
Nettle rash, 49.
Nirles, 78.
Nitrate of silver-stain, 244.
Noli me tangere, 250.

Ointment, camphor, 320.
      cucumber, 319.
      Helmerich's, 113.
      hemlock,  320.
      scrophularia, 101.
      stavesacre, 115.
      white hellebore, 115.
Ointments, 317.
Ointment,
       astringent, 203.
       sedative, 319.
 Pachydermia, 219.
 Papula,  17.
 Papulae, 26, 145.
       syphilitic, 291.
 Papulous scall, 139.
 Pemphigus, 94.
       acutus, 95.
       chronicus, 97.
         foliaceus, 99.
       contagiosus, 100.
       gangraenosus, 97.
       infantilis, 96.
       simultaneus, 94.
       successivus, 94.
       syphilitic, 287.
 Petechiae,  226.
 Phlegmonous erysipelas, 3!»
 Phlyzacia, 26.
 Phthiriasis, 162.
       capitis, 162.
       corporis, 162.
       pubis, 162.
 Pills, Asiatic, 186.
       diaphoretic, 323.
 Pimples, 17, 26, 145.
 Pityriasis, 190.
       capitis,  193.
       diffusa, 191.
       labiorum,  192.
       localis, 192.
       nigra, 192, 215.
       oris, 192.
       palmaris, 192.
       palpebrarum, 192.
       plantaris,  192.
       praeputialis, 192.
       pudendalis, 192.
       rubra, 190.
       versicolor, 190, 264.
 Plica Polonica, 305.
 Pomade, cucumber, 319.
       Helmerich's, 113.
       turpentine, 240.
 Pompholyx, 94.
       benignus, 96.
       diutinus, 97.
       solitarius, 96.
 Porcupine men, 203.
 Porrigo, 264.
       decalvans, 305.
       favosa, 265. 
INDEX.
Porrigo,
      lupinosa, 268.
Powders, 321.
      dusting, 321.
Prepuce, herpes of, 81.
Prickly heat, 151.
Prurigo,  159.
      formicans, 160.
      mitis, 159.
      palmaris, 163.
      pedicularis, 162.
      podicis, 163.
      praeputialis, 163.
      pubis, 163.
      prudendi,  163.
       scroti,  163.
       senilis, 162.
       urethritis, 163.
       vulgaris, 160.
Psoriasis, 169.
       aggregata, 172.
       annulata, 177.
       capitis, 174.
       centrifuga, 175.
       confluens, 172.
       diffusa, 172.
       guttata, 170.
       infantilis, 177.
       inveterata, 173.
       labialis, 174.
       lepraeformis, 175.
       orbicularis, 177.
       palmaris, 174.
         centrifuga, 175.
         syphilitic, 293.
       palpebrarum, 174.
       preputialis,  174.
       pudendalis, 174.
       scrotalis, 174.
       syphilitic, 292.
       unguium, 175.
       vulgaris, 172.
Psydracia, 26.
Pudendum, herpes of, 81.
Purples, 226.
Purpura, 226.
       cachectica, 231.
       contagiosa, 231.
       febrilis hemorrhagica, 230.
         simplex, 227.
       hemorrhagica, 229.
       senilis, 228.
       simplex, 227.
       urticans, 228.
Pustulae, 18, 116.
      syphilitic, 288.
Pustules, 18, 26, 116.

Rainbow ringworm, 86.
Rash, 17.
      nettle, 49.
      rose, 57.
      tooth, 149.
      wildfire, 150.
Red gum, 149.
Red precipitate  soap, 322.
Regional classification, 17, 21.
Rheumatism and urticaria, 53.
Ringworm, 83.
      of the scalp, 84.
      rainbow,  86.
Robin's description of porrigo,
Rose rash, 57.
Roseola, 57.
      aestiva, 58.
      annulata, 58.
      autumnalis, 58.
      cholerica, 60.
      febrilis, 60.
      idiopathica, 57.
      infantilis, 58.
      miliaria,  60.
      punctata, 59.
      symptomatica, 59.
       syphilitic, 285.
      vaccina, 60.
      variolosa, 60.
Rosy drop, 120.
Rupia,  102.
       escharotica, 97, 103.
      prominens, 103.
      simplex,  103.
       syphilitic, 287.

Sacred fire, 81.
Sarcoptes hominis, 107.
Scabies, 106.
       cachectica, 110.
       lymphatica, 110.
       papuliformis, 110.
       purulenta,  110.
Scald head, 265.
Scale, 17, 168.
       dry, 169.
Scall, 63.
       head, 265.
       papulous, 139.
Scalp, eczema of,  68.
       herpes of,  84. 
332                         INDEX.
Scalp,
      impetigo of, 131.
      psoriasis of, 174.
      ringworm of, 84.
Scrophularia ointment, 101.
Scrofula, esthiomanic, 253.
Sebaceous flux, 212.
Secondary eruptions, 281.
Sedative alkaline lotions, 316.
      ointments, 319.
Shell-fish, urticaria caused by, 53.
Shingles, 81.
Silver, nitrate of, stain from, 244.
Skin, diseases of appendages of, 304.
Soap of corrosive sublimate, 322.
      red precipitate,  322.
      sulphur, 322.
       white precipitate, 322.
Soaps, 321.
      Marsh's, 322.
Soft corns, 222.
Solution of iodide  of potassium and
  arsenic, 185.
Spedalskhed, 218.
Squama, 17.
Squamae, 26, 168.
       syphilitic, 292.
St.  Anthony's fire, 37.
Stains,  18.
       syphilitic, 296.
Stavesacre ointment, 115.
Stearrhoea, 212.
      flavescens, 213.
      nigricans, 214.
      simplex, 212.
Steatozoon folliculorum, 119.
Stimulant wash, 317.
Stokes,  Whitley, on pemphigus, 97.
Strophulus,  146.
      albidus, 150.
      candidus, 150.
      confertus, 149.
      intertinctus, 149.
      volaticus, 150.
Sudamina, 71.
Sulphur baths, 313.
      soap, 322.
Sulphurous lotion, 317.
Sun burn, 241.
      rash, 70.
Sycosis, 274.
      mentis, 275.
Syphilide squameuse corne"e, 293.
Syphilides, 28, 281.
Syphilitic acne, 288.
      condylomata, 294.
      ecthyma, 290.
      eczema, 286.
      ephelis, 296.
      eruptions, 281.
      erythema, 284.
      exanthemata, 284.
      herpes, 286.
      hypertrophiae, 294.
      impetigo, 289.
      lepra, 292.
      lichen,  291.
      maculae, 296.
      papulae, 291.
      pemphigus, 287.
      psoriasis, 292.
      pustulae, 288.
      roseola, 285.
      rupia, 287.
      squamae, 292.
      tubercles, 294.
      urticaria, 285.
      vesiculae, 286.

Tetter, 78.
      crusted, 126.
      dry,  169.
      eating, 253.
      humid, 63.
Therapeutics, 309.
Tinea, 265.
      favosa, 265.
Tooth-rash, 145.
Topical medication, 309.
Traumatic erysipelas,  40.
Tropical lichen, 151.
Trouts,»243.
Tubercle, 17,  294.
Tubercles,  syphilitic,  294.
Tubercula,  199.
Tumour, cheloi'd, 261.
Turpentine  pomade, 240.

Ulcer, Jacob's, 252.
Urticaria, 49.
      conferta, 51.
      evanida, 51.
      febrilis, 50.
      intermittens, 51.
      perstans, 51.
       subcutanea, 51.
       syphilitic, 285.
       tuberosa, 52. 
INDEX.                         333
Velpcau's treatment of erysipel
  49.
Venereal eruptions, 281.
Verrncse, 221.
Vesicle, 17, 63.
Vesiculce, 25, 63.
       syphilitic, 286.
Vibices, 226.
Vitiligo,  238.
Vitiligoidea plana, 215.
       tuberosa, 215.
Warts, 221.
Washerwomen's itch, 70, 153.
Water-blebs, 94.
White gum, 150.
      hellebore ointment, 114.
      precipitate soap, 322.
Wild-fire rash,  150.
Willan's classification, 17.
Wilson's  classification, 19.
Wolf, the, 246.
 
 
 
 
CATALOGUE
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ABEL (F.A.), F.C.S., and C. L. BLOXAM. — Handbook of Chemistry, Theoretical, Practical,
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ASHWELL (SAMUEL), M.D.—A Practical Treatise on the Diseases Peculiar to Women.
  Illustrated by Cases derived from Hospital and Private Practice.  With additions by Paul
  Beck Goddard, M.D.  Second American edition.  In one octavo volume of 520 pages.
ARNOTT (NEILL), M.D. —Elements of Physics; or, Natural Philosophy, General and Me-
  dical. Written for universal use, in plain or non-technical language.  A new edition, by
  Isaac Hays, M.D.  Complete in one octavo volume, of 484 pages, with about two hundred
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BENNETT (J. HUGHES). M.D.— The Pathology and Treatment of Pulmonary Tubercu-
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  taken for, or associated with, Phthisis.  In one liandsome octavo volume, with beautiful
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BENNETT (HENRY), M.D. — A Practical Treatise on Inflammation of the Uterus, its
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  from the third and revised London edition. In one neat octavo volume, of 430 pages, with
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BE ALE (LIONEL JOHN), M.R.C.S. — The Laws of Health in Relation to Mind and Body.
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BILLING (ARCHIBALD), M.D.—The Principles of Medicine.  Second American, from the
  Fifth and Improved London edition.  In one handsome octavo volume, extra cloth, 250
  pages.               /
BLAKISTON (PEYTON), M.D.—Practical Observations on Certain Diseases of the Chest,
  and on the Principles of Auscultation.  In one volume, 8vo., 384 pages.
                                                                  (D 
2          BLANCHARD  & LEA'S MEDICAL PUBLICATIONS.
BURROWS (GEORGE), M.D. — On Disorders of the Cerebral Circilation, and on the Con-
  nection between the Affections of the Brain and Diseases of the Heart.  In one 8vo. vol.,
  with colored plates, pp. 216.
BUDD (GEORGE), M.D.—On Diseases of the Liver.  Second American, from the second and
  enlarged London edition.  In one very handsome octavo volume, with four beautifully-
  colored plates, and numerous wood-cuts.  468 pages.  New edition.  (Just Issued.)
BUCKLER (T. H.), M.D. — On the Etiology, Pathology, and Treatment of Fibro-Bronciiitis
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BUSHNAN (J. S.), M.D. — Principles of Animal and Vegetable Physiology.  A  Popular
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BLOOD AND URINE (MANUALS ON). — By John William Griffith, G. Owen Reese, and
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BRODIE (SIR BENJAMIN C), M.D., Clinical Lectures on Surgery. One vol., 8mo., cloth.
  S50 pages.
BRODIE  (SIR BENJAMIN C), M. D. —Select  Surgical Works, 1 vol. 8vo. leather, con-
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BIRD (GOLDING), M. D. — Urinary  Deposits: their Diagnosis, Pathology, and  Thera-
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BIRD (GOLDING), M. D.—Elements of Natural Philosophy; being an Experimental Intro-
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  the third London edition.  In one neat volume, royal 12mo.  402 pages.
BARTLETT (ELISIIA) M.D.—The History. Diagnosis, and Treatment of the Fevers of the
  United States.  Third edition, revised and improved.  In one octavo volume, of 6ix hun-
  dred pages, beautifully printed, and strongly bound.
BOWMAN (JOHN E.), M.D. — Practical Handbook of Medical Chemistry.   In one neat
  volume, royal 12mo., with numerous illustrations.  288 pages.
BOWMAN (JOHN E.), M.D. — Introduction to Practical Chemistry, including Analysis.
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BARLOW (GEORGE II.), M.D.— A Manual of the Principles and Practice of Medicine.
  In one octavo volume.  (Preparing.)
COLOMBAT DE L'ISERE.—A Treatise on the Diseases of Females, and on the  Special
  Hygiene of their Sex.  Translated, with many Notes and Additions, by C. D. Meigs, M.D.
  Second edition, revised and improved.  In one large volume, octavo, with numerous wood-
  cuts.  720 pages.
COPLAND (JAMES), M. D.—Of the Causes, Nature, and Treatment of Palsy and Apopiext,
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BLANCHARD & LEA'S MEDICAL PUBLICATIONS.           8
CLYMER (MEREDITH), M.D., &c. — Fevers; their Diagnosis, Pathology, and Treatment.
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  of Practical Medicine.  In one octavo volume, of 600 pages.
CAR SON (JOSEPH), M. D. — Synopsis of  the  Course of Lectures on Materia Medica and
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  of 208 pages.
CARPENTER (WILLIAM B.), M.D. — Principles of Human Physiology; with their chief
  applications to  Psychology, Pathology, Therapeutics, Hygiene, and Forensic  Medicine.
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  fourteen illustrations.  Edited, with additions, by Francis Gurney Smith, M. D., Professor
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CARPENTER (WILLIAM B.), M. D. —Principles of Comparative Physiology.  New Ame-
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CARPENTER (WILLIAM B.), M. D— The Microscope and its Revelations.  In one hand-
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CARPENTER (WILLIAM B.), M.D.— A Prize Essay on the Use of Alcoholic Liquors in
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CHRISTISON (ROBERT), M. D. — A Dispensatory; or, Commentary on the Pharmacopoeias
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CHELIUS (J. M.), M. D.—A System of Surgery.  Translated from the German, and accom-
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CONDIE (D. F.), M. D.—A Practical Treatise on the Diseases of Children.  Fourth edition,
  revised and augmented. In one large volume, 8vo., of nearly 750 pages.  (Just Issued.)
COOPER  (BRANSBY B.), M. D.—lectures on the Principles and Practice of Surgery.  In
  one very large octavo volume, of 750 pages.  (Lately Issued.)
COOPER (SIR ASTLEY P.) — A Treatise on Dislocations and Fractures of the Joints.
  Edited by Bransby B. Cooper, F.R.S., Ac.  AVith additional  Observations by Prof. J. C.
  Warren.  A new American edition.  In one handsome octavo volume, with numerous
  illustrations on wood.
COOPER (SIR ASTLEY P).—On the Anatomy and Treatment  of Abdominal Hernia. One
  large volume, imperial 8vo., with over 130 lithographic figures. 
4           BLANCHARD <fe  LEA'S MEDICAL PUBLICATIONS.
COOPER (SIR ASTLEY P.)—On the Structure and Diseases of the Testis, and on the
  Thymus Gland.  One vol. imperial 8vo., with 177 figures, on 29 plates.
COOPER (SIR ASTLEY P.)—On the Anatomy and Diseases of the Breast, with twenty-five
  Miscellaneous and Surgical Papers.   One large volume, imperial 8vo. with 252 figures, on
  36 plates.
CHURCHILL (FLEETWOOD),  M. D. —On the Theory and Practice of Midwifery.  A new
  American, from the last and improved English edition.   Edited, with Notes and Additions,
  by D. Francis Condie, M. D., author of a " Practical Treatise on the Diseases  of Children,"
  &c.  With 139 illustrations.  In one very handsome octavo volume, 510 pages.  (Lately
  Issued.)
CHURCHILL (FLEETWOOD), M. D. —On the Diseases of Infants and Children.  In one
  large and handsome volume of over 600 pages.
CHURCHILL (FLEETWOOD), M. D.—Essays on the Puerperal Fever, and other Diseases
  Peculiar to Women.  Selected from the writings of British Authors previous to the close
  of the Eighteenth Century.  In one neat octavo volume, of about 450 pages.
CHURCHILL (FLEETWOOD), M.D.—On the Diseases of Women; including those of Preg-
  nancy and child-bed.  A new American edition, revised by the Author.  With Notes and
  Additions, by D. Francis Condie, M. D., author of " A Practical Treatise on the Diseases of
  Children."  In one large and handsome octavo volume, with wood-cuts, 684 pages.  (Just
  Issued.)
DEWEES (W. P.), M. D.—A Comprehensive System of Midwifery.  Illustrated by occasional
  Cases and many Engravings.  Twelfth edition, with the Author's last Improvements and
  Corrections.  In one octavo volume, of 600 pages.  (Just Issued.)
DEWEES (W. P.), M. D.—A Treatise on the Physical and Medical Treatment of Children.
  Tenth edition.  In one volume, octavo, 548 pages.  (Just Issued.)
DEWEES (W. P.), M.D.—A Treatise on the" Diseases of Females.  Tenth edition.  In one
  volume, octavo, 532 pages, with plates.  (Just Issued.)
DRUITT (ROBERT), M.R.C.S.—The Principles and Practice of Modern Surgery. A new
  American, from the improved London edition.  Edited by F. W. Sargent, M. D., author of
  " Minor Surgery," &c.  Illustrated with one hundred and ninety-three wood-engravings.
  In one very handsomely-printed octavo volume, of 576 large pages.
DUNGLISON, FORBES, TWEEDIE, AND CONOLLY.—The Cyclopedia of Practical Medi-
  cine: comprising Treatises on the Nature and Treatment of Diseases. Materia Medica and
  Therapeutics, Diseases of Women and Children, Medical Jurisprudence, Ac. &c.  In  four
  large super-royal octavo volumes, of 3254 double-columned pages, strongly and hand-
  somely bound.

  *** This work contains no less than four hundred and eighteen distinct treatises, contri-
buted by sixty-eight distinguished physicians.
DUNGLISON  (ROBLEY), M. D. — Medical Lexicon; a Dictionary of Medical Science, con-
  taining a concise Explanation of the various Subjects and Terms of Physiology, Pathology
  Hygiene, Therapeutics, Pharmacology, Obstetrics, Medical Jurisprudence, &c.  With the
  French and other Synonymes;  Notices of Climate and of celebrated Mineral Waters; For-
  mulae for various Officinal, Empirical, and Dietetic Preparations, &c.  Eleventh edition
  revised.  In one  very  thick octavo  volume, of over 900 large double-columned pa*es!
  strongly bound in leather, with raised bands. (Just Issued.) 
BLANCHARD & LEA'S MEDICAL PUBLICATIONS.          8
DUNGLISON (ROBLEY), M.D.—The Practice of Medicine.  A Treatise on Special Pathology
  and Therapeutics.  Third edition. In two large octavo volumes, of 1500 pages.
  Upon  every topic embraced in the work, the latest information will be found carefully
posted up.—Medical Examiner.
DUNGLISON (ROBLEY), M. D. — General Therapeutics and Materia Medica; adapted for a
  Medical Text-book.  Fifth edition, much improved.  With one hundred and eighty-seven
  illustrations.  In two large and handsomely-printed octavo volumes, of about 1100 pages.
  (Just Issued.)
DUNGLISON  (ROBLEY), M.D.—New Remedies, with Formulae for their Administration.
  Sixth edition,^with extensive Additions. In one very large octavo volume, of over 750 pp.
DUNGLISON (ROBLEY), M.D.—Human Physiology.  Seventh edition.  Thoroughly revised
  and extensively modified and enlarged, with nearly five hundred illustrations.  In two
  large and handsomely-printed octavo volumes, containing nearly 1450 pages.
DUNGLISON  (ROBLEY), M. D.—Human Health; or, the Influence of Atmosphere andLo.
  cality, Change of Air and Climate, Seasons, Food, Clothing, Bathing, Exercise, Sleep, &<:. &c,
  on Healthy Man; constituting Elements of Hygiene.  Second edition, with many Modifi-
  cations and Additions.  In one octavo volume, of 464 pages.
DURLACHER (LEWIS). — A Treatise on Corns, Bunions, the Diseases of Nails, and the
  General Management of the Feet.  In one 12mo. volume, cloth.  134 pages.
DE JONGH (L. J.), M. D.—The Three Kinds of Cod-Liver Oil, comparatively considered, with
  their Chemical and Therapeutic Properties.  Translated, with an Appendix and Cases, by
  Edward Carey, M. D.  To which is added an  article on the subject from " Dunglison on
  New Remedies."  In one small 12mo. volume, extra cloth.
DAY (GEORGE E.), M. D. —A Practical Treatise on the Domestic Management and More
  Important Diseases of Advanced Life.  With an Appendix on a new and successful mode
  of treating Lumbago  and other forms of Chronic Rheumatism. One volume octavo, 226
  pages.
ELLIS (BENJAMIN), M.D. — The Medical Formulary : being a Collection of Prescriptions,
  derived from the writings and practice of many of the most eminent physicians of America
  and Europe.  Together with the usual  Dietetic Preparations and Autidotes  for Poisons.
  To which is added an Appendix, on the Endermic use of Medicines, and on the use of Ether
  and Chloroform.   The whole accompanied with a few brief Pharmaceutic and Medical
  Observations.  Tenth edition, revised and  much extended, by Robert P. Thomas, M. D.,
  Professor of Materia Medica in the Philadelphia College of Pharmacy.  In one neat octavo
  volume, of 296 pages.  (Now Ready. Revised and enlarged to 1854.)
ERICHSEN (JOHN).—The Science and Art of Surgery; being a Treatise on Surgical Inju-
  ries. Diseases, and Operations.  With Notes and Additions by the American Editor.  Illus-
  trated with over three hundred engravings on wood.  In one large and handsome  octavo
  volume, of nearly 900 closely-printed pages.  (Now Ready.)
                     This is a new work, brought up to May, 1854.
FERGUSSON (WILLIAM), F.R.S.—A System of Practical Surgery. Fourth American, from
  the third and  enlarged London edition.   In one large  and beautifully-printed octavo
  volume, of about 700 pages, with three hundred and ninety-three handsome illustrations.
  (Just Issued.)
FRICK (CHARLES), M. D.—Renal Affections ; their Diagnosis and Fathology.  Witli  illus-
  trations.  One volume, royal 12mo., extra cloth.
FOWNES  (GEORGE), PH.D. — Elementary Chemistry; Theoretical and Practical.  With
  numerous illustrations.  A new American, from  the last and revised London edition.
  Edited, with Additions, by Robert  Bridges. M. D.  In one large royal 12mo. volume, o*
  over 560 pages, with 181 wood-cuts: sheep, or extra cloth.  (Ar«!" Ready.) 
6          BLANCHARD  & LEA'S MEDICAL PUBLICATIONS.
GRAHAM (THOMAS), F.R.S.—The Elements of Chemistry.  Including the Application of
  the Science to the Arts. With numerous illustrations.  With Notes and Additions, by
  Robert Bridges, M. D., &c. &c.   Second American, from the second and enlarged London
  edition.
PART I. (Lately Issued) large 8vo., 430 pages, 185 illustrations.
PART II. (Preparing) to match.
GROSS (SAMUEL D.), M.D. — A Practical Treatise on the Diseases and injuries of the
  Urinary Organs.  In one large and beautifully-printed octavo volume, of over 700 pages.
  With numerous illustrations.
GROSS (SAMUEL D.), M. D. —A Practical Treatise on Foreign Bodies in the Air-Passages.
  In one handsome octavo volume, with illustrations.  (Nearly Ready.)
GROSS (SAMUEL D.), M. D.—A System of Surgery; Diagnostic, Pathological, Therapeutic,
  and Operative.  With very numerous engravings on wood.  (Preparing.)
GLUGE (GOTTLIEB), M. D. — An Atlas of Pathological Histology.  Translated, with Notes
  and Additions, by Joseph Leidy, M. D., Professor of Anatomy in the University of Penn-
  sylvania. In one volume, very large imperial quarto, with 320 figures, plain and colored,
  on twelve copperplates.
GRIFFITH (ROBERT E.), M. D. — A Universal Formulary, containing the Methods of Pre-
  paring and Administering Officinal and other Medicines. The whole adapted to Physicians
  and Pharmaceutists.  Second edition, thoroughly revised, with numerous Additions, by
  Robert P. Thomas, M. D., Professor of Materia Medica in.the Philadelphia College of Phar-
  macy. In one large and handsome octavo volume, of over 600 pages, double columns.
  (Just Ready.)
GRIFFITH (ROBERT  E.), M.D.— Medical Botany;  or, a  Description  of  all the more
  important Plants used in Medicine, and of their Properties, Uses, and Modes of Adminis-
  tration.  In one large octavo volume, of 704 pages, handsomely printed, with nearly 350
  illustrations on wood.
GREGORY (WILLIAM), F. R. S. E. — Letters to a Candid Inquirer on Animal Magnetism.
  Description and Analysis of the Phenomena.  Details of Facts and Cases.  In one neat
  volume, royal 12mo., extra cloth.
GARDNER (D. PEREIRA), M. D—Medical Chemtstry, for the us=e of Students and the Pro-
  fession:  being a Manual of the  Science, with its Applications to Toxicology, Physiology,
  Therapeutics, Hygiene, &c.  In one handsome royal 12mo. volume, with illustrations.
HASSE (C. E.), M. D.—An Anatomical Description of the Diseases of Respiration and Cir-
  culation. Translated and edited by Swaine.  In one volume, octavo.
HARRISON  (JOHN). M. D.—An Essay towards a Correct Theory of the Nervous System.
  In one octavo volume, 292 pages.
HUGHES  (H. M.), M.D. — A Clinical Introduction to- the Practice of Auscultation, and
  other Modes of Physical Diagnosis, in Diseases of the Lungs and Heart.  Second American
  from the second and improved London edition.  In one royal 12mo. volume. (Just Ready.)
HORNER (WILLIAM E.), M. D.—Special Anatomy and Histology.  Eighth edition.  Exten-
  sively revised and modified.   In two large octavo volumes, of more than 1000 pages, hand-
  somely printed, with over 300 illustrations.
HOBLYN (RICHARD D.), A. M.—A Dictionary of the Terms used in Medicine and the Col-
  lateral Sciences.  Second and improved American edition. Revised, with numerous Ad-
  ditions, from the second London edition, by Isaac Hays, M. D., &c.  In one large royal
  12mo. volume, of over 400 pages, double columns.  (Nearly Ready.) 
BLANCHARD & LEA'S  MEDICAL PUBLICATIONS.           1
HOPE  (J.), M. D. — A Treatise on the Diseases of the Heart and Great Vessels.  Edited by
  Pennock.  In one volume, octavo, with plates, 572 pages.
HERSCHEL (SIR JOHN F. W.), F.R.S.—Outlines of Astronomy.  New American, from the
  third London edition.  In one neat volume, crown octavo, with six plates and numerous
  wood-cuts.  (Just Issued.)
HUMBOLDT (ALEXANDER).—Aspects of Nature in Different Lands and Different!  Cli-
  mates.  Second American edition, one vol. royal 12mo., extra cloth.
JONES (T. WHARTON), F.R.S.—The Principles and Practice of Ophthalmic Medicine and
  Suroery.  Edited by Isaac Hays, M. D., &c.  In one very neat volume, large royal 12mo.,
  of 529 pages, with four plates, plain or colored, and ninety-eight wood-cuts.
JONES (C. HANDFIELD), F.R.S., AND EDWARD II. SIEVEKING, M.D. —A Manual of
  Pathological Anatomy.  With numerous engravings on wood.  In one handsome volume.
  (In Press.)
KIRKES (WILLIAM SENHOUSE), M. D., AND JAMES PAGET, F.R.S.—A Manual of Phy-
  siology.   Second  American,  from the  second and improved London edition.   With 165
  illustrations.  In one large and handsome royal 12mo. volume.  550 pages.  (Just Issued.)
KNAPP (F.), Ph.D. — Technology; or, Chemistry applied to the Arts and to Manufactures.
  Edited, with  numerous Notes and  Additions, by Dr. Edmund Ronalds and Dr. Thomas
  Richardson.  First  American edition, with Notes and Additions, by  Professor Walter R.
  Johnson. In two handsome octavo volumes, printed and illustrated in the highest style
  of art, with about 500 wood-engravings.
LEnMANN.—Physiological Chemistry. Translated by George E. Day, M.D.  (Preparing.)
LEE (ROBERT), M. D.—Clinical Midwifery; comprising the Histories of Five Hundred and
  Forty-five Cases of Difficult, Preternatural, and Complicated Labor, with Commentaries.
  From the second London edition. In one royal 12mo. volume, extra cloth, of 238 pages.
LA ROCHE (R.), M. D.—Pneumonia; its Supposed Connection, Pathological and Etiological,
  with Autumnal Fevers, including an Inquiry into the Existence and Morbid Agency of
  Malaria.  In one handsome octavo volume, extra cloth, of 500 pages.  (Now Ready.)
LONGET (F. A.)—Treatise on Physiology.  With numerous Illustrations.  Translated from
  the French by F. G. Smith, M. D., Professor of Institutes of Medicine in the Pennsylvania
  Medical College.  (Preparing.)
LAWRENCE (W.), F.R.S.—A Treatise on Diseases of the Eye.  A new edition, edited, with
  numerous Additions, and  243 Illustrations, by Isaac Hays, M. D., Surgeon to Wills' Hos-
i  pital, &c. In one very large and handsome octavo volume, of 950 pages, strongly bound
  in leather, with raised bands.  (Now Ready.)
  This work is thoroughly revised, and brought up to 1854.
LAWRENCE (W.), F.R.S. —A Treatise on Ruptures.  From the fifth London edition.  In
  one octavo volume, sheep, 480 pages.
 LISTON (ROBERT), F. R. S. —Lectures on the Operations of Surgery, and on Diseases and
   Accidents requiring Operations.  Edited, with numerous Additions and Alterations, hy
'  T. D. Mutter, M.D.  In one large and handsome octavo volume, of 566 pages, with'216
   wood-cuts. 
6           BLANCHARD &  LEA'S  MEDICAL PUBLICATIONS.
LALLEMAND (M.).—The Causes, Symptoms, and Treatment of Spermatorrhoea.  Translated
  and edited by Henry J. McDougal.  In one volume, octavo, of 320 pages.  Second Ame-
  rican edition.  (Now Ready.)
LARDNER (DIONYSIUS),  D.C.L.—Handbooks of Natural Philosophy and  Astronomy.
  Revised, with numerous Additions, by the American editor.  First Course, containing
  Mechanics, Hydrostatics, Hydraulics, Pneumatics, Sound, and Optics.  In one large royal
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MEIGS (CHARLES D.), M.D.—Woman: iter Diseases and their Remedies.  A Scries of Lec-
  tures to his Class.  Third and improved edition.  In one large  and beautifully-printed
  octavo volume.  (Just Ready.  Revised and enlarged to 1854.)
MEIGS  (CHARLES D.), M. D. — Obstetrics : the  Science and the  Art.   Second edition,
  revised and improved.  With 131 illustrations. In one beautifully-printed octavo volume,
  of 752 large pages.  (Lately Puolislied.)
MEIGS (CHARLES D.), M. D. — A Treatise on Acute and Chronic Diseases of the Neck of
  the Uterus.  With numerous plates, drawn and colored from nature, in the highest style
  of art.  In one handsome octavo volume, extra cloth.  (Nino Ready.)
MEIGS (CHARLES D.), M.D— Observations on Certain of the Diseases of Young Children.
  In one handsome octavo volume, of 214 pages.
MEIGS (CHARLES D.), M. D.—On the Nature, Signs, and Treatment of Puerperal Fever.
  In one handsome octavo volume.   (In Press.)
MILLER (JAMES), F.R.S.E.—Principles of Surgery.  Third American, from the second and
  revised Edinburgh  edition.  Revised, with Additions, by F. W. Sargent, MJD., author of
  "Minor Surgery," &c.  In one large and very beautiful volume, of 752 pages, with 240
  exquisite illustrations on wood.
MILLER (JAMES), F.R.S.E.—The Practice of Surgery.  Third American, from the second
  Edinburgh edition.  Edited, with Additions, by F. W. Sargent, M. D., one  of the Surgeons
  to Wills' Hospital, Ac.  Illustrated by 319 engravings on wood.  In one  large octavo
  volume, of over 700 pages.
MALGAIGNE (J. F.). — Operative Surgery, based on Normal and Pathological Anatomy.
  Translated from the French, by Frederick Brittan, A. B., M. D.  With numerous illustra-
  tions on wood.  In one handsome octavo volume, of nearly 600 pages.
MOHR (FRANCIS), Ph. D., AND REDWOOD (THEOPHILUS).—Practical Pharmacy.  Com-
  prising the Arrangements, Apparatus, and Manipulations of the  Pharmaceutical Shop
  and Laboratory.  Edited, with extensive Additions, by Prof. William Procter, of the Phi-
  ladelphia College of Pharmacy.  In one handsomely-printed octavo volume, of 570 pages,
  with over 500 engravings on wood.
MACLT3E (JOSEPH).—Surgical Anatomy.  Forming one volume, very large imperial quarto.
  With  sixtv-eight large and splendid Plates, drawn in the best style, and beautifully
  colored. Containing 190 Figures, many of them the size of life.  Together with copious
  and explanatory letter-press.  Strongly and handsomely bound in extra cloth, being one
  of the cheapest and best executed Surgical works as yet issued in this country.
            Copies can be gent by mail, in five parts, done up in stout covers. 
BLANCHARD & LEA'S MEDICAL PUBLICATIONS.           8
MAYNE  (JOHN), M. D. — A Dispensatory and Therapeutical Remembrancer.  Comprising
  the entire lists of Materia Medica, with every Practical Formula contained in the three
  British Pharmacopoeias.  With relative Tables subjoined, illustrating, by upwards of six
  hundred  and sixty examples, the Extemporaneous Forms and Combinations suitable for
  the different Medicines. - Edited, with the addition of the Formulse of the United States
  Pharmacopoeia,  by R. Eglesfeld Griffith, M. D.  In one 12mo. volume, extra cloth, of over
  300 large pages.
MULLER (PROFESSOR J.), M. D. — Principles of Physics and Meteorology.  Edited, with
  Additions, by R. Eglesfeld Griffith, M. D.   In one large and handsome octavo volume,
  extra cloth, with 550 wood-cuts, and two colored plates.
NEILL (JOHN), M. D., AND FRANCIS GURNEY SMITH, M.D.—An Analytical Compendium
  of the Various Branches of Medical Science; for the Use and examination of Students.
  Second  edition, revised and improved.  In one very large and handsomely-printed royal
  12mo. volume, of over 1000 pages, with 350  illustrations on wood.  Strongly bound in
  leather, with raised balids.
NELIGAN (J. MOORE), M.D.—A Practical Treatise on Diseases of the Skin.  In one neat
  royal 12mo. volume, of 334 pages.
OWEN (PROF. R.). — On the Different Forms of the Skeleton.  One royal 12mo. volume,
  with numerous illustrations.   (Now Ready.)
PHILLIPS (BENJAMIN), F.R.S. — Scrofula ; its Nature, its Prevalence, its Causes, and the
  Principles of its Treatment. In one volume, octavo, with a plate.
PANCOAST (J.), M.D. — Operative Surgery; or, A Description and Demonstration of the
  various Processes of the Art; including all the New Operations, and exhibiting the state
  of Surgical Science in its present advanced condition.  Complete in one royal 4to. volume,
  of 380 pages of letter-press description, and eighty large 4to. plates, comprising 486  illus-
  trations.  Second edition, improved.
  Blanchard & Lea having become the publishers of this important book, have much plear
sure in offering it to the profession.


PARKER (LANGSTON).—The Modern Treatment of Syphilitic Diseases, both Primary and
  Secondary;  comprising the Treatment of Constitutional and Confirmed Syphilis, by a safe
  and successful method.  With  numerous  Cases, Formulae, and Clinical Observations.
  From the third and entirely rewritten  London edition.   In one neat octavo volume.
  (Now Ready.)


PEREIRA (JONATHAN), M.D.—The Elements of Materia Medica and Therapeutics.  Third
  American edition, enlarged and improved by the author; including Notices of most of the
  Medical Substances in use in the civilized world, and forming an Encyclopaedia of Materia
  Medica. Edited, with Additions, by Joseph Carson, M. D., Professor of Materia Medica and
  Pharmacy in the University of Pennsylvania.  In two very large octavo volumes of 2100
  pages, on small type, with over 450 illustrations.  (Now Complete.)
Volume I.—Lately issued, containing the Inorganic Materia Medica, over 800 pages, with 145
  illustrations.                               .„,.,,,.      j *             ,
Volume II. —Now ready, embraces  the Organic Materia Medica,  and forms a very large
  octavo volume of 1250 pages, with two plates, and 300 handsome wood-cuts.
PEASELEE (E. R,), M.D— Human Histology, in its Applications to Physiology and General
  Pathology, designed  as a Text-book for Medical Students.  With numerous illustrations.
  In one handsome royal 12mo. volume.  (Preparing.)


PIRRIE fWILLTVM) F. R. S. E— The Principles and Practice of Surgery.  Edited by John
  Neill  M D., Demonstrator of Anatomy in the University of Pennsylvania, Surgeon to the
  Pennsylvania Hospital, &c.  In one very handsome octavo volume, of 780 pages, with 316
  illustrations.  (Just Issued.)

RAMSBOTHVM (FRWCIS II). M. P.—The  Principles and Practice of Obstetric Medicine
  a^d Surgfry, in reference to the Process of Parturition.  Sixth American, from the last
  London edition.  Illustrated .with 14S Figures, on  fifty-five Plates.  In one large  and
  handsomely-printed volume, imperial octavo, with 520 pages. 
K)         BLANCHARD & LEA'S MEDICAL PUBLICATIONS.
RICORD (P.), M.D.—Illustrations of Syphilitic Disease.  Translated from the French, by
  Thomas F. Betton, M. D. With the addition of a History of Syphilis, and a complete Bibli-
  ography and Formulary of Remedies, collated and arranged by Paul B. Goddard, M. D.
  With fifty large quarto plates, comprising 117 beautifully-colored illustrations.  In one
  large and handsome quarto volume.
RICORD (P.), M. D. —A Treatise on toe Venereal Disease.  By John Hunter, F. R. S.  With
  copious Additions, by Ph. Ricord,  M. D.  Edited, with Notes, by Freeman J. Bumstead,
  M.D.  In one handsome octavo volume, with plates.  (Now Ready.)
RICORD (P.), M. D. — Letters on Syphilis, addressed to the Chief Editor of the Union Mcdi-
  cale.  With an Introduction, by Amedee Latour.  Translated by W. P. Lattimore, M. D.
  In one neat octavo volume.
RICORD (P.), M.D. — A Practical Treatise on Venereal Diseases.  With a Therapeutical
  Summary and Special Formulary.  Translated by Sidney Doane, M. D. Fourth edition.
  One volume, octavo, 340 pages.
RIGBY (EDWARD), M.D. —A System of Midwifery.  With Notes and Additional Illustra-
  tions.  Second American Edition. One volume, octavo, 422 pages.
ROYLE (J. FORBES), M. D.—Materia Medica and Therapeutics; including the Preparations
  of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States.  With
  many new medicines. Edited by Joseph Carson, M. D., Professor of Materia Medica and
  Pharmacy in the University of Pennsylvania. With ninety-eight illustrations.  In one
  large octavo volume, of about 700 pages.
SKEY (FREDERICK C), F.R.S.  Operative Surgery. In one very handsome octavo volume
  of over 650 pages, with about 100 wood-cuts.
SHARPEY (WILLIAM), M.D., JONES QUAIN, M.D., AND RICHARD QUAIN, F.R.S., Ac-
  Human Anatomy.  Revised, with Notes and Additions, by Joseph Leidy, M. D.  Complete
  in two large octavo volumes, of about 1300 pages.  Beautifully illustrated with over 500
  engravings on wood.
SMITH (HENRY H.), M. D., AND WILLIAM E. HORNER, M. D. — An Anatomical Atlas
  illustrative of the Structure of the Human Body.  In one volume, large imperial octavo,
  with about 650 beautiful figures.
SARGENT (F. W.), M. D.—On Bandaging and other Points of Minor Surgery.  In one hand-
  some royal 12mo. volume of nearly 400 pages, with 128 wood-cuts.
STANLEY (EDWARD).—A Treatise on Diseases of the Bones.  In one volume, octavo,
  extra cloth, 286 pages.
STILLlS (ALFRED), M.D. —Principles of Therapeutics. In one handsome volume.  (l\e-
 paring.)
SIMON (JOHN), F.R.S.—General Pathology, as conducive to the Establishment of Rational
  Principles for the Prevention and Cure of Disease.   A Course of Lectures delivered at St.
  Thomas's Hospital during the summer Session of 1850.  In one  neat octavo volume.
  (Lately Issued.)
SMITH (TYLER W.), M.D.—On Parturition, and the Principles and Practice or Obstetrics.
  In one large duodecimo volume, of 400 pages.
gIBSON (FRANCIS), M. D. — Medical Anatomy. Illustrating the Form, Structure, and Po-
  sition of  the Internal Organs in Health and Disease.  In'large imperial quarto, with
  splendid colored plate3.  To match " Maclise's Surgical Anatomy."  (Preparing.) 
BLANCHARD & LEA'S  MEDICAL PUBLICATIONS.          11
SOLLY (SAMUEL), F.R.S. —The Human Brain; its Structure, Physiology, and Diseases.
  With a Description of the Typical Forms of the Brain in the Animal Kingdom. From the
  Second and much enlarged London edition.  In one octavo volume, with 120 wood-cuts.
SCHOSDLER (FRIEDRICH), Ph. D.—The Book of Nature; an Elementary Introduction to
  the Sciences of Physics, Astronomy, Chemistry, Mineralogy, Geology, Botany, Zoology, and
  Physiology.  First American edition, with a Glossary and other Additions and Improve-
  ments; from the second English, edition.  Translated from the sixth  German  edition, by
  Henry Medlock,  F.C.S., &c.  In one thick volume, small octavo, of about 700 pages, with
  679 illustrations on wood.  Suitable for the higher schools  and private students.  (Now
  Ready.)
TAYLOR (ALFRED S.), M. D., F.R.S.—Medical Jurisprudence.  Third American, from the
  fourth and improved English edition.  With Notes and References to American Decisions,
  by Edward Hartshome, M.D.  In one large octavo volume, of about 700 pages. (Just Issued.)
TAYLOR (ALFRED-S.), M. D.—On Poisons, in Relation to Medical Jurisprudence and Medi-
  cine.  Edited, with Notes and Additions, by It. E. Griffith, M.D.  In one large octavo
  volume, of 688 pages.
THOMSON (A. T.), M. D. — Domestic Management of the Sick-Room, necessary in aid of Me-
  dical Treatment for the Cure of Diseases.  Edited by R. E. Griffith, M. D.  In one large
  royal 12mo. volume, with wood-cuts; 360 pages.
TOMES (JOHN), F.R.S.—A Manual of Dental Practice. Hlustrated by numerous engravings
  on wood.  In one handsome volume.  (Preparing.)
TODD (R. B.), M.D., AND WILLIAM BOWMAN, F.R.S. — Physiological Anatomy and Physi-
  ology of Man. With numerous handsome wood-cuts.  Parts I., II., and III., in one octavo
  volume,  552 pages.  Part IV. will complete the work.
WATSON  (THOMAS),  M.D.,  &c. — Lectures on the  Principles and Pfactice of Physic.
  Third American,  from the  last London edition.   Revised, with Additions, by D. Francis
  Condie, M.D.,  author of  a  "Treatise on the Diseases of Children," &c. In  one octavo
  volume, of nearly 1100 large pages, strongly bound, with raised bands.
WALSHE  (W. n.), M. D.—Diseases of the Heart, Lungs, and Appendages; their Symptoms
  and Treatment.  In one handsome volume, large royal 12mo., 512 pages.
What to Observe at the Bedside and after Death, in Medical Cases.  Published under the
  authority of the London Society for Medical Observation.  In one very handsome volume,
  royal 12mo., extra cloth.  (Just Issued.)
WILDE (W. R.).—Aural Surgery, and the Nature and Treatment of Diseases of the Ear.
  In one handsome octavo volume, with illustrations.  (Now Ready.)
WHITEHEAD (JAMES), F.R.C. S., Ac.— The Causes and Treatment of Abortion and Ste-
  rility; being the Result of an Extended Practical Inquiry into the Physiological and
  Morbid Conditions of the Uterus.  Second American Edition.  In one volume, octavo, 368
  pages.  (Now Ready.)
WEST  (CHARLES), M.D.—Lectures on the Diseases of Infancy and Childhood.  Second
  American, from the second and enlarged London edition.  In one volume, octavo, of nearly
  500 pages. (Now Ready.) 
12          BLANCHARD & LEA'S MEDICAL PUBLICATIONS.
WEST (CHARLES), M. D.—An Inquiry into the Pathological Importance of Ulceration of
  the Os Uteri. Being the Croonian Lectures for the year 1854.  In one neat octavo volume,
  extra cloth.  (In Press.)
WILSON (ERASMUS), M.D., F.R.S. —A System !of Human Anatomy, General and Special.
  Fourth American, from the last English edition.  Edited by Paul B. Goddard, A. M., M. D.
  With 250 iUustrations. Beautifully printed, in one large octavo volume, of nearly 600 pages.
WILSON (ERASMUS), M.D., F.R.S. —The Dissector; or, Practical and Surgical Anatomy.
  Modified and Rearranged, by Paul Beck Goddard, M.D.  A new edition, with Revisions and
  Additions.  In one large and handsome volume, royal 12mo., with 115 illustrations.
WILSON (ERASMUS), M.D., F.R.S.—On Diseases or the Skin.  Third American, from the
  third London edition.  In one neat octavo volume, of about 500 pages, extra cloth.  (Just
  Issued.)
Also, to be had done up with fifteen beautiful steel plates, of which  eight are  exquisitely
  colored; representing the Normal and Pathological Anatomy of the Skin, together with
  accurately-colored delineations of more than sixty varieties of disease, most of them the
  size of nature.  The Plates are also for sale separate, done up in boards.
WILSON (ERASMUS), M. D., F. R. S. — On Constitutional and Hereditary Syphilis, and on
  Syphilitic Eruptions.  In ono small octavo volume, beautifully printed, with four exqui-
  site colored plates, presenting more than thirty varieties of Syphilitic Eruptions.
WILSON (ERASMUS), M. D., F.R. S—Healthy Skin; a Treatise on the Management of the
  Skin and Hair in Relation to Health.  Second American, from  the fourth and improved
  London edition.  In one handsome royal 12mo. volume, extra cloth, with numerous illus-
  trations.  Copies may also be had in paper covers, for mailing, price 75 cents. (Now Ready.)
WILLIAMS (C. J. B.), M.D., F.R.S.—Principles of Medicine; comprising General Pathology
  and Therapeutics, and a brief general view of Etiology, Nosology, Semeiology, Diagnosis,
  Prognosis, and Hygienics. Edited,  with Additions, by Meredith Clymer, M.D.  Fourth
  American, from the last and enlarged London edition. In one octavo volume, of 476 pages.
  (Now Ready.)
WILLIAMS  (C. J. B.), M. D., F.R.S.—A Practical Treatise on Diseases of the Respiratory
  Organs; including Diseases of the Larynx, Trachea, Lungs, and Pleura?.  With numerous
  Additions and Notes, by M. Clymer, M.D.  With wood-cuts. In one octavo volume, pp. 508.
YOU ATT (WILLIAM), V.S. —The Horse.  A new edition, with numerous  illustrations;
  together with a General History of the Horse; a Dissertation on the American Trotting
  Horse; how Trained and Jockeyed; an Account of his Remarkable  Performances; and an
  Essay on the Ass and the Mule.  By J. S. Skinner, formerly Assistant Postmaster-General,
  and Editor of the Turf Register.  One large octavo volume.
YOUATT (WILLIAM), V. S.—The Dcg.  Edited by E. J. Lewis, M. D.  With numerous and
  beautiful illustrations.  In one very handsome volume, crown 8vo., crimson cloth, gilt.
  Blancbard A Lea have now ready a detailed Catalogue of their publications, in Medical and
other Sciences, with Specimens of the Wood-engravings, Notices of the Press, Ac. Ac, forming
a pamphlet of sixty-four large octavo pages. It has been prepared without regard to expense,
and may be considered as one of the handsomest specimens of printing as yet executed in
this country.  Copies will be sent free, by post, on receipt of two three-cent postage stamps.
  Detailed Catalogues of their  publications, Miscellaneous, Educational,  Medical, Ac, fur-
nished gratis, on application. 
 
 
 
 
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