CONTRIBUTIONS TO DERMATOLOGY.  
CONTRIBUTIONS TO DERMATOLOGY : 
ECZEMA. IMPETIGO, SCABIES, 
ECTHYMA, KUPIA, LUPUS. 
By Silas Durkee, M.D., 
C ONSULTING PHYSICIAN OF THE BOSTON CITY HOSPITAL. ETC., ETC 
SECOND EDITION, 
BOSTON: 
JAMES CAMPBELL, PUBLISHER, 
18 Tkkmont Street. 
1870. INDEX. 
ECZEMA. 
Has three well marked stages ......... 1 
These may be present at the same time ....... 2 
Eczema in children .......... 2 
Character of the vesicles .......... 2 
Comparative frequency of the disease ........ 3 
Most frequent locality .......... 3 
Usual time of its first appearance ......... 3 
Barely occasions permanent modification of the skin ..... 4 
Danger from too suddenly arresting the serous discharge ..... 4 
Views of different recent authors on the subject ...... 5 
The eruption prone to chronicity ........ 7 
Varieties of Eczema .......... 7 
Eczema infantile usually hereditary .......* 8 
Dentition and vaccination, sometimes exciting causes ..... '9 
Other exciting causes .......... 9 
Is Eczema ever contagious ? . , . . . . . 19 
Treatment of Eczema in infants ......... 10 
Eczema in the adult ......... 18 
Leading principles of treatment ......... 19 
Local treatment .......... 21 
Eczema of the eye-lids .......... 23 
Eczema of the legs 25 
Eczema mercuriale ........... 27 
Eczema mercuriale; treatment ........ 28 
IMPETIGO. 
Description of the eruption ......... 29 
Its most frequent localities ......... 29 
Is sometimes mistaken for favus ......... 30 
Impetigo sparsa .......... 31 
Impetigo of the face .......... 32 
Impetigo of the upper lip ........ 35 
Impetigo of legs and thighs ......... 35 
Impetigo acniforme of Hardy and Fox ....... 36 
Distinctive characters of Impetigo ........ 37 
May be mistaken for Scabies ........ 37 
Treatment of infantile impetigo ......... 38 
Treatment of Impetigo in the adult ....... 
SCABIES. 
Exists among all classes . . . . . • ■ • • 44 
In nearly all parts of the skin ........ 45 
The itch insect and burrows, or cuniculi ....... 4;> 
Ova of the female acarus .....»*•* 48 IV 
INDEX. 
Diagnosis of Scabies . . , o 
Sometimes confounded with Eczema, &c. 49 
Extracting the Acarus ■ 50 
Scabies exhibits different appearances in different regions .... 50 
Treatment of Scabies gj 
ECTHYMA. 
Its characteristics ......... 
Acute Ecthyma ......... gg 
Eayer’s description ......... 55 
Chronic Ecthyma ......... 
Causes ...... 
. ••••.... 56 
Diagnosis ......... g^ 
Treatment ••■••..... 57 
EUPIA. ’ 
Is nearly allied to Ecthyma ....... g„ 
Two varieties: simplex and prominens ...... 59 
Syphilis a frequent cause 02 
Diagnosis ’ 62 
Treatment of Eupia ••..... ' 02 
LUPUS. 
What is Lupus ? 0.3 
Is confined to no age or sex 
Presents three different forms or varieties . . . . . . ’ g3 
Distinctive features of each ■•••... 04 
Pathology of Lupus 69 
Causes 
Treatment CONTRIBUTIONS TO DERMATOLOGY, 
Eczema. 
A discrepancy of views has recently sprung up among dermatolo- 
gists with regard to the position which this cutaneous affection should 
occupy. If its elementary type is selected as our guide, its general 
claims to be considered a vesicular lesion admits of no rational 
doubt. It is true that the original pimple, in some very mild cases, 
does not advance to the size and maturity of a perfect vesicle, as 
exhibited in ordinary examples of eczema. There is an arrest of 
development, and the eruption simulates lichen. In such instances, 
it is usually disseminated sparsely along the dorsal aspect of the 
forearm, on the neck, chest, &c. To the unaided eye of the observer 
there is perhaps no evidence that it is anything more or less than 
a true lichen; whereas, if these doubtful specimens are punctured 
with the point of a needle or lancet, their watery contents will fre- 
quently follow the operation, and thus afford ocular demonstration 
that the eruption is vesicular. But if they yield no serous fluid, they 
are only exceptional cases, and do not militate against the views of 
those who consider a vesicle to be the characteristic mark of the 
primary lesion of the disease under consideration. Occasionally, 
eczema is complicated by lichen, and hence we have an eczema lichen- 
oides or lichen eczematodes, in which the characters of the two erup- 
tions are blended together—vesicles and papules. 
Eczema usually exhibits three different and well-marked stages in 
its history. The first is that of erythematous inflammation, more or 
less severe, with the superaddition of vesicles; the second consists 
in the formation of thin, yellow, superficial incrustations, formed in 
consequence of the bursting of the vesicles and the drying up of 
their contents, which occupy the adjacent excoriated and exudative 
surfaces; in the third, these incrustations disappear, the inflammatory 
1 2 
CONTRIBUTIONS TO DERMATOLOGY. 
action subsides, and the affected integument is covered with scales, 
resembling in character those of ordinary healthy epidermis. All 
these different stages may be present at the same time on the same 
person—the eruption commencing in one spot, while in another it has 
passed through its several phases and nearly disappeared. 
Without invalidating the above remark with regard to the differ- 
ent stages of the disease, it may be stated in this connection that in- 
dividual cases occur which show that the period during which vesi- 
cles continue to be developed is extremely variable—sometimes last- 
ing only a day or two, while in other instances it is prolonged by the 
occasional appearance of a few vesicles throughout the whole course 
of the eruption. 
Although this eruption has the same starting points in the very 
young and in the adult subject, yet its physiognomy in the former dif- 
fers somewhat from the features which characterize it in the latter. 
In the infant, its simplest type commences with small, slightly raised 
vesicles, sometimes closely crowded together and sometimes isolated. 
In a few hours, these vesicles become more prominent and transpa- 
rent, and are free from any well-marked inflammation or redness at 
their base. In four or five days, more or less, they burst, and a dis- 
charge of a serous, limpid fluid is poured out upon the adjacent skin. 
Anon the discharge becomes turbid and less copious; the ruptured 
vesicles dry up; and, to an observer not entirely familiar with the 
natural history of the eruption, it might seem that it was at an end. 
Instances of this kind do occasionally present themselves, but, in a 
great majority of cases, the malady is of a much more serious and 
persistent form. Successive crops of vesicles arise; the adjacent 
integument is inflamed, and the serous exudation desiccates into yel- 
lowish laminae, which adhere closely to the subjacent tissue. The erup- 
tion may be quite circumscribed, and occupy but a very limited portion 
of skin, as, for instance, the summit of the scalp, or about the ears, 
the face, the arms, the hands or feet; or it may cover the entire sur- 
face of the body and limbs, and maintain its hold upon the little suffer- 
er for several months, with repeated alternations of transitory amend- 
ment and relapse, whatever remedial measures may be used for its 
radical and perfect cure. But although with regard to its obstinacy 
and chronicity it may not be unlike what we meet with in the adult, yet 
Eczema in Children. ECZEMA IN CHILDREN. 
3 
the diseased skin of the infant with this complaint never presents 
that thickened, hard, cedematous, infiltrated, furfuraceous condition so 
common in chronic eczema in persons of mature life. The most ex- 
traordinary examples of the abnormal features here spoken of are 
to be found in aged people, especially when the morbid action has 
implanted itself on the lower limbs. These remarkable transforma- 
tions of the cutaneous membrane, which every physician must often 
have seen in individuals of advanced age, are but the ulterior expres- 
sion of the same diathesis which exists in the infant during the pe- 
riod of lactation, and which manifests its initial presence in a super- 
ficial group of acuminate vesicles. The contrast is indeed great, and 
the medical philosopher finds in it a theme for profound study. 
Of all the diseases that invade the human skin, eczema consti- 
tutes more than one third; and in children the hairy scalp is its most 
frequent locality. Perhaps, for all practical purposes, it will be suf- 
ficient to consider the eruption under two principal varieties or forms, 
namely, the acute and the chronic. These terms are easily under- 
stood ; and, by employing them, all danger of confusion, misappre- 
hension and obscurity of language is avoided. It generally makes 
its first appearance in the young subject at about the fifth or sixth 
month, that is, the period of the first dentition; sometimes much ear- 
lier. It breaks forth without any premonitory symptoms, except, 
perhaps, a slight itching of the parts. The vesicles burst about the 
fourth or fifth day of their evolution, and if the scalp is the part im- 
plicated, the hairs become agglutinated; and as the semi-opaque se- 
cretion from the ruptured vesicles continues to flow over the surface, 
which soon becomes inflamed and irritated, soft, small incrustations 
are produced. There is now considerable heat and redness in the 
parts. The foetid serosity oozes out almost constantly from beneath 
the incrustations; and when these are removed the surface is found 
,to be inflamed, and from the open pores, on the site of the ruptured 
vesicles, the acrid secretions can be plainly seen to escape. The in- 
crustations are reproduced in quick succession. They are irregular 
in outline, and are sometimes lamellar and imbricated, sometimes 
thin and soft, sometimes depressed, unequal, smooth, or rugous, and 
are usually moistened by the viscid secretion to which their formation 
is due. 
Throughout all the active stages of the disease there is violent itch- 
ing, which is apt to be more intense during the hours usually allotted 4 
CONTRIBUTIONS TO DERMATOLOGY. 
to sleep than at any other time. The child scratches itself with a ve- 
hemence which it is distressing to witness. It forces its nails into 
the affected skin and tears off the cuticle in every direction; and, 
as a consequence, it is no uncommon thing to see the blood and se- 
rum trickling down along the lacerations thus produced—and for 
the time being we have no means of appeasing the irritation and 
suffering. 
It is a singular fact that, notwithstanding the severity of the com- 
plaint in children, it is seldom that it produces any permanent modi- 
fication of the normal structure, such as baldness of the scalp, or 
cicatrices in other portions of the cutaneous integument; whereas, in 
the adult, it is not uncommon to meet with alopecia, more or less ex- 
tensive, as one of the consequences of the disease. 
It has long been a popular tradition, and many learned practition- 
ers of the present day entertain the opinion, that, if the serous dis- 
charge of eczema is suddenly arrested, the brain or some other vital 
organ will be endangered and the life of the patient sacrificed. 
Other physicians reject this theory as being entirely fallacious. We 
once entertained the latter view of the subject, but as time has given 
us more extended opportunities for clinical observation, we have 
found occasion to modify somewhat our former views. If the excre- 
mentitious matter of eczema and other exudative eruptions in a 
young child is profuse, and has continued for some months, and is 
suddenly arrested, either spontaneously or through remedial mea- 
sures, the result may be prejudicial to the welfare of the patient; 
more especially if the scalp is the seat of the eruption. In the adult 
subject there is little or no danger from a repulsion of the eruption. 
But with children, in whom a slight disturbing cause is not unfre- 
quently productive of serious mischief, the case is quite otherwise, 
as clinical facts bear witness. Whoever has had much practical ex- 
perience in the management of children suffering with the disease 
under consideration, cannot have failed to observe instances where the 
exudation has suddenly stopped, and the general condition of the patient 
has been thereby apparently rendered more uncomfortable and unsatis- 
factory. Mothers and nurses not unfrequently report that when the 
eruption has become crustaceous and dries up rapidly, the child 
seems to lose appetite, is more restless and feverish, and that the 
normal organic functions are performed with less regularity than 
when there is a free discharge; and one can hardly resist the conclu- ECZEMA IN CHILDREN. 
5 
sion that this discharge seems to act, for the time being, as a safety- 
valve to the system. The danger produced by the too sudden arrest 
of the secretion is rendered still more apparent by the fatal cases 
recorded by different authors. M. Caillault,* an excellent French 
writer, relates the case of a child two years of age, which suffered 
for many months from a vesicular eruption “ in a very high degree.” 
The health was good, the external aspect, excepting the eruption, 
was highly satisfactory. Topical applications of the oil of cade 
were prescribed, with the caution that it should only be applied to a 
small surface at once, so that the cure might progress gradually. 
The nurse, in her misplaced zeal, covered with it the whole face and 
a portion of the scalp. Twenty-four hours after the sudden stop- 
page of the abundant secretion, the child was attacked with catar- 
rhal pneumonia, so rapid in its progress that nothing could check it. 
M. Brequet has witnessed an analogous case, in which death superven- 
ed from a cerebral affection. Recently there was in one of the wards 
of the Hospital for Sick Children, under the care of M. See, of Paris, 
a boy six years of age, with a dartrous affection of the face; every 
time the eruption disappeared, the patient was seized with a violent 
attack of asthma. Such cases as these are doubtless rare, and we 
would not by any means attempt to magnify their importance in con- 
nection with the subject before us; nevertheless we may find in them, 
and in other instances of less gravity, sufficient grounds for cautious 
therapeutic measures in our dealings with the disease in question. 
Dr. McCall Anderson says:—“ I have rarely witnessed any bad 
effect even from the rapid removal of the disease. That deleterious 
effects are occasionally witnessed, however, I am quite prepared to 
allow.”—Page 45. 
Burgess, in his “ Treatise on Eruptions of the Face, Head and 
Hands,” remarks :—“ It should be borne in mind that in children 
particularly, eczema of the face and head is often a salutary dis- 
charge, which it is dangerous to heal suddenly.”—Page 33. 
There exist in science so many facts of this kind, which have been 
collected by practitioners of every period, and which, consequently, 
are above any suspicion of preconceived theory, that it is impossible 
not to admit the relation of cause and effect between the sudden 
stoppage of the plastic exudation and the production of various dis- 
* Diseases of the Skin in Children. 6 
CONTRIBUTIONS TO DERMATOLOGY. 
eases which suddenly appear. Moreover, both physiology and pa- 
thology can account for facts of this kind.—M. Caillault, p. 57, 
2d English Edition. 
It is not difficult to discover in the premises a sort of quasi-physi- 
ological function which may not be rudely assailed with impunity; 
we likewise perceive, as we do in measles, scarlatina, urethritis, pa- 
rotitis, &c., certain relations of equilibrium and bonds of sympathy 
between different organs and tissues, which, although not always 
well understood, we know to exist both in health and disease. 
In spite of the best treatment that can be adopted, eczema is ex- 
ceedingly prone to pass into a chronic state, and to be prolonged for 
many months or even year after year, with only occasional exemp- 
tions from any actual manifestations of its presence. Each season 
of truce is interpreted by the immediate friends of the child as in- 
dicative of the final subsidence of the malady; but not many months 
pass before there is a renewed attack, and a very remarkable morbid 
condition ensues. 
We will assume now that the eruption has become chronic. The 
observer notices, at a glance, that it presents a variety of aspects; 
and the several anatomico-pathological elements which appear 
simultaneously on different parts of the surface offer no little em- 
barrassment to his judgment, as to the appropriate nosological posi- 
tion in which the eruption should be placed; for, taken as a whole, 
it consists, so to speak, of a heterogeneous multiform character 
which seems to be unconformable to any exact and classical nomen- 
clature of the dermatologists. For instance, the physician is called 
for the first time to see a young child which has had for some weeks 
a cutaneous eruption, commencing with a small circumscribed blotch 
of pimples, causing but little disturbance at first, but soon augment- 
ing in size, becoming vesicular, itchy, and yielding an ichorous dis- 
charge which irritates the neighboring skin, which in turn takes on 
a similar action; and thus the local disease spreads in all directions. 
From the account given by the nurse of the development of the dis- 
ease, it is evident that its primal type was eczema papulosum; but 
it is seldom that eczema presents the simple attributes here enume- 
rated, or that it can be represented by one single term; and accord- 
ingly, in the case supposed, the physician finds that different portions 
of the skin are occupied by eruptions which are seemingly different 
as elementary lesions; and it is only by patient study of these ECZEMA IN CHILDREN. 
7 
several existing forms or varieties that any embarrassment or con- 
fusion of judgment can be cleared up, and that he can be reconciled 
to the theory and the fact that each one of the different phases of 
the eruption in the case before him is to be regarded as a true 
representative of eczema. They simply constitute the several pa- 
thological conditions of the skin arising during the progress of the 
disease; and they fully justify the appellations which the ablest 
writers on cutaneous pathology have employed, but which to the 
general practitioner may sometimes appear superfluous and obscure. 
But let us look at the supposed case before us more minutely. The 
eruption is general. Its leading feature in one place is extreme 
redness. This is a specimen of eczema erythematosum. In another 
portion of the skin, it is raised into little papules as a leading mark. 
Here the case is an eczema papulosum. In another part of the skin, 
vesicles constitute the prominent sign or condition, and we have an 
example of eczema vesiculosum. In still another region, the exuda- 
tion may be excessive and constitute a leading feature, and then we 
have an eczema ichorosum. If pustules are scattered here and there 
within the precincts of the diseased surface, as is very frequently the 
case, then eczema pustulosum or impetiginodes is the appropriate 
name. If the morbid action has continued a long time, and a dry, 
scaly condition of the epiderm is a chief characteristic, then it is an 
eczema squamosum. When this last named variety is seated on the 
scalp, the hairs are frequently enclosed in the glossy, thick, silvery 
scales throughout their whole length, at the same time forming them 
into little delicate meshes; and this condition led Alibert to com- 
pare it to asbestos, and is described by him under the name of 
porrigine amiantacee. Chronieity is one of its most constant and 
undesirable attributes. It has sometimes been mistaken for pityria- 
sis, and it is by no means always easy to point out the difference. 
There is, however, a difference.* The scales of the former are thicker 
than those of the latter. They have always been preceded by a 
more or less humid condition of the scalp; whereas this is not the 
case with pityriasis, which is a strictly squamous affection from the 
beginning. The scales in pityriasis are also thinner, drier, and 
more adherent than those of eczema. 
Eczema squamosum usually appears at a later period of childhood 
than the other varieties; and is in reality but a sequel of some'other 
form of the eruption which has probably existed for a long time. 8 
CONTRIBUTIONS TO DERMATOLOGY. 
The different appearances presented by eczema in the course of its 
development and progress fully justify the names above given to its 
different forms. They show that the eruption undergoes several 
metamorphoses, but does not lose its identity; it is still eczema; 
and the idea that it has changed its character so as to be called with 
propriety by any other name, as impetigo, porrigo, tinea, psoriasis 
or pityriasis, is entirely erroneous. It seems unphilosopliical to hold 
that one disease can be converted into another, and yet Wilson leans 
to this view. 
Some dermatologists make still other varieties of eczema, accord- 
ing as it is partially developed in certain situations; so that we 
have, for instance, eczema capitis, eczema aurium, eczema palpebra- 
rum, eczema pudendi, eczema perinaei, eczema digitorum, eczema 
inguinum, &c. The foregoing varieties or divisions are appropriate 
ones, and, by adopting them, we avoid circumlocution. They might 
be extended still further, but perhaps those already given will suffice. 
In some quite severe and obstinate cases, where the child is na- 
turally robust and well cared for, the mucous membrane remains 
undisturbed; while in other cases the mucous lining of the nose, 
eyes, mouth, bronchial tubes, and alimentary canal affords unmis- 
takable evidence of participating to a greater or less degree with 
the cutaneous affection, in the excessive mucous or catarrhal dis- 
charges from these parts. The lymphatic cervical and axillary 
glands are generally swollen, and give rise to chronic adenitis 
which not unfrequently advances to suppuration. In not a few in- 
stances, especially among the poorer classes, where the child is 
subjected to unfavorable hygienic influences, there is evident mal- 
assimilation ,• the patient becomes anasmic, wastes away, the mus- 
cles become soft and flabby, and if the patient possesses a pyogenic 
diathesis, the deeper portions of the derma are engaged in the mor- 
bid processes. A low degree of inflammatory action sets in; and 
little abscesses form upon some portion of the scalp, about the ears, 
in the axillae, and on the hands, fingers, and toes; and the mother is 
in a state of anxiety, from the groundless apprehension that her 
offspring is the victim of that much abused malady—the scrofula. 
In a majority of cases of infantile eczema, the disease is traceable 
to hereditary predisposition. It is usually found, upon inquiry, that 
one or the other of the parents or grandparents has been affected 
with the complaint. Deficient lactation or bad milk will bring it ECZEMA IN CHILDREN. 
9 
out. This fact is not unfrequently illustrated where mothers have 
a deficiency of nourishment for their children, or foolishly insist upon 
nursing them for too long a time—some sixteen or twenty months. 
Dentition is sometimes an exciting cause; so also is vaccination; 
and physicians are thus wrongfully blamed for using impure matter, 
because as an occasional, but unavoidable sequel to vaccinia an 
eczematous eruption supervenes, especially in young children with 
an excessive lymphatic temperament. The eruption in these cases 
usually commences near the spot where the vaccine virus was in- 
serted ; but at other times at a distance, as on the head, nates, and 
genitals. The most trivial causes that disturb the normal processes 
of digestion and assimilation in the young infant are sometimes 
sufficient to induce the eruption; as, for instance, a chill or a little 
feverish attack of a day or two, or a sudden fright experienced by 
the nursing mother. 
Mothers and wet nurses, having the care of infants suffering from 
eczema, often put the question—is it contagious ? The attending 
physician should give a qualified answer. If the eruption, for in- 
stance, is on the face or head, and is accompanied for the time being 
with copious discharge, it is not strange that its irritating qualities 
should produce a similar eruption on the tender skin of the breast 
or arm of the nurse in suckling the child; or if she sleeps with it 
and it nestles up to her, as is usual, she is liable to be affected in 
like manner. But this liability is to be measured in part, at least, 
by the susceptibility of the exposed person. Considering the patho- 
logical condition of the child, and its relations to the nurse under 
these circumstances as a source of injury or poison, we are reminded 
of what may happen when one comes in contact with the poison 
oak (Rhus toxicodendron). In some individuals of peculiarly deli- 
cate skin, it is well known that handling the leaves of this shrub 
will produce itching, inflammation and vesicular eruptions, similar, 
although not identical with eczema; while other persons alike ex- 
posed do not suffer. In the case of the eczematous child, it is cer- 
tain that it can and does inoculate itself; and the same acrid dis- 
charge, when long or often in contact with the skin of a healthy per- 
son, may act as an irritant and produce an eruption. Such instances 
have transpired within our own knowledge; and it is presumed have 
been observed by the readers of this communication. And yet, in 
the ordinary sense of the word, eczema is not contagious. 10 
CONTRIBUTIONS TO DERMATOLOGY. 
When a physician is called to prescribe for a young child that is 
suffering from an attack of eczema, he is conscious that so far as re- 
lates to constitutional measures but little can be done. Yet that lit- 
tle may be of much importance to the future welfare of the child; 
and it requires the exercise of the highest medical talent to know 
just what to do, and what not to do. The disease is apparently 
purely local, but in reality it is not so. The blood, the nerves and 
their functions are more or less implicated. The pulmonary appara- 
tus and the intestinal canal may also be in an abnormal state; and 
although our chief reliance must be in the employment of topical 
remedies, it is the part of sound discretion to combine with it some 
general course of treatment as auxiliary. This course should be 
equally distant from all extremes of practice. In the first place, we 
should ascertain what is the exact condition of the child; whether 
the eruption is a sequel of any antecedent malady—as, for instance, 
scabies, as is sometimes the case; whether it is the result of some 
existing derangement of the stomach or bowels, or is connected with 
difficult dentition. If none of these things have induced the com- 
plaint, it should probably be considered as hereditary. If the child 
is robust and hearty, it will be advisable to prescribe an aperient 
every ten or twelve days, with a view to prevent all danger of trans- 
ferring the eruption—or, to speak more logically, for the purpose 
of preventing any vicarious action of the internal organs, while at 
the same time it will tend to give relief to the morbid condition of 
the skin. The kind of laxative best suited to the case will be a 
small quantity of fluid magnesia, or some thirty or forty drops of 
castor oil in as much lemon syrup, or simple syrup, in the early part 
of the day. In a child from six to twelve months old, one grain of 
calomel, with as much refined sugar, may be dropped upon the tongue. 
By thus producing a little extra activity of the alimentary canal oc- 
casionally, we avoid all danger in our attempts to suppress the cuta- 
neous discharge by the cautious employment of suitable astringent 
applications, even if the eruption has existed a long time and yields 
an abundant secretion. The effect of the laxative upon the general 
condition of the child should be carefully observed, and the fre- 
quency of its repetition and the period of its continuance be rcgula- 
Treatment of Eczema in Infants and Young Children. ECZEMA IN CHILDREN. 
11 
ted accordingly. It should be borne in mind that eczema, in all its 
stages and varieties, is an inflammatory affection, and the slight de- 
pletion produced by the internal medicines above suggested is a sani- 
tary measure which ought always to be employed for children of a 
full, gross habit. As regards the mercurial, we know with what re- 
markable ability they tolerate it, especially if they are endowed with 
a lymphatic temperament, and we find that children of this tempera- 
ment are more subject to eczema than others. They seem to pos- 
sess a more delicate skin. We apply the terms lymphatic tempera- 
ment, lymphatic constitution, lymphatic predominance, to children 
who are uncommonly fat and pale, and who, with softness and puffi- 
ness of the muscular tissue, together with atony of the general organ- 
ism, yet exhibit fair health and grow rapidly. We are aware that 
the word temperament, as applied to young subjects, is less definite 
and less marked than when we apply it to the adult; and yet we 
find that the best writers speak of the scrofulous, nervous, and other 
temperaments of children—and, in our daily professional intercourse, 
we do the same thing. But, at best, the language is somewhat vague. 
In addition to the occasional use of an aperient, it will be good 
practice to administer to the child the syrup of the iodide of iron. 
This will be especially called for, if the eczematous fluid continues 
to flow with unusual obstinacy, and the lymphatic glands are in a 
hypertrophied condition. The iron will give tone to the system in 
the most gentle manner, and without disturbing the stomach. The 
minimum dose to an infant of six to twelve months should be five min- 
ims thrice daily. It sometimes proves laxative, but when it does not 
operate on the bowels it augments the quantity of urine. Its effects 
should be carefully noted, and the daily quantity gradually increased 
to twenty-five or thirty minims, unless some circumstance should 
contra-indicate it. For a child from two to four years old, the usual 
dose may be from ten to fifteen minims three times a day. If severe 
pruritus should continue, and render the child feverish and fretful, a 
moderate looseness of the bowels, occasioned by the iron, will con- 
tribute to its relief. 
The above pharmaceutical remedies are about all that can be ad- 
dressed to the constitution, in the earlier period of the eruption, when 
it breaks out on a strong, robust child; but if it should be feeble, 
anaemic, and badly nourished, it would be injudicious to resort to the 
use of mercury, unless the bowels are much constipated, or the pul- 12 
CONTRIBUTIONS TO DERMATOLOGY. 
monary organs are in a state of congestion. Under such circum- 
stances, it may be given without hesitation. 
At a later period, when the eruption is assuming a chronic form, 
the question as to the expediency of resorting to some medicinal 
agent well known for its special therapeutic action on the diseased 
cutaneous membrane, naturally suggests itself to the medical attend- 
ant. We refer here to arsenic. Shall it be given to a young child? 
We are not ignorant of the dread which the name of this drug often 
inspires in the mind of a doting mother, for we have often been wit- 
ness of the fact. We have, nevertheless, in most instances where 
we have deemed its administration important, succeeded in gaining 
free consent for its use; and we have often prescribed it for young 
children not only with impunity, but with marked benefit. But the 
younger the child, the less its utility and the greater the danger. The 
conditions under which any form of arsenic should be administered 
may be summed up substantially thus. The patient should not be 
under one year old. There should be no functional disturbance of 
any of the internal organs, no inflammatory condition of the gastro- 
intestinal or pulmonary mucous membrane; the tongue clean, the 
digestion normal; no diarrhoea, no scrofulous diathesis apparent; 
little or no serous exudation from the eruption, but a scaly condition 
approximating that of pityriasis or psoriasis. Under these circum- 
stances, there can be no rational objection to the employment of 
arsenic, with a fair prospect that its curative effect will be displayed 
in a satisfactory manner, and the above are the limits within which 
its employment in any form or combination should be restricted. 
If arsenic is prescribed for young children in combination with a 
small quantity of iodide of potassium, which will act slightly as a 
diuretic, any unpleasant effects will be less likely to occur; while at 
the same time its peculiar action on the skin will be heightened rath- 
er than lessened. The subjoined formula will be convenient. R. 
Liquoris potassae arsenitis, ; potassii iodidi, 3 i.; syrupi 
tolutani, § i.; aquae fontanae, § iij. M. Dose.—For a child from 
one year to two years old, a teaspoonful every morning and evening. 
For a child from, two to four years old, one teaspoonful three times 
a day. For a child from four to eight, two teaspoonfuls morning 
and night. For a child from eight to twelve years old, two teaspoon- 
fuls three times a day; to be continued for each patient from three to 
four weeks. Strict instructions should always be given to the nurse ECZEMA IN CHILDREN. 
13 
to watch the child, and if any symptoms of illness appear which can 
possibly be attributed to the arsenic, then have it omitted for a few 
days, or have it given every other day only. But it is well known 
that young children bear the presence of this medicine remarkably 
well; and we consider it scarcely possible that any evil can result 
from the cautious method above directed for its use. Wilson pre- 
scribes Fowler’s solution in doses of two minims to an infant from 
a month to a year old, repeated three times a day immediately 
with the meals. He combines it with the wine of iron and syrup 
of tolu. 
The bichloride of mercury has long been used as a remedy for 
eczema in the London Hospital for Diseases of the Skin. For in- 
fants and young children it is much safer than arsenic, and it has 
proved efficacious in many obstinate cases of this complaint, as well as 
in other eruptions of a chronic type. The following is a convenient 
mode of prescribing it. R. Hydrargyri bichloridi, gr. i.; syrupi 
tolutani, § ij.; Aquas fontanas, § vi. M. The dose is one teaspoon- 
ful each morning to a chiM from six months to two years old. For 
a child from two to five years old, the dose may be repeated morn- 
ing and evening. And where we have any hesitation in regard to 
the use of arsenic, we can with a good prospect of beneficial results 
prescribe the bichloride, which may be continued for many months, 
with only occasional intermissions. 
The importance of a suitable diet should not be overlooked! Milk 
is the proper food under all circumstances, for an infant less than 
twelve months old. If it cannot live and prosper with that, it must 
die; and the physician should not fail to ascertain beyond all doubt 
if the nurse has a full supply of that which is good. The micro- 
scope, if at hand, will readily determine its richness, by bringing to 
view the relative number of nutritive globules, and if there is any 
deficiency in this particular or any other, then the child should be 
supplied from a different quarter. 
The question is not unfrequently propounded to the physician, can 
the nourishment derived from a mother who has eczema do injury to 
her child, who has the same eruption also ? In these circumstances, 
it is wholly presumable that the unfortunate child received its pecu- 
liar diathesis from the mother before it was born. Nevertheless, if 
she continues to supply her offspring with nourishment, the source of 
original injury to the child is perpetuated, although the mode of com- 14 
CONTRIBUTIONS TO DERMATOLOGY. 
munication is changed. Before its birth, the blood was the immedi- 
ate vehicle that conveyed the morbific element into the organism of 
the offspring; after birth, the milk, which is eliminated from the blood, 
is the medium of transmission of the same morbific principle; and 
in our efforts to relieve or cure the child, we are contending not only 
with the disease itself, but with a constant repetition of the cause 
that produced it. Perhaps these views may seem pregnant with the 
humoral pathology. Be it so; and now let it be asked, would a 
medical attendant be justified in recommending to a family that a wet 
nurse known to be full of eczema should have the care of a child 
and supply it with nourishment from her breast ? Although we can- 
not demonstrate, as we can a problem in mathematics, that milk de- 
rived from the source here supposed would do injury to a child, pro- 
bably no intelligent physician would feel disposed to endorse a wet 
nurse whose skin was occupied with the eruption in question. What- 
ever may be our views theoretically, the practice of us all is doubt- 
less the same. 
In reference to the diet of those who are afflicted with eczema, 
but little need be said, for but little can be accomplished in virtue 
of any prohibitions that may be imposed; accordingly, in addition 
to the suggestions given above with regard to the nourishment suita- 
ble for infants, but a few words need be offered on the general subject. 
Plain, simple, nutritious food—a fair mixture of animal and vegeta- 
ble substances, such as constitutes the usual dietary of families that 
are well to do, is appropriate for the class suffering from the disease 
in question, or from any other form of cutaneous affection, except the 
eruptive fevers; and any marked deviation from such a course of 
living, continued for any length of time, will be fraught with danger, 
for it will impair the general health. There is no one article of 
food so comprehensive and so valuable for all persons that are af- 
flicted with eczema as good milk. It is generally conceded by der- 
matologists that pork and shell fish should be interdicted. 
To keep the child perfectly clean, and to have it surrounded by a 
pure atmosphere, are two cardinal virtues during the entire treat- 
ment. 
Having marked out and initiated a course of treatment, as far as 
practicable, for internal medicines, for food, cleanliness, salubrious 
air, clothing and whatever else may be deemed essential in the do- 
mestic arrangements, the next point that should engage the consi- ECZEMA IN CHILDREN. 
15 
deration of the physician, is the local treatment. This is a matter, 
as all experience testifies, of much greater difficulty and embarrass- 
ment than the simple plan which is a leading feature in the consti- 
tutional measures. 
In very many cases where our best efforts are put forth to render 
good service, we find that we have to do with a most capricious 
enemy; and that what appeared to be the plain indications of to- 
day, as to what should be done directly to the eruption, will be con- 
tra-indicated to-morrow. Whether we order cold water or warm 
water, a poultice, a dry powder, a liniment, a lotion, an embrocation, 
or an ointment, we but too often find that the result is contrary to 
expectation. All parties are disappointed; and the physician is 
not a little mortified at his defeat. Very likely that since the last 
professional visit some slight disturbing cause has been called into 
action, and thus prevented the anticipated benefit. The nursing 
mother may have committed some error in diet and induced a de- 
rangement of the digestive organs; or she may have had a slight 
feverish attack, or have been thrown into distress by some sudden 
calamity, or some abrupt change in the weather, as from heat to cold, 
from dry to wet, or the reverse. Either of these circumstances may 
serve as a disturbing cause, and for the time being render the pa- 
tient worse. Other incidental causes, scarcely appreciable, may 
give a shock to the whole organism of the little sufferer, and its 
force be especially displayed upon the diseased skin. Every phy- 
sician in active practice must have witnessed the things here 
spoken of. 
A great variety of topical remedies are in vogue for the allevia- 
tion of the pruritus, with a view at the same time of arresting the 
further spread and continuance of the eruption; and as it appears 
more frequently on the head and face in young children than on any 
other region, we will first consider it on these localities. It is 
hardly worth while to attempt a description of all the preparations 
in general use in the local treatment of the disease, or to discuss 
their relative merits. Those only which are most reliable will be 
noticed, and the indications for their employment pointed out as far 
as may be. 
If the eruption is on the hairy scalp, and incrustations are pre- 
sent, the first thing to be done is to remove them. When this is 
accomplished, we can obtain a fair view of the condition of the dis- 16 
CONTRIBUTIONS TO DERMATOLOGY. 
cased integument, and not until then. There are several applica- 
tions that have been favorites among medical men for getting the 
scalps free from these crusts. One of the most convenient and 
cleanly is the crystallized carbonate of soda. A solution of this salt, 
containing one drachm, to twelve ounces of water, should be applied 
to the crusts by means of soft linen rags, or, what is still better, 
surgeon’s lint, or that used by dentists, over which a cap of thin 
gutta percha or oiled silk should be secured so as to prevent evapo- 
ration. The lint should be thoroughly saturated and be renewed 
morning and evening, or oftener if need be, so that the parts may be 
kept constantly wet. If half an ounce of the liquor sodas chlorinatas 
be added to the above solution, it will be an improvement, as it will 
effectually prevent any unpleasant smell that would otherwise ema- 
nate from the eruption. It is well to keep on hand a supply of the 
chlorinated water, for it will be needed all through the treatment, 
and should be used about in the proportion just stated whenever the 
child is to be washed. It is a sine qua non that the lint should never 
be allowed to dry, otherwise the application will do no good. 
In the present state of pathological knowledge, the explanation of 
the curative action of the carbonate of soda solution is hypothetical. 
But it is evident that it produces an immediate sedative effect upon 
the diseased surface. It acts of course primarily upon the nervous 
filaments of the parts. Perhaps it combines with and neutralizes 
some peculiar acid principle which enters into the composition of 
the acrid discharge. We have cured many severe cases of eczema 
in patients of all ages, with whom no topical means have been em- 
ployed except a solution of carbonate of soda during the whole 
period of attack. This treatment originated with Bennett, of Edin- 
burgh ; and whenever the locality of the disease will allow of its use; 
we need not hesitate to apply it. On the face and about the ears, 
neck, and some other localities, it would be somewhat inconvenient 
to employ it on a young child, on account of the difficulty of keeping 
the dressings in place. The strength of the solution should be about 
one drachm to the pint of water, if no incrustrations are to be re- 
moved. Its therapeutic influence in allaying the pruritus and inflam- 
mation of the skin is very similar to that of the weak solution of 
potassa fusa (two or three grains to the ounce of water) recommend- 
ed by Hebra, Anderson, &c. 
The benzoated oxide of zinc ointment of Dr. Bell, is a mild astrin- ECZEMA IN CHILDREN. 
17 
gent application, and is extremely well suited to certain places that 
are excoriated and highly inflamed, and on which lotions cannot be 
advantageously applied constantly, as the ears, the face, the hates, 
and the genital and anal regions. It may be used with a liberal 
hand, and be repeated two or three times in the course of the twenty- 
four hours. It should remain undisturbed, as a permanent covering 
to the parts for several days in succession. It can of course be used 
on any portion of integument; and it will generally alleviate the 
pruritus and lessen the morbid secretion in a satisfactory manner. 
If applied on the scalp, it may become matted down with the hairs 
if allowed to accumulate for several days; it will therefore be advisa- 
ble partially to cleanse the hairs every third or fourth day with the 
carbonate of soda solution, warm, or with a lather made of white 
Windsor soap. When this is done, wipe the scalp perfectly dry and 
apply fresh ointment. The cleansing of the head should be done in 
the most gentle manner, and with the least possible friction, and a 
soft linen rag used in the process. We have prescribed the benzoa- 
ted oxide of zinc ointment in numerous cases in all stages of eczema, 
and for persons of all ages; and, in a majority with 
great relief and comfort to the patients. 
In cases of purely local eczema occupying quite a limited portion 
of integument, as the ears, face, hands, axill®, &c., and the ichorous 
discharge very copious, we have often employed with much satisfac- 
tion the following ointment. R.‘ Plumbi carbonatis, 3 ij.; cret® 
pixeparat®, § ss.; unguenti ros®, § ij. M. Apply this ointment 
freely to the parts two or three times in the twenty-four hours. It 
rarely fails to ameliorate the intensity of all the symptoms. It may 
be prescribed without regard to the age of the patient. 
After the incrustations have been removed, and the exposed sur- 
face is found to be much inflamed, the subjoined formula will prove 
valuable as a local application. It may be used with freedom. R. 
Pulveris camphor®, 9 iv.; pulveris zinci oxidi, § j.; olei bergamot®, 
gtt. xv.; glycerin®, § iv. M. Signa. Shake the mixture before 
using it. Our experience in the use of the three last mentioned 
local remedies has been about the same with each, and they have 
all seemed to promote convalescence about alike. Either of them 
is entitled to confidence when employed at the proper time; and we 
have pointed out the condition of things when the one or the other 
of them is indicated. In repeating the dressings with either, the 18 
CONTRIBUTIONS TO DERMATOLOGY. 
nurse should be instructed not to remove any portion of what has 
been applied previously, but let it remain undisturbed for four or 
five days unless it becomes detached and is nearly cast off with the 
loosened incrustations. 
When the disease is decidedly on the decline and there is more or 
less infiltration and thickening of the skin, a weak solution of the 
choride of zinc will usually act favorably. R. Zinci chloridi, 9ss.; 
aquae fontanae, § iv. M. To be painted on the affected parts three 
or four times a day, with a soft rag attached to a stick. 
As a constant application in the circumstances just specified 
above, we have often witnessed good results from the use of the 
liquor plumbi mixed with thick cream, in the proportion of one 
drachm of the former to four or five ounces of the latter. It allays the 
excessive itching and checks the remaining inflammatory tendency. 
It should be applied several times in the twenty-four hours on any 
portion of the skin of infants and other young children. It should 
be prepared fresh every day, especially in warm weather. 
We have occasionally prescribed chloroform as a topical applica- 
tion, in the proportion of one drachm to an ounce of simple ointment. 
It often alleviates the distressing pruritus. This ointment should 
be put up in a phial with a wide mouth. 
A mixture of equal parts of lime water and linseed oil is another 
local remedy of decided utility, where the surface has long been the 
seat of the eruption. The preternatural redness, infiltration and 
excessive itching will frequently subside, when the diseased skin is 
protected by this well-known ointment. 
We speak from experience. 
Eczema in the Ad,ult. 
Eczema in the adult presents the same elementary lesions as in the 
young subject. The same forms or varieties of this disease are met 
with in persons of all ages, although in those who have arrived at 
maturity, and more especially in those of advanced years, and where 
the complaint has acquired a chronic character, the infiltration of the 
derma is much greater and more persistent than in the young; so, 
also, are the oedema and the pruritus, together with the thick, dense 
incrustations or furfuraceous scales which sometimes remain as the 
relics, so to speak, of a former acute eczematous eruption that was 
perhaps wholly neglected, or but casually or blindly treated by some ECZEMA IN THE ADULT. 
19 
irresponsible individual. There are not a few cases, however, where 
the malady pursues the uncertain tenor of its way through a long series 
of years, with only occasional periods of respite, however judicious 
and protracted the treatment for its cure may have been. Especially 
is this the case where it affects the lower extremities of the aged. 
The leading principles of treatment for all subjects are virtually 
the same, although the measures to be employed must necessarily 
vary according to the age of the patient, the temperament, the exist- 
ing state of health, the extent and severity of the disease, and the 
region upon which it is developed. 
In prescribing constitutional remedies, our first inquiry should be 
in regard to the condition of the alimentary canal. Throughout the 
entire administration of medicines, this should be kept in the best 
possible condition, whether the eruption is acute or chronic. If the 
bowels are costive, an aperient will be required, and should be re- 
peated as occasion may demand. Small doses of sulphate of magne- 
sia, or liberal draughts of the Congress Spring water, or the com- 
pound colocynth pill, will usually accomplish all needful purposes in 
this particular, especially if the diet be properly attended to. The 
following prescription is a favorite one with Mr. Milton, Surgeon to 
St. John’s Hospital for Skin Diseases in London: R. Extracti hyos- 
cyami, extracti colocynth. comp., aa 9 j. j pil. hydrargyri, sodac 
carbonat., aa 9 ss. M. ft. pil. No. xij. Give one or two at night. 
If the patient is accustomed to the use of tobacco in any form, he 
should be persuaded to discontinue it. 
The tincture of the chloride of iron is one of the best remedies for 
internal use. It may be prescribed in large doses well diluted, thus: 
R. Tincturse ferri chloridi, § ij.; syrupi zingiberis, gij.j aqua; fon- 
tanm, § iv. M. Dose, 5 ij. three times a day, in half a gill of water. 
If the pruritus is severe, five drops of the tinctura aconiti radicis 
may be added to each dose of the iron, with good effect. This is a 
minimum quantity of the tincture of aconite for an adult. (The 
tincture made from the root is much stronger than that of the leaves, 
and the whole name of the one intended should be written in full.) 
The liquor ammoniae acetatis is a valuable remedial agent in all 
stages of eczema, but especially if there be any feverish habit on the 
patient. Two drachms mixed with about a gill of mint water, or 
sweetened water, make an agreeable drink, and may be taken three 
or four times a day. It acts favorably as a diuretic and diaphoretic* 20 
CONTRIBUTIONS TO DERMATOLOGY. 
and thus relieves the hypertrophied condition of the cutaneous tissue. 
Effervescent draughts will also be useful, particularly in the acute 
stage of the eruption. The mistura ferri composita, the syrup of the 
iodide of iron, the citrate of iron and quinine, and cod-liver oil, will 
be found suitable tonics in a great many cases where the vitality of 
the general system requires to be invigorated. When the vital 
functions are in a normal state, and the cutaneous affection is attend- 
ed with little or no exudation (and this is the fact with a large pro- 
portion of cases), then is the opportune moment to commence with 
some arsenical preparation with every probability of doing good with 
it. This nerve-tonic should be taken in immediate connection with 
the food, and should be given with great caution to the adult subject 
as well as to the young. We have no faith in heroic doses of this 
mineral. When given thus, we defeat the very object of its adminis- 
tration. The stomach or bowels, or pulmonary organs, are almost 
certain to be disturbed by its irritant qualities fretting their delicate 
mucous lining, which soon becomes wholly intolerant of its presence, 
and we are forced to abandon its use with perhaps no little distrust 
as to its curative powers in the very case where it would have been 
most appropriate and useful if employed in small quantities. Mr. 
Hunt, of London, a successful and learned practical dermatologist, 
long since advocated the employment of minute doses of arsenic and 
these only; such as two or three drops of Fowler’s solution two or 
three times a day to an adult. We have frequently followed his 
suggestions with good results; and we never on any occasion pre- 
scribe beyond fifteen drops a day of Fowler’s solution to the most 
robust individual. 
There is another formula for the administration of arsenic of 
still greater potency, and with which we may succeed in curing 
chronic eczema, especially eczema squamosum, even after having been 
disappointed in regard to Fowler’s solution. In fact, we now in 
most cases prescribe it for adults instead of the solution. We refer 
to what is termed the “ Asiatic pill”—a combination of arsenious 
acid with black pepper, in the proportion of one part of the former 
to about eight of the latter. The formula which we prefer contains 
equal parts of the pepper and the extract of conium, as we think the 
last named ingredient gives additional security against any unpleasant 
griping of the bowels which might possibly be produced by the ar- 
senic. R. Acidi arseniosi, grs. vij.; pulveris piperis nigri, extracti ECZEMA IN THE ADULT. 
21 
conii, aa 5j- M. Divide in pilulas No. c. The dose is one pill every 
morning directly after breakfast, until the patient has taken fifty pills, 
afterwards one pill every other morning. Each of these pills con- 
tains one fourteenth of a grain of arsenious acid; and when pre, 
scribed in the manner directed, they will in very many cases exert a 
sovereign power over the disease, and thus prove their claim to our 
confidence when all other remedies have failed. 
Local Treatment. 
If the scalp is the seat of the eruption, the hair should be cut short, 
and kept so by the use of the scissors. The solution of the carbon- 
ate of soda, as mentioned in our remarks on infantile eczema, may 
then be applied and continued so long as it gives proof of doing 
good. In regard to this and the other local applications mentioned, 
no extended additional remarks need be offered in this place, for these 
external appliances are equally useful to persons of all ages who are 
similarly affected. If the eruption has continued for a long period 
and the scalp presents a brawny or furfuraceous surface, the follow- 
ing liniment can in a majority of cases be used advantageously : R. 
Olci olivaj camphorati, giij.; olei cadini, 5 j.; unguenti hydrar- 
gyri nitratis, § ss. M. Ft. linimentum. Signa. Shake before using. 
Two or three drachms of the above may be rubbed into the scalp 
somewhat briskly with a soft flannel, every night at bed time. Oc- 
casionally the diseased integument should be cleansed with the car- 
bonate of soda solution, or with soap and warm water. The lini- 
ment will be found well adapted to any portion of the cutaneous 
membrane under similar circumstances, and where the eruption is 
quite limited in extent. If spread over a broad surface and followed 
up for some time, it might induce ptyalism. 
What is familiarly known as “ Hebra’s Tincture ” makes a valua- 
ble local dressing after the acute inflammation has been subdued, 
and when the infiltration is but slight. It may be applied twice a 
day. The formula for this remedy is as follows : R. Saponis 
mollis, picis, spiritus vini rectificati, aa § j- It is necessary that 
the patient should wear a cap constantly while using this tincture, 
lest it should soil or even spoil any article of clothing or bedding 
that may come in contact with it. For these reasons some patients, 
especially fastidious females, refuse to use it. 22 
CONTRIBUTIONS TO DERMATOLOGY. 
If there is much exudation, thickening and infiltration, and the 
eczema occupies but a small surface, as the ears, the forehead, the 
face, hands, fingers, feet, etc., a solution of potassa fusa will prove 
an important local agent. The strength of the solution should be 
from half a drachm to a drachm of the caustic to an ounce of water. 
It should be applied by the medical attendant himself for a few times, 
at least until the patient learns how to use it. A small bit of rag 
should be saturated with the liquid and then passed rapidly over the 
surface. The pain is quite severe for the moment. A little warm 
water in a wash-bowl should be at hand, and the caustic should be 
instantly washed off with a soft linen rag. The pain continues but 
an instant. The part is to be wiped dry, and the benzoated zinc 
ointment thickly spread on lint should be put on to the surface that 
has been subjected to the potash. The process should be repeated 
every third or fourth day. If the eruption covers an extensive sur- 
face, a portion of it only should be dealt with in the manner here 
described, at any one time. 
If the infiltration is slight, the aqua potassse of the Pharmacopoeia 
will answer quite well instead of the potassa fusa. It may be used 
freely once or twice each day, care being taken to remove any excess 
by means of warm water, if it produces severd smarting. The 
strength of the caustic applications may be reduced and employed 
less frequently, as the infiltration, itching and exudation diminish. 
They are not well adapted to individuals of nervous temperament, or 
to persons who are in feeble health or advanced in years. 
Hydrocyanic acid in combination with other ingredients, is often 
beneficial in checking the unbearable itching which is one of the most 
constant and unmanageable attributes of chronic eczema. The follow- 
ing lotion is among the best. R. Acidi hydrocyanici diluti, 3 j.; olei 
cadini, § j.; saponis viridis, § ij.; olei rosmarini, 3 j.; aquas fon- 
tanas, § vj. M. Signa. Shake before using. To be rubbed over any 
portion of the skin implicated in the disease, two or three times a 
day. Another: R. Acidi hydrocyanici diluti, 3 j.; liquoris plumbi, 
3 iij.; glycerinae, § j.; emulsionis amygdalae, § vj. Ft. lotio. To 
be applied freely pro re nata. ' 
When the eruption is quite limited in extent, topical applications 
constitute about all that need or can be done. Constitutional meas- 
ures are certainly less demanded, and usually less efficacious than 
they arc when the whole or nearly the whole surface is engaged. And ECZEMA IN THE ADULT. 
23 
as topical measures in the treatment are to be our chief reliance, 
they may be more potential than would otherwise be expedient. 
The sulphate of zinc in the proportion of four or five grains to the 
ounce of water, applied with a camel’s-hair pencil, will quiet the pru- 
ritus and promote the entire restoration of the part. The application 
may be repeated once or twice daily. 
A solution of chloride of zinc, twenty grains to the ounce, is like- 
wise an efficient lotion to small patches of the eruption. Both of 
these lotions may be used by the patient himself, and any excess may 
be washed off with warm water. 
The cyanuret of mercury is likewise a beneficial application in the 
inveterate forms of eczema, when purely local and covering but a 
small area. R. Hydrargyri cyanuret, grs. vj.; glycerin®, 5 ij.; 
aqua? destillat®, g iv. M. Signa. Lotion. To be applied with a 
camel’s-hair brush two or three times daily. 
As a local remedy, creosote is entitled to favorable consideration, 
in many cases of chronic eczema. It is not suited to the eruption if 
there is serous discharge; but when there is much infiltration, pruri- 
tus and hypertrophy, and a scaly condition of the parts, it often acts 
very favorably. In presenting the claims of this article, we are re- 
minded particularly of several cases of chronic eczema of the scrotum 
and perineum in which it was employed with the most beneficial 
results. It assuaged the most tormenting itching almost immediately, 
and ultimately restored the patients to a perfectly comfortable con- 
dition, without resort to any other local measures. The following is 
a suitable formula. R. Creosoti, 5 j.; unguenti simplicis, § ij. M. 
To be applied freely twice a day. The scrotum should be protected 
by a suspensory bag. 
Glycerine makes a convenient vehicle also with which to combine 
the creosote, thus: R. Creosoti, 3 j.; glycerin®, g ij. M. To be 
used like the preceding. 
Eczema of the eyelids (eczema tarsi, ophthalmia tarsi, tinea ciliorum, 
psoriasis tarsi) is often met with in children and adults. The affec- 
tion is apt to be regarded as evidence of a scrofulous diathesis, but 
without good reason. It is simply a local variety of eczema, and 
undergoes the same changes here as in other localities, viz., inflam- 
mation, itching, thickening of the lids—that is, infiltration. Not 
unfrequently, minute pustules arise and form (eczema impetiginodes 
of some writers) incrustations or delicate scales, which impart to 24 
CONTRIBUTIONS TO DERMATOLOGY. 
this variety of eczema some of the features of pityriasis or psoria- 
sis. But the disease should, amid all these phases, be recognized as 
an eczema. And it will generally be found associated with some 
other form of the same eruption in a distant or adjacent region. 
Chronicity is one of the most common attributes of this local affec- 
tion. The hair follicles and tarsal glands become involved, and 
there is more or less weeping from the lids of an ichorous discharge, 
which chafes and inflames the surface over which it flows, and thus 
the cheeks in time take on a similar action. 
The treatment is simple. At almost any period of the eruption, 
the following local application will be appropriate :—14. Ilydrargyri 
oxidi rubri, gr. ij.; glycerinse, gtt. ij.; unguenti rosac, 3 ij. M. A 
portion equal to a pin’s head may be placed between the lids, at the 
outer canthus, at night, or every other night, and care taken not to 
let it get upon the eyeball. A camel’s hair pencil should be used. 
If a collyrium is desired, a weak solution of the chloride of zinc 
will be appropriate. R. Zinci chloridi, gr. i.; aquae rosrn, § iv. M. 
Two or three drops of this lotion are to be applied to the diseased 
lids twice daily with a camel’s hair pencil. 
Eczema of the lips is often met with. It is sometimes confined 
entirely to these parts; but, in most cases, the eruption exists on 
other portions of integument simultaneously. Not unfrequcntly, it 
is associated with eczema of the anus. Sometimes these two distant 
regions seem to act in sympathy, and take turns in relieving each 
other of the existing trouble, so that when one part is involved the 
other is free. This metastasis or migration of the disease from 
one extreme to the other of the alimentary canal may be kept up for 
a long period. 
Nearly all the forms of the eruption may break out on the lips, 
and become a source of much annoyance and actual suffering to the 
individual. The lips swell, inflame, bleed, crack, discharge a serous 
fluid more or less abundantly, and are often disfigured by deep and 
ugly-looking fissures, which refuse to heal for months or even years. 
The patient can neither eat, drink, speak, or smile without pain. 
The treatment for this local affection must necessarily be simple. 
If there is much thickening of the lips, it will be proper to touch 
them a few times with the aqua potassa or the potassa fusa, about 
one half drachm to the ounce of water, every fourth day. After 
the application of the caustic, the parts should be liberally coated ECZEMA IN THE ADULT. 
25 
with the following cerate. R. Pare olive oil, one ounce; yellow 
beeswax, half a drachm. Direct the apothecary to melt the beeswax 
in the oil in a sand- or water-bath, and, when melted, stir in new 
honey one drachm, pulverized oxide of zinc half a drachm, and keep 
stirring till cool. After thoroughly removing the potash with warm 
water, and wiping the lips dry, the cerate should be applied, and 
should be renewed two or three times in the twenty-four hours. 
This cerate makes a very soothing application for sore nipples, 
in most instances ; sore nipples being usually nothing more nor 
less than a variety of eczema. The eruption occurs usually in 
connection with lactation, and occasionally produces inflammation of 
the deeper parts, giving rise to mammary abscess. The cerate is 
also a suitable application in most cases of eczema of the external 
auditory passage (Eczema meatus). 
In eczema of the legs (eczema crurale) the medical attendant has 
generally to contend not only with the fitful character of the disease, 
but also with the usual habits of the patient, whether male or female. 
This remark is applicable, at least, to nearly all patients in private 
practice. In hospital practice the physician can have his own way. 
Now one of the most important items in the treatment of the disease 
in question, when seated on the lower extremities, is to have the 
patient confined to the bed. A surgeon might as well expect a frac- 
tured leg to get well while the patient is allowed to hobble about 
with it, as the dermatologist to hope that a severe case of eczema 
of the legs will be cured while the individual is suffered to roam 
abroad wherever he pleases. In almost every populous community, 
scores of eczematous legs are carried about, because the owners 
thereof cannot be induced to submit to quiet rest and a horizontal 
position. So long as the limb is in a dependent state the capillary 
circulation is impeded and congestion is consequently the result, and 
the most assiduous professional efforts are well nigh without benefit. 
The patient generally gets uneasy and dissatisfied if not cured im- 
mediately, and neither gives thanks nor credit to his physician for 
his services, but strays away .to some one else. 
In the treatment of eczema of the legs, therefore, it is the duty of 
the surgeon to state to the patient, in explicit terms, the paramount 
importance of rest in a recumbent position until convalescence is 
well established. We arc led to dwell upon this point with the 
more emphasis, because failures not a few occur in the practice of 26 
CONTRIBUTIONS TO DERMATOLOGY. 
every medical man, in cases where the benefit of repose in a proper 
position has been ignored by the patient; and where he thus deals 
unfairly towards his medical adviser, the latter is often under strong 
temptation to abandon the case. 
Eczema of the lower extremities is met with more frequently 
than on any other region, and it is much more unmanageable than 
when developed elsewhere. In some instances where varicose veins 
coexist, or where the patient is quite in years, the eruption is apt 
to degenerate into chronic ulcers of vast extent, and the whole limb 
swells to an enormous size, and feels to the touch almost as hard 
and solid as marble. Under such circumstances, all efforts at cure 
avail little or nothing. The patient is doomed to a life of suffering. 
When it is desirable to correct the offensive discharge arising 
from old ulcers of the legs which are frequently met with in chronic 
eczema of these parts, a solution of the nitrate of lead, in the pro- 
portion of eight ounces to half a gallon of water, will be a conveni- 
ent agent for the purpose. Rags or bandages saturated with the 
solution may be employed in the dressings and kept wet with it more 
or less as the case may require. By this procedure the patient 
will be relieved of a very great annoyance, and the apartment ren- 
dered comparatively free from any fetid smell. The sores may also 
be washed with the solution morning and evening if necessary. 
The employment of most of the local measures, already sufficient- 
ly alluded to, will be equally proper in eczema of the legs. To 
remove the incrustations nothing can surpass the solution of the 
carbonate of soda, which exerts also a soothing influence and quiets 
the most urgent pruritus, in all ordinary cases. If pieces of sur- 
geon’s lint are saturated with it and laid smoothly on the part, the 
moisture can be retained by means of oiled silk or thin gutta percha 
for several hours, and the patient can repeat the solution at pleasure. 
Should it be thought advisable to rely on the benzoated 
oxide of zinc ointment, or the mixture of the oxide of zinc 
with glycerine and camphor, a thick coating of either can be 
used and repeated two or three times a day without disturbing what 
has been previously put on. If the limb is swollen or if the eruption 
is complicated with a varicose condition of the veins, the use of a 
bandage is to be recommended. It should be narrow, and smoothly 
adjusted, commencing with the foot. It should be re-adjusted two 
or three times a day, if necessary, so as to keep up equable pressure. ECZEMA MERCURIALE. 
27 
These measures will suffice, when the eruption is of quite limited 
extent and the infiltration moderate; but if a large surface is involv- 
ed and the disease chronic, with great infiltration, then it will be 
advisable to employ the schmierseife or German soap—sapo viridis; or 
the common sapo mollis, such as the washerwomen of the country 
ordinarily use. The two articles just named are essentially alike in 
their composition and in their caustic action on the skin, and it is 
immaterial which is selected. When there is but little infiltration, a 
rubbing with the soap once or twice a day is sufficient; but when 
the infiltration is more considerable, a more frequent application is 
necessary. When the skin has been thoroughly rubbed with the 
soap, the surface should be washed, and cold water dressing applied 
until the next rubbing. This procedure must be continued as long 
as the moisture and itching and infiltration continue, and until 
the frictions no longer give rise to heat and excoriations of the skin. 
The soap must then be replaced by cold applications, and the 
treatment terminated by other local measures. This treatment is 
identical in its effects with that recommended by Hebra. 
If the eruption becomes chronic, and is a variety of eczema squa- 
mosum, equal parts of tar, cod-liver oil and glycerine make a suitable 
dressing. The Norwegian tar-soap (black variety) is likewise a 
very valuable preparation for topical use in eczema squamosum. 
It may be rubbed on the parts very briskly, two or three times 
in the twenty-four hours, with a piece of flannel, and then washed off, 
and the surface may then be protected by the last-mentioned dress- 
ing. Or, the soap may be allowed to remain on for one, two, or three 
hours at a time, unless it produces too much irritation. 
t 
Eczema Mercuriale.—This variety of eczema is entitled to a brief 
notice, though of rare occurrence. In most instances, women of a 
peculiar idiosyncrasy are the subjects of it. In the application of 
the emplastrum ammoniaci cum hydrargyri as a discutient in enlarged 
glands, swelling of the joints, chronic hepatitis, &c., the mercury is ab- 
sorbed in sufficient quantity to produce the complaint, and sometimes a 
very small quantity of a mercurial preparation taken internally will 
produce it. The vesicles are exceedingly minute, and are developed 
upon an intensely inflamed ground. There is great heat, in severe 
cases, accompanied with a smarting and burning sensation and itch- 
ing. The surface soon becomes of a dusky-red hue. In very bad 28 
CONTRIBUTIONS TO DERMATOLOGY. 
cases, the entire surface of the body and limbs is involved. The 
face becomes enormously swollen, the eyes are completely buried in 
the tumefaction of the lids, so that the patient is blind for several 
days, and the ears are greatly swollen and distorted in consequence 
of the infiltration of serous fluid into their substance. The integu- 
ment of the pudendal region is involved to a most distressing de- 
gree. The parts are much inflamed and hypertrophied. The inflam- 
mation extends to the mucous membrane of the vagina, producing 
the most intense suffering, especially in micturition, and in the course 
of four or five days a copious discharge of serous fluid escapes from 
these parts. The mucous membrane of the mouth, fauces, throat 
and bronchial tubes participates in the affection, and salivation is in- 
duced and continues with more or less severity for several weeks. 
Meanwhile, the vesicles on the skin burst and pour out an abundant 
ichorous fluid, the odor of which has been compared to that of putrid 
fish. The entire apartment occupied by the patient is filled with the 
nauseous eflluvia arising from the offensive discharge. In severe cases, 
the constitutional symptoms run high, the tongue is coated with a 
white fur, and there is nausea, fever, pains in the head, delirium, and 
sleeplessness. In eight or ten days from the outbreak of the erup- 
tion, the cuticle begins to fall off in large flakes, and the severity of 
all the symptoms begins to abate. The exfoliation of the epidermis 
takes place several times, and the surface thus denuded of its natu- 
ral covering presents quite a unique appearance, as the large flakes 
of the cuticle hang loose from various parts of the body and limbs. 
Sometimes the exposed derma is excoriated and bleeds at many 
points, and the patient in consequence suffers intensely. The dis- 
ease is very apt to return. In mild cases, only a limited portion of 
integument is disturbed by the eruption, and no constitutional symp- 
toms are developed; and in a few days the eruption entirely disap- 
pears, without any occasion for medical treatment worth naming. 
We have seen three cases of eczema mercuriale. The patients were 
all young females. 
Treatment. 
Tonics, moderate doses of liquor ammonias acetatis, orangeade, de- 
mulcent drinks internally; and externally, equal parts of lime water 
and linseed oil, glycerine somewhat diluted with water, warm baths 
daily, with about three ounces of the carbonate of soda to twenty- 
five or thirty gallons of water, and the bran bath. IMPETIGO. 
29 
If the mucous membrane of the labia or vagina is much inflamed, 
a weak solution of the liquor sodas chlorinatae, one part to twenty- 
four of water, should be injected several times a day, and the labia 
kept apart by means of lint saturated with the solution. 
Impetigo. 
This eruption consists of small pustules ; whereas ecthyma and 
rupia give rise to much larger ones. In both of the last named 
affections the pustules are at length covered with more or less coni- 
.cal incrustations or scabs. Those of rupia resemble the limpet 
shell: while those of ecthyma are less regular in their formation, 
and are without the concentric markings of rupia. 
Impetigo, like eczema, is very frequently developed in early life. 
Indeed it is met with in infants and young children oftener than in 
persons who have reached a mature age. Like eczema, also, its 
characteristic features in the young differ from those which it exhi- 
bits in the adult. But unlike eczema it is usually quite amenable to 
a judicious course of treatment. It seems fit that our study of the 
affection should commence with it as seen in that class of subjects 
which are first and most frequently attacked. The inflammatory 
action which gives rise to a particle of yellow pus upon the surface 
of the derma arises from a deeper portion of its structure than the 
inflammation which produces the transparent vesicle of eczema. 
This globule of pus elevates the epiderma very slightly, and thus a 
flattened pustule is formed. The fluid is pus from the beginning. 
The pustules of impetigo are minute, distinct or formed into clus- 
ters, which burst in three or four days from their development and 
pour out their contents upon the surface, and become covered with 
thick, laminated or prominent incrustations. 
The disease may appear on any part of the body, but its favorite 
and most frequent localities are the scalp and the face. This is the 
case particularly as regards young children. At the commencement 
of the disease the first abnormal condition consists of unusual red- 
ness, tension and thickening and pruritus of the skin where the pus- 
tules are about to be developed. These are acuminated, of a light 30 
CONTRIBUTIONS TO DERMATOLOGY. 
yellowish color, hard, with scarcely any inflammatory areola at the 
base; they are usually formed into clusters or groups, at other 
times are sparsely disseminated, being at a distance of half an inch 
or an inch apart (impetigo sparsa of authors). These pustules 
were denominated psydracious by Willan; and nearly all derma- 
tologists since his day have adopted this name. When the scalp is 
the seat of the eruption, the occipital and vertical portions are usu- 
ally the only parts invaded, while the forehead and face remain intact. 
When the pustules are ruptured and their contents exude, incrusta- 
tions or scabs are immediately formed of irregular outlines, of a 
light brown color, with frequently a tint of green. They often break 
very readily into granular masses of unequal size, and are compared 
by Alibert to the seeds of certain plants, to broken mortar, or to 
plaster detached from a wall which has become dirty by moisture 
and dust. The purulent matter in the process of desiccation seems 
to pass into a state approaching crystallization, and sometimes the 
crusts assume an appearance like gypsum; hence Alibert styled them 
lapidescent. The exudation is exceedingly unpleasant so long as it 
continues in a fluid state, but the peculiar odor passes off as the 
secretion dries. In some instances the scabs become the hiding 
place of numerous animal parasites, which with their constantly in- 
creasing progeny prove a source of no slight torment to the child; and 
the utmost care and cleanliness are required to maintain a decent 
and bearable condition of the little sufferer. The hair is matted 
/ 
together unless it is properly attended to, and in some cases there is 
partial alopecia, which, however, is but a mere temporary baldness, 
and very different from that which takes place in favus and ring- 
worm. The matrices of the hair are not destroyed. They are 
merely inflamed, and a new crop of hair springs up in a few months, 
the same as if the parts were never affected. In some instances, 
the subcutaneous cellular tisue becomes inflamed, and small abscesses 
form which require to be opened. The foregoing remarks apply 
more particularly to that variety of impetigo termed by dermatolo- 
gists, Impetigo jigurata, and which is more frequently met with on 
the scalps of young children than the other variety, denominated 
Impetigo sparsa, which will be noticed presently. 
The disease has sometimes been mistaken for favus; but the cup- 
shaped appearance of the crusts in the latter disease is always 
wanting in impetigo capitis. Hardy classes impetigo with eczema IMPETIGO SPAESA. 
31 
as a sub-division; but we choose to consider it as a distinct affection, 
although we are free to admit that it is often a result of eczema and 
has many features in common with it. 
If the discharge continues for a long time unchecked and the 
affection becomes chronic, the incrustations undergo considerable 
change; and instead of being thin, soft, and yellow, they become 
thick, hard, dry and brownish and are tinged with particles of blood, 
are very adherent, and can only be removed by the application of 
emollient poultices, fomentations or strong alkaline solutions; and 
when they are detached the secretion, from which they are formed, is 
found to proceed from numerous points on the surface of the inflamed 
and denuded corium. The parts in the immediate neighborhood of 
the crusts continue red, inflamed, shining and tender, and bear traces 
of the morbid action for several weeks or even months after the 
formation of the scabs has ceased; although the eruption seldom 
leaves any permanent scars or other disfigurement. The constitu- 
tional disturbance is rarely of much account, and is merely symp- 
tomatic of defective nutrition. 
Impetigo Sparsa. 
This variety or form of the disease is not so common as impetigo 
figurata. It is characterized by the development of small, solitary, 
irregular pustules on different parts of the scalp, and is met with 
more frequently in children than in adults. In the latter it is a rare 
disease. Successive pustules appear, attended by itching and heat 
in the parts. The amount of the incrustation or scabbing depends 
on the extent of the secretion. It may be thin and yellow, soft or 
hard. Its character is influenced a good deal by time. In the early 
period of its formation and when developed on quite young children 
at the breast, it is soft and moist; hence the terms of crusta lactea, 
porrigo larvalis, &c., of the older dermatologists. There is at times 
much local irritation, and if nothing effectual is done to check the 
progress of the abnormal action, it will run on indefinitely and 
the exudation will furnish new supplies for the augmentation of the 
scabs in size and thickness; and as the disease acquires age, it will 
increase in obstinacy. The characteristic symptoms of the affection 
are of course more fully pronounced, more disgusting and more 
difficult to subdue in children who have been neglected, and in 
whom it is allowed to continue without any attempts to check it, 32 
CONTRIBUTIONS TO DERMATOLOGY. 
than they are in patients that are well cared for and kept in a cleanly 
condition. In the latter, the disease is generally mild in its features 
and exempt from those disagreeable accompaniments so often en- 
countered among the children of poverty, filth and privation; and 
when appropriate means are employed it can usually be cured in a few 
months. When it is seated on the hairy scalp of infants, its duration 
and the sufferings induced by it are not, cetceris paribus, so tedious 
as when developed in the adult and occupying the arms or legs. In 
the last named situation it is seen oftener than on any other region, 
and it is here that it is especially formidable. In very rare and 
exceptional cases, when the eruption is seated on the scalp, the in- 
flammation extends through the whole thickness of the integument, 
and indolent ulcers are produced in spite of all efforts to arrest its 
progress. The lymphatic glands of the neck also become enlarged 
and painful, when the complaint assumes its worst form, and consti- 
tutional symptoms of considerable severity are induced. 
On the face, as ■well as in the scalp, the eruption presents various 
degrees of severity, being in some cases so mild as to require but 
temporary medical treatment, while in others it passes to an opposite 
extreme, and becomes chronic and troublesome for several months. 
It rarely attacks a child before the tenth or twelfth month, or even a 
little later. If neglected, it is apt to spread over quite a portion of 
the face; and the cheeks, the forehead, nose and chin are sometimes 
buried in a mass of incrustation, and the poor child is a piteous 
object to behold. Under these circumstances, the malady bears a 
strong resemblance to a case of confluent smallpox. The child suf- 
fers considerably at times from pruritus, the nails are applied to 
various points, and thus lacerations are produced and the disease 
thereby aggravated, as in eczema. 
In mild cases the eruption commences on a small disc, and if it 
remains circumscribed for some time, the incrustation gradually in- 
creases in thickness and presents a rough, uneven and dark-brown 
surface, which projects from the base not unlike a crust of rupia. 
Sometimes the disease is located about the commissures of the lips, 
and gives rise to small persistent sores; at other times it is seen 
occupying the also nasi, where it forms quite largo deposits of crus- 
taceous matter, which partially closes up the apertures and mate- 
Impetigo of the Face. IMPETIGO OF THE FACE. 
33 
rially interferes with respiration, and the child is forced to breathe 
with its mouth wide open. The morbid action extends gradually to 
the cheeks on either side, and also upon the upper lip, which be- 
comes much swollen, and there is great distortion of the features, 
giving to the countenance a most repulsive appearance. Occasion- 
ally it commences in the eyebrows, both of which are generally 
affected, and when situated in the latter region it may spread upon 
the forehead or eyelids and produce ophthalmia or a loss of the eye- 
lashes. In nearly all cases as seen in young children, the head and 
face are the only regions attacked; we will therefore now pass to the 
consideration of the complaint as it is developed in the adult. 
In persons of adult age impetigo very seldom appears on the scalp, 
but when it does, the matting of the hair renders it a more troublesome 
affection than when it occurs in young children. In the former class 
of subjects the inflammation is apt to be more acute and profound 
than in the latter; the incrustations also acquire greater thickness 
and occupy a more extensive portion of integument, sometimes cover- 
ing the entire scalp. The constitutional symptoms are usually very 
light or entirely absent; and after the pustules have come to matu- 
rity and poured out their contents, the local symptoms gradually 
subside into a milder form. As the disease begins to decline, the 
incrustations cease to be formed or become thinner as each succes- 
sive crop is produced; the redness, tumefaction, heat and pruritus 
gradually disappear, although the skin remains of a vivid red, and 
is tender for several weeks, and liable to be attacked by a fresh out- 
break of the eruption. In some instances, the local applications 
that are injudiciously employed not only occasion a continuance of 
the malady, but greatly augment its severity and increase the diffi- 
culties in the way of cure. The topical use of arsenical and mer- 
curial preparations of a too stimulating nature has been known to 
produce very serious injury, especially where the face has been 
the seat of the disease. Two instances of the kind have come within 
our knowledge. In the one, arsenic, in the other, corrosive sublimate 
was employed, and in both the deeper tissues of the skin were at 
once involved in a high degree of irritation and inflammation. 
Thickening and infiltration of the integument and subjacent cellular 
membrane took place to an alarming extent, together with enormous 
swelling of the neighboring lymphatic glands, and several months 
elapsed before the mischief thus induced could be repaired. Both 34 
CONTRIBUTIONS TO DERMATOLOGY. 
patients were young men, and the eruption was on the face and neck, 
reaching from ear to ear. 
In men, the face is the part most frequently affected. The erup- 
tion generally commences with a few pustules crowded together 
about the upper lip, the chin, or in front of the ears. These pustules 
occasion a slight itching sensation, but no other inconvenience. The 
patient pricks them, and they dry up without receiving or seemingly 
requiring further attention. But the portion of skin upon which 
they are developed remains red, hardened, thick and itchy; and 
quite soon a large crop of pustules appears, with an increase of the 
local disturbance. There are now considerable heat, smarting and 
burning sensations, which are felt over quite an area, and the morbid 
action spreads rapidly in all directions. Under these circumstances, 
the individual, instead of applying to a regular physician for advice, 
is quite as likely to procure some patented article from an irrespon- 
sible source and apply it to the face, which is thereby, in all proba- 
bility, made very much worse. Such is the early history of very 
many cases of impetigo, which has, we think, got a bad name for obsti- 
nacy because it has so often been badly treated in its earliest days of 
development. In some cases, where no local applications are resort- 
ed to and the eruption is left to itself, the inflammation gradually 
subsides, and the affection passes into a chronic state and remains 
somewhat stationary for many weeks, when, provoked by some slight 
cause, it seems to acquire new life, and the morbid action is greater 
than ever. Several red patches, studded with pustules, spring up 
almost simultaneously and soon coalesce; and in this way it is not long 
before the eruption spreads over quite a large space. This process 
being repeated from time to time, nearly the whole of the face is at 
length covered by a succession of these characteristic pustules and the 
variegated incrustations to which they give rise. The latter present 
different shades of coloration and different degrees of thickness, 
according to their age and according to the amount of inflammatory 
action at the several points of attack. Some are very thick, dry, 
nearly amber-colored and friable; some are of less thickness, pasty, 
tinged with bloody serum, and very dark; while others are of a yel- 
lowish or greenish hue; and still others are met with that are per- 
fectly white and conical in their shape. These latter are compared 
by Alibert to stalactites, and are usually seen on the eyelids, borders 
of the eyebrows, nose, &c. When the eruption has continued for a IMPETIGO OP THE FACE. 
35 
long period, all these different shades of color may be seen at the 
same time, and the diseased surface bears no little resemblance to a 
piece of mosaic work. 
As the eruption advances towards a radical cure, these incrusta- 
tions become gradually thinner and of lighter color, and correspond 
very much in appearance and structure to the laminated crusts of 
chronic eczema. They no longer adhere to the derma, but are shed, 
as numberless flakes or micaceous scales, and at this stage are 
entirely without moisture. Finally they cease to be reproduced, and 
a faintly red surface alone remains to indicate the former site of the 
malady. In some cases, when the inflammatory action is very in- 
tense, it culminates in the formation of several hard hypertrophous 
ridges of the skin, an inch or two in length and raised two or three 
lines above the surrounding integument. These resemble the cica- 
trices of a deep burn, or the thickening of the skin produced by the 
blending of the tubercles of Kelis cylindracea. These ridges often 
remain for some weeks. They rarely exhibit any tendency to ulcer- 
ation, but are carried away by absorption. A case of this kind is 
now under our care. 
Impetigo sometimes confines itself entirely to the upper lip and 
the mucous lining of the anterior nares. The scab is dense and ad- 
herent, making the individual look as if he wore a moustache. In 
other instances the lower lip is the only spot invaded by the malady? 
and here it remains for years unless properly treated. When the 
lips are the parts affected, the purulent discharge is very trifling in 
amount, but the patient experiences particular discomfort from the 
constant recurrence of deep transverse cracks which are liable to 
bleed whenever he laughs or eats; and at times the parts are cov- 
ered with numerous filiform shreds of dry epithelium which prick 
the tongue, and the patient is continually tempted to pull them off. 
This variety of the eruption is commonly seen on young persons. 
The legs and the thighs are often invaded with the disease under 
consideration. The form which is especially apt to attack these 
parts is termed impetigo scabida; a name first given by Willan. 
The pustules commence at some distance apart, and usually on the 
outer aspect of the limb. They burst in two or three days, shed 
their contents upon the surface, where they harden into thick yel- 
lowish brown incrustations which are continually moistened by 
the discharge that is poured out from beneath. In a little time, the 36 
CONTRIBUTIONS TO DERMATOLOGY. 
exudation begins to diminish, and the scabs acquire more solidity 
and seem to be nearly ready to be detached from the derma; when, 
in all likelihood, a new crop of pustules appears here and there, the 
malady extends, and in time nearly the whole limb is encased in the 
thick, rough incrustations, which are cracked in numerous places and 
which give to the limb the appearance of the bark of a tree—hence 
the epithet scabida. The pruritus is very severe. Sometimes the 
eruption extends down to the ankle and along the foot, where the 
scabs are of immense thickness, wrinkled or fissured, and nearly 
black. There is infiltration of the subcutaneous structure, and the 
disease sometimes extends even to the nails, which are broken and 
loosened from their attachment, and the lunula is destroyed. Re- 
lapses are apt to recur, and the malady passes into a chronic state 
unless great care is taken to prevent it. We once saw a very extra- 
ordinary case of this kind produced by the injudicious employment 
of a strong ointment of the iodide of potassium for the cure of 
scabies on a young man. Nearly the entire surface of both thighs 
was encased in thick, dark colored incrustations. 
Individuals are occasionally visited with repeated attacks of im- 
petigo, in immediate succession, sometimes by a continuance of the 
original cause of the eruption, at other times in consequence of the 
use of remedies not well suited to the morbid condition of the affect- 
ed parts. Again, in some instances the complaint returns periodi- 
cally in the spring or autumn for several years in succession. All 
parts of the body and limbs are subject to the disease. The upper 
extremities, however, are usually exempt, unless the eruption has a 
syphilitic origin. In such cases, it is quite common to see large 
crops of pustules and thick, black incrustations nearly surrounding 
the elbow joint and the integument in its vicinity; and the disease 
under these circumstances always assumes a chronic form. The in- 
tegument does not become very deeply infiltrated or thickened, but is 
more or less excoriated, yields a viscous, semi-purulent, or sanguineo- 
purulent secretion, which dries up into incrustations, and these in- 
crustations often form a thick investment upon the part affected. 
Other concomitant circumstances and symptoms will sufficiently aid 
the judgment in arriving at a correct diagnosis in regard to this par- 
ticular variety of impetigo. We mean the history of the case. 
Hardy and Pox, both able writers, speak of a variety of the 
eruption which they term impetigo acniforme, characterized by the IMPETIGO OP THE FACE. 
37 
development in the beard of a number of little vesico-pustules, which 
are isolated, rounded, of transient duration, without any indurated 
base, and about the size of a pin’s head. One may see eight, ten, 
or twelve appear at the same time on the lower part of the face, but 
always discreet and isolated. They last from three to five days, 
when they break and are replaced by crusts. There may be a suc- 
cession of vesico-pustules and crusts, which prolong the disease for 
months and years. This variety of the disease is peculiarly difficult 
to cure. There is no induration of the cellular tissue, no parasite, 
no loss of hairs. To us it seems that the eruption is nearly identi- 
cal with what is denominated by other writers, eczema impctiginodes. 
The distinctive characters of impetigo in all its varieties are, small 
psydracious pustules, not at all, or only in the slightest degree, elevated 
above the surrounding skin; viscous, purulent secretion more or less 
abundant, and thick, yellowish-green, brown, greyish, honey-like or 
semi-transparent incrustations. 
Eczema impetiginodes is a mixed form of eruption, in the com- 
mencement of which there is, as a general rule, vesiculation which is 
to be regarded as constituting the ordinary elementary type of the 
disease, although the discharge at a late day in the progress of the 
eruption becomes like that of impetigo. 
If the chin is the affected locality, the disease may be confounded 
with sycosis. But in the latter, the pustules are larger and on a 
hard indurated base and are phlyzacious and discreet; the secretion 
is scanty, and in certain stages of the affection the presence of par- 
asitic formations can frequently be detected under the microscope. 
The crusts in sycosis are not renewed when they are cast off; where- 
as the contrary is the fact in impetigo. As sycosis becomes chronic 
it generally exhibits little bald patches, from which the hair has 
dropped out; it usually affects the chin only and rarely occupies the 
sides of the face. In these particulars it differs from impetigo. 
Impetigo is sometimes mistaken for scabies. It is true that as re- 
gards the choice of locality the two eruptions often resemble each 
other, in being situated usually upon the back of the hands, the fin- 
gers, about the elbows and the inner and front part of the thighs. 
In impetigo the eruption shows a disposition to heal in the centre, 
while the periphery of the diseased patch remains unchanged; sca- 
bies betrays no such tendency, and if it is situated on the hands wo 
can generally discover two or three suspicious pustules near the 38 
CONTRIBUTIONS TO DERMATOLOGY. 
wrist or along its inner border. These pustules like all others of 
scabies are more hemispherical, distinct and elevated than those of 
impetigo. If scabies is situated on the thigh, it simulates impeti- 
go more nearly than it does elsewhere; but even here there need 
not be any doubt to a careful observer. If the disease is really 
scabies, the itching is more intense and urgent when the limb is ex- 
posed to the air or warmth, than is the case with impetigo. Besides, 
the eruption of scabies spreads with greater rapidity than impetigo. 
Moreover, the two eruptions have a very distinct and dissimilar his- 
tory, which, if investigated, will sufficiently proclaim their individu- 
ality. We need not dwell here upon the presence of the acarus in 
the one and its absence in the other. 
Impetigo is in most cases produced by constitutional causes. 
Among the young, it prevails chiefly in children that are poorly fed, 
poorly clothed, and live in badly ventilated and dirty apartments. 
In persons who are predisposed to cutaneous affections, very slight 
irritants will evoke the eruption. It is frequently developed on the 
face, hands and other portions of the skin in workers in iron, brass, 
silver, copper, &c. Taxidermists also, who make use of large quan- 
tities of arsenic in their occupation, occasionally suffer from this 
eruption on the hands, face and neck, and we have seen several in- 
stances of the eruption on the hands and fingers of individuals 
occupied in the manufacture of a certain modern style of bank notes 
familiarly known as “ greenbacks.” These greenbacks contain arsenic 
in their composition. 
The prognosis is favorable. If the disease is treated judiciously 
it can generally be brought to an end without difficulty in a few 
weeks; but in very many instances the physician finds it impracti- 
cable to call into exercise all those hygienic aids and therapeutic 
measures which the case demands, and then it is apt to become 
chronic, tedious and extremely difficult to manage satisfactorily. 
Treatment of Impetigo in Children. 
If the patient is a nursing child, the milk should be examined under 
the microscope, if practicable, and if found at fault, the child should 
receive its supplies of good nourishment from other sources. If it is 
old enough to be weaned, this change should be made rather than to 
procure a new wet-nurse for it, for in the latter event great risk is 
run, that the blood and therefore the milk of this nurse is of impure IMPETIGO IN CHILDREN. 
39 
quality. The child will thrive well on good milk from the cow, or 
a little cream added to the milk occasionally; strong beef tea now 
and then, will also be proper, care being taken to watch its effect 
on the bowels ,* or it may be allowed to suck a bit of lean beef two 
or three times a day. The above will afford a generous bill of fare 
from which a judicious mother can make a selection that will keep 
her offspring in a healthy state, so far as diet is concerned. Gin- 
gerbread, and all kinds of cake are to be avoided, for they will soon 
take from the child the power to digest the simplest food. Having 
suitably regulated a scale of dietetics, and made all needful provi- 
sion to secure salutary hygienic influences, the way is prepared for 
general and local treatment. In regard to the former, but little is 
required for a young child. 
If the disease is on the head, it will be proper to administer a 
laxative of the submuriate of mercury, one grain rubbed up with the 
same quantity of loaf sugar, and dropped upon the tongue of a child 
from one to two years old. This may be repeated every eight or 
ten days to a child of good general health. If it is of a feeble 
frame and condition, then the calomel is contra-indicated. Tonics 
are called for instead. The syrup of the iodide of iron and Fowler’s 
solution of arsenic, as recommended in the treatment of eczema in- 
fantile in a previous paper, are equally indicated in cases of infan- 
tile impetigo. And these are about all the constitutional remedies 
that are applicable to a young child from one year to eight or ten 
years old. 
The local treatment should now engage our attention. The scabs 
formed by the contents of the psydracious pustules are easily soften- 
ed and made ready for removal by the application of a solution of 
the carbonate of soda; when the scalp is the seat of disease, R 
Soda3 carbonatis, 3 i.; aquae fontanae, § viij. M. Soft rags satu- 
rated with this solution are to be constantly applied to the diseased 
integument, and an oiled silk cap should be placed over the rags to 
prevent evaporation. As soon as the scabs are removed, the raw 
surface should be wiped dry and carefully examined to ascertain if 
any small ulcerated spots have formed, and if so, they should be 
coated over with a weak oxide of mercury ointment, 9 i. to § i. If 
any little abscesses are detected, they should be punctured with the 
point of a lancet. They soon heal up without further trouble. If 
there is much hair on the scalp, it should be clipped short and kept so. 40 
CONTRIBUTIONS TO DERMATOLOGY. 
After the scabs are removed, a solution of the carbonate of soda, 
9 i. to § viii. of water, will make a suitable dressing to the scalp. 
Cloth saturated with this should be laid on smoothly, so that the 
lotion shall come in contact with the entire surface. The pruritus, 
which is generally a characteristic of the eruption in its early stages, 
is in most instances allayed by this local remedy, which is to be em- 
ployed so long as its efficacy is apparent. If it proves inadequate 
to the exigencies of the case, the following will be found an excellent 
adjuvant. R. Acidi hydrocyanici diluti, 3 i.; spiritus vini, gss.j 
emulsionis amygdala?, § viii.; M. Signa.—Lotion. Lint saturated 
with this is to be applied for an hour or two each day, to the affected 
parts; and during the rest of the time the alkaline solution is to be 
employed. If the sedative effect of the hydrocyanic acid is not suffi- 
ciently powerful, it can remain on for a longer time than is mentioned, 
and can be repeated with safety morning and evening. 
The benzoated oxide of zinc ointment is also an appropriate local 
application at this crisis,’especially by night. It should be laid on 
so as to form a thick coating to the scalp, and a night cap should be 
fitted to the head. 
A mixture containing the oil of cade, rectified spirit, and a small 
quantity of caustic potash, and used as a local application, is also 
beneficial when the itching and irritation in the parts are obsti- 
nate. R. Potassae fusae, grs. xv.; olei cadini, § ss.; olei camphor- 
ati, § i.; spiritus vini, § ii. M. A portion of this is to be rubbed 
briskly over the eruption night and morning, and to be washed off with 
warm water and soap before each re-application. As the pruritus 
abates, the lotion may be used less frequently; and during the inter- 
vals of its application the scalp is to be covered with the benzoated 
zinc ointment. 
After the severity of the local symptoms has materially subsided 
and the eruption has passed into a chronic state, an ointment of the 
nitric oxide of mercury will be found appropriate. R. Hydrargyri 
oxidi rubri, grs. xxiv.; pulv. eamphorae, grs. vi.; unguenti simplicis, 
S ii. M. This ointment is to be applied freely two or three times 
a day to the affected surface. In a majority of cases of impetigo 
capitis the foregoing method of treatment will be found efficacious, 
and sufficient to cure the complaint. 
If the face is the seat of the eruption, it may perhaps be imprac- 
ticable to employ lotions with the same freedom as when the head is IMPETIGO IN THE ADULT. 
41 
the locality affected, and our chief reliance must be upon ointments. 
But whether lotions or ointments are to be employed, those which 
have been suggested for the treatment of the complaint wdien de- 
veloped upon the head of a young child, are equally important and 
valuable in our attempts to cure the same affection when it occurs on 
the face or any other region. 
Treatment of Impetigo in the Adult. 
When this eruption makes its appearance on any portion of the 
cutaneous investment of an individual who has arrived at maturity, 
it is in most instances a much more intractable disease to manage 
successfully than in patients only a few months or a few years old. 
The causes that give rise to it and perpetuate it in the adult are 
sometimes a little obscure in individual cases; or if apparent, it is 
not always an easy matter to remove or overcome them. The habits 
or employment and other surroundings of the patient may be so 
entirely antagonistic to good health, and withal so steadfastly fixed, that 
the physician in consultation encounters at the very threshold of 
his endeavors, obstacles of no mean weight and power which stand 
in the way of success. But as regards these impediments there is 
no door of escape. They are to be endured; and the physician is 
expected to proceed and to cure, or peradventure forfeit the confi- 
dence of the patient and his numerous sympathizing friends. With 
these possible circumstances in view, let us consider the best means 
of cure. 
The condition of the system generally is the first thing to be as- 
certained ; and if there is any irregularity in the functions of any 
of the internal organs, these are to receive attention, ahd then the 
way is prepared to make a direct attack upon the cutaneous lesion. 
In very many cases that present themselves, the eruption is quite 
limited in extent and is chronic, and the sides of the face seem, as if 
by preference, to be the parts most frequently implicated. If the 
local inflammation is mild, and the patient otherwise in good health, 
there is no objection to the immediate use of some arsenical prepa- 
ration internally. For this purpose the choice may be Fowler’s 
solution, at the rate of twelve minims a day, or one Asiatic pill a 
day for three or four weeks, unless some gastric disturbance is pro- 
duced by the mineral. After its employment for the time above 
mentioned, it should be taken in the same quantities every other day 42 
CONTRIBUTIONS TO DERMATOLOGY. 
only, and in this way continued for six or eight weeks longer. It 
will be good practice to combine the internal administration of cod- 
liver oil with the arsenic. A common tablespoonful two or three 
times each day will ordinarily agree well with the patient and pro- 
mote his recovery. 
With regard to diet, no special care is requisite other than to 
have the patient live on good, substantial food. Nothing can be 
gained in any case by a starvation plan in the daily allowance of 
food. Stimulating drinks, of course, are to be prohibited. If the 
patient’s health is below a fair standard, it will be advisable to pre- 
scribe for him some ferruginous preparation, such as the judgment of 
the practitioner may prefer. The tincture of the chloride of iron is 
our choice, then the citrate of iron and quinine, tartrate of iron 
and potassium, or mistura ferri composita, the latter in pretty large 
quantities if anaemia decidedly exist. 
The liquor hydriodatis hydrargyri et arsenici (Donovan’s solution) 
is recommended by some authorities; but it is an exceedingly poten- 
tial agent, and is not very uniform in its effects, nor yet manageable, 
and will seldom act in a way to warrant its employment for any length 
of time. After a few doses of only a few drops each, the stomach is 
apt to manifest great repugnance to its presence, and its use has to 
be abandoned. Such, at least, has been our experience with it. 
If the complaint originates in a venereal diathesis, as is but too 
often the fact, it may be expedient to administer minute quantities 
of the bichloride of mercury in conjunction with the iodide of potas- 
sium for several weeks, or the mercury may be alternated with some 
of the preparations of iron, or with some of the mineral acids. 
Local Treatment.—Whatever part is affected, ointments of differ- 
ent kinds are the chief local means to be employed. Of these are 
several which stand about on an equality with each other. If the 
case is an ordinary one, and not attended with a great amount of 
inflammation and pain, the nitric oxide of mercury ointment may be 
applied. R. Hydrargyri oxidirubri, 9i.; pulveris camphorm, 9ss.; 
glycerinas, 3 i.; unguenti benzoati, § ij. M. The diseased surface 
is to be kept constantly covered with a portion of this ointment, 
which should be renewed three or four times in the twenty-four 
hours. 
In the chronic stages of the eruption, good results will follow the 
frequent use of a local steam-bath, which can be administered by the IMPETIGO IN THE ADULT. 
43 
patient himself by means of a wash-bowl of hot water and a napkin. 
Let some eighteen or twenty minutes be devoted to this procedure, 
and the oftener it is repeated the greater will be the benefit. It will 
keep the diseased surface free from incrustations, and will also great- 
ly tend to diminish the local engorgement of the capillaries and 
equalize the circulation in these vessels. In the earlier stages of the 
complaint, and while the inflammation is at a high point, this remedy 
is not beneficial. 
The oxide of lead is a valuable discutient application in old cases, 
where there is a good deal of thickening and infiltration of the in- 
tegument, and more especially if there is chronic glandular swellings 
in the cervical region; and it is appropriate for individuals of all 
ages. R. Plumbi iodidi, 5 ij.; pulveris camphor®, 9ss.; unguenti 
simplicis, § ij. M. The iodide of sulphur is an ingredient of well- 
known efficacy in the local treatment of this eruption. The follow- 
ing is a suitable formula:—R. Sulphuris iodidi, 9i.; pulveris cam- 
phor®, 9 ss.; olei bergamotae, gtt. x.; unguenti simplicis, § ij. M. 
There is another preparation of sulphur which is entitled to confi- 
dence. It has for many years borne the test of a large experience 
in almost every medical man’s practice in this country; and in pre- 
senting it in this connection we bring to mind an encomium once 
passed upon it in our hearing by an eminent surgeon, who, speaking 
of it as a local remedy, said that “ it would cure anything.” The 
formula is as follows:—R. Pulveris ammoni® chloridi, 3 i.; olei 
camphorati, 3 i.; glycerinse, 3 ij.-iij.; sulphuris sublimati, unguenti 
simplicis, aa § i. M. The quantity of glycerine can be varied at 
pleasure, according to the desired consistence of the ointment. The 
ammonia should be reduced to an impalpable powder before being 
mixed with the other ingredients. This preparation is particularly 
adapted to the disease when it is in a chronic state and situated on 
the face or head. 
If a topical remedy of a soothing character is required at any stage 
of the treatment, the following will be beneficial:—R. Liquoris 
plumbi, 3 i.; olei camphorati, aqu® calcis, aa § ij. M. Signa. 
Liniment. Or the almond emulsion, with prussic acid, the formula for 
which has already been given, may be employed. For the removal 
of incrustations, which are sometimes very thick and troublesome, 
particularly in the adult subject, and also with a view to diminish any 
profound infiltration, the alkaline lotions, warm emollient fomenta- 
tions, and poultices will be required. 44 
CONTRIBUTIONS TO DERMATOLOGY. 
If the eruption is on the face, the beard and whiskers should be 
kept short with scissors. The treatment now set forth is all that is 
required in the cure of the disease under consideration, whatever 
portion of the cutaneous membrane may be affected. 
An attack of impetigo docs not possess the clinical advantage, of 
destroying in the economy the liability to a second invasion, as is the 
case with the eruptive fevers which have their origin in specific poi- 
sons ; but on the contrary, we are obliged to acknowledge that an in- 
dividual who has once suffered from it, or from eczema, is a prominent 
candidate for subsequent manifestations of the same complaint. 
Scabies. 
This eruption is endowed with an ubiquity unsurpassed by any 
other cutaneous disease. It prevails in all climates, at all seasons, 
among all ages and descriptions of men, women and children—thus 
showing that it is no respecter of persons. It has its origin in an 
animal parasite which has received the names of acarus scabiei, sar- 
coptes hominis, &c. &c. It is found more frequently among the poor 
than the rich, on account of the crowding together of the former, 
and their greater liability to contract those diseases which are pro- 
pagated by contact. Neglect of personal cleanliness is only indi- 
rectly instrumental in the production of scabies. It furnishes a foot- 
hold for the disease, while the rapidity and extent of the invasion 
are in proportion to the unguarded state of those parts of the integu- 
ment which are first attacked. The use of the stronger alkaline 
soaps by the poorer classes is one of their greatest safeguards 
against the complaint; not alone because it insures a clean skin, but 
because it destroys at the same time the living cause of the malady. 
More will be said on this subject in the treatment. 
This affection has been familiarly named the itch, from its most 
characteristic symptom. In no other cutaneous disease is the pruri- 
tus so intense as it is at times in this. The intolerable itching and 
the mechanical irritation of scratching, by which the patient seeks to 
afford relief to the perverted sensibility of the skin, are the causes 
of many of the subsequent lesions of this organ. The condition of 
the system and the duration of the disease are potent agents in the 
character and extent of the eruption. Its chronicity is often due SCABIES. 
45 
not only to the neglect of proper measures for destroying the animal 
parasite which is it’s cause, but also, it is probable, to the deteriora- 
ted condition of the tegumentary and general system in consequence 
of the excessive nervous irritation. If we omit, for the present, the 
characteristic lesions which are produced by the burrowing of the 
parasites, the earliest appreciable change in the condition of the skin 
is the pruritus. This is at first of a purely local character. As the 
disease becomes more extensive, the pruritus is not limited to those 
parts of the integument which present the traces of the acari, but is 
of a general character. It is possible that a portion of this exces- 
sive nervous irritation is subjective. The pediculus corporis fre- 
quently occasions a similar excitable condition of the different por- 
tions of the entire surface of the body, although a few only may be 
present, and these at places remote from the seat of pruritus. 
Much has been said about the regions of the body upon which the 
acarus of scabies is most commonly found. This would be of little 
importance did it not sometimes furnish a distinctive element in the 
diagnosis of the disease. The positive statements of some writers 
upon this subject would seem to leave no doubt as to the places of 
election in this disease. Certain observers, as the Germans, are in 
the habit of examining the nates as one of the most favorable re- 
gions for the purpose of finding the characteristic burrows of the 
acari; others, as the French, are not satisfied until the prepuce and 
glans penis are thoroughly exposed; while the English and American 
dermatologists are contented if they find a burrow between the fin- 
gers, or in the palms of the hands, or the soles of the feet. There 
is no doubt but the burrows or cuniculi are to be found in all these 
regions in most cases. Warmth and undisturbed condition of the 
parts are both favorable to the attacks and the propagation of the 
parasites. All those influences, whether atmospheric or chemical, 
which disturb the above conditions, render the soil so far unfit for 
the habitation and multiplication of the itch insect. Habit and the 
occupation have also much to do in affording facilities for its inroads. 
Shoemakers are most liable to the localization of scabies on the nates 
from the habitual warmth of these parts. Those whose hands are 
constantly wet or exposed to cold, or in contact with acrid sub- 
stances, are seldom affected with scabies on these parts. The deli- 
cate skin of women and children affords the most favorable condi- 
tions for the general distribution of the acari. Thus, we find the 46 
CONTRIBUTIONS TO DERMATOLOGY. 
cuniculi not only upon the hands and feet of children, but elsewhere 
upon the surface. In infants, the soles of the feet are often the best 
places for finding the furrows. They are also found in the palms of 
the hands, and may be rendered more apparent if ink is spread over 
the suspected part and in a few minutes wiped away with a rag that 
is slightly moistened with water. The loose, dead epidermic cells im- 
bibe the coloring matter and are blackened by the tannate of iron, 
so that the furrows appear either as straight, curved, or tortuous 
lines, or composed of series of little black dots. The usual length 
of one of these little canals is two to three lines; they may, how- 
ever, be much longer. They are situated in the epiderma, and are 
caused by the female, which penetrates this tissue for the purpose of 
depositing her eggs. The parasite may be removed by means of a 
pin or needle pushed into the open end of the canal and raised so 
as to rupture a portion of the cuticle which forms its exterior cover- 
ing. The animal is then displaced most easily by the blunt point of 
a pin. It is very minute, glistening, and just distinguishable by the 
unassisted eye as a little oval, pearly mass. A lens magnifying five 
or ten diameters will reveal its movements to the eye and some of its 
most distinct characteristics. Higher magnifying powers will be re- 
quired in order to study the details of its structure. 
The disease presents certain distinctive features, which are imme- 
diately recognized as soon as it is seen by the experienced observer. 
The presence of the burrows helps to confirm the diagnosis, but is 
not altogether essential to the validity of our conclusions. YFe re- 
cognize scabies as we do the familiar features of an old acquaint- 
ance, not from a minute examination of the individual traits, but by 
the general aspect. Indeed, diagnosis in all skin diseases is much 
facilitated in this manner, to say nothing of the broader basis upon 
which our conclusions are thus made to rest. It is safe, then, if, in 
the presence of other well-pronounced symptoms, there is a failure 
for some reason or other to detect the furrows, to still adhere to our 
opinion that the disease is scabies ,* since our general convictions are 
often the most reliable ones in such cases. 
The eruptive appearances in scabies are quite various. They con- 
sist of papules, vesicles and pustules; and of all of the conditions of 
the skin which arise from the elementary lesions. They constitute, 
apart from their cause, and the peculiarities of their situation, all of 
the different grades of inflammation which are to be found in an 
eczematous or impetiginous affection. THE ACARUS. 
47 
The papular and vesicular forms of the eruption are, however, of 
the most common occurrence in scabies. Generally speaking, it is 
in the chronic forms, or when the disease attacks the debilitated, that 
a pustular eruption makes its appearance. This is peculiar, even 
then, to certain portions of the skin, such as the hands and feet, in 
most instances. In children, also, it is more liable to occur than in 
adults. The papules are quite numerous upon the back of the hands 
and upon the arms. The vesicles occur upon the inner borders of 
the fingers; and the pustules are also found in the same position, and 
likewise in the palms of the hands. In the latter situation they are 
broad and flat, on account of the thick and unyielding nature of the 
epiderma. 
The Acarus. 
The length of the acarus is about of an inch, and its breadth 
about the same when arrived at adult life. The head is oblong, 
obtusely pointed, short-set; has slightly dentated jawrs, with upper 
and lower lips, and is capable of elongation or retraction at will 
from beneath the dorsal plate, or carapax, as it is termed. It has 
two eyes, placed laterally near the attachment of the head to the 
body. The animal has eight legs, of which four are near the head, 
ending in sucking cups or discs, and four more posteriorly inserted, 
each terminating in a bristle. It has twelve hair-like filaments, or 
spines, projecting backwards from the posterior segment of the body, 48 
CONTRIBUTIONS TO DERMATOLOGY. 
some long and some short, and being all directed backwards they 
assist the creature in its attempts to penetrate the epidermis with 
its flattened snout, and render any retrograde motion or retreat ut- 
terly impossible. The males are much less numerous than the females 
(1 to 10, according to Bourguignon). The move- 
ments of the male are much more rapid than 
those of the female. The form of the acarus has 
been compared, and not inaptly, to that of a tor- 
toise. Under a high power of the microscope, 
it appears almost transparent. The male makes 
no furrow or cuniculi; he either burrows a short 
distance in the cuticle or is found on the surface. 
The female produces the cuniculi for the purpose 
of depositing her ova, which vary in number from 
25 to 50. Some observers tell us that she de- 
posits one ovum each day until she completes 
this labor; others state that she lays four eggs at a time, and that 
the period of incubation extends over three or four days. During 
this process the acarus remains at rest in its furrow. The eggs are 
arranged either in pairs, the outer surface of each touching the walls 
of the furrow, or they are disposed in a single line. 
The contagious nature of scabies depends on the transmission of 
sarcoptes of both sexes, or of a pregnant female, from one person to 
another. A single unimpregnated female or male acarus alone can- 
not produce the disease. 
The two accompanying wood-cuts represent the female acarus 
and the moniliform arrangement of her ova, together with frag- 
ments of excrementitious matter as deposited in the cuniculi. 
Diagnosis.—To those who are not perfectly familiar with cutaneous 
eruptions the diagnosis of scabies is not always an easy matter; and 
yet a correct diagnosis is of the highest importance, not only as re- 
gards the reputation of the attending physician, but also because an 
erroneous decision may throw a whole family off their guard and 
cause all its members to be infected with the loathsome malady in 
question. And we could relate more than one instance where a phy- 
sician has lost desirable family practice in consequence of mistake 
in regard to this disease. 
The sulci or furrows which are the characteristic mark of the 
presence of the acarus, may often be detected on the buttocks, on the THE ACARUS. 
49 
lateral surfaces of the fingers, or on the inner margin of the wrists* 
and in young children on the inner edge or border of the feet. These 
furrows or cuniculi are more frequent in the papular form of scabies, 
than in the vesicular or pustular varieties. The desirableness of find- 
ing the cuniculi, acari and their ova, is admitted; but it sometimes— 
indeed we may say it frequently happens, that neither the one nor 
the other can be detected, especially when the eruption has become 
chronic and chiefly pustular in character; and the diagnosis must be 
established by considering its locality, its history, its present appear- 
ance, and in ascertaining whether there is evidence of its contagious- 
ness or otherwise. 
The eruptions with which scabies is likely to be confounded are 
eczema simplex, lichen simplex, and prurigo. 
Eczema simplex presents vesicles more flattened, and clustered to- 
gether, and less acuminated and less discrete than those of scabies. 
The pruritus in the two diseases is very different. In eczema it 
amounts to a painful smarting sensation; and scratching does not 
relieve, but rather augments it: whereas in scabies the sensation is 
not altogether unpleasant, and a thorough application of the nails is 
an efficient and delightful remedy. 
Lichen simplex always attacks the dorsal aspect of the hands, arms, 
and legs, and never appears in the inter-digital commissures. The 
papules are exceedingly small and are generally closely grouped to- 
gether, which is rarely the fact with scabies. The papules of lichen 
are of the color of the skin and produce but very little itching. In 
young children and in adult females with soft tender hands, the erup- 
tion of scabies is very often seen in the palms :—there will be, per- 
haps, some half a dozen vesicles or large and flattened pustules scat- 
tered here and there in this locality. 
Prurigo is also a papular eruption developed in places exactly op- 
posite to those attacked by the itch. When the papules of prurigo 
are torn by scratching, little black scabs are formed on the summit; 
whereas the scabs in scabies are merely thin yellowish scales loosely 
attached to the parts beneath. 
A peculiar rough scaliness or desquamation of the epidermis in 
the immediate vicinity of the eruption of scabies is a fact spoken of 
by some dermatologists, by others not. When the eruption is seated 
on the hands, this furfuraceous condition is most observable in the 50 
CONTRIBUTIONS TO DERMATOLOGY. 
space between the thumb and index finger. The same appearance 
of the cuticle is exhibited when the disease occupies the elbow, the 
inner border of the axillae, or the loins. The condition of the sur- 
face here referred to is produced by the repeated efforts of the para- 
sites in their search after food and shelter. We have often observed 
it in chronic cases, and have directed the attention of those who were 
in a position to examine several cases of scabies daily for a long 
period, to this diagnostic mark. They have fully confirmed the ob- 
servations of Prof. Wilson and our own in regard to this point.* 
By most dermatologists the physician is taught how to extract with 
a pin or needle the acarus from its retreat in the little mound at the 
terminus of the furrow which it cuts through the epidermis, and how 
to transfer it to a glass slide for microscopical examination, and thus 
determine with certainty the nature of the eruption. This procedure 
is truly scientific; but let us see to what extent it can be reduced to 
practice. Probably not one physician in forty in this country is the 
owner of a microscope, so that to the great mass of the medical pro- 
fession all directions given for obtaining the parasite as the es- 
sential element in diagnosis are, for all practical purposes, a dead 
letter; and other methods of identifying scabies must be employed; 
and in our opinion there is none superior to an exact knowledge of 
the several cutaneous affections particularly mentioned a moment ago. 
This knowledge is always available, whether the physician is at home 
in his office or abroad among his patients; and with it he never need 
falter in arriving at a differential and correct diagnosis. The micro- 
scope long since performed a valuable service in revealing the cause 
of scabies; but it does not describe the eruption itself; and unless 
physicians generally acquire the ability to recognize the disease in- 
dependently of this instrument, is it not truth to say they never will 
be able to recognize it ? 
In very chronic cases the eruption of scabies sometimes covers the 
entire cutaneous surface; in young infants including the scalp. Where 
the complaint occupies such extensive ground, the papular form is 
usually developed on the scalp, the back, abdomen, and upper portion 
of the extremities. On the hands, fore-arms, feet, ankles and buttocks, 
the disease is vesicular or pustular, or more frequently both. Oc- 
* Nayler and Caillault make mention'of the same peculiarity of the skin in connection 
with scabies. THE ACARUS. 
51 
casionally a few pustules appear on the inner aspect of the thighs. 
Here, as well as elsewhere, they acquire a much larger size and are 
more distinct than those of impetigo, and they push higher upward, 
above the adjacent surface. Where the disease has continued un- 
checked for a long period in young subjects, the whole of the hands 
and fingers is completely covered with the eruption, and they become 
badly swollen and painful, the patient being scarcely able to bend 
the fingers. Sometimes little abscesses form on various portions of 
the surface during the existence of scabies as a consequence of the 
excessive irritation which this disease produces. Sometimes the erup- 
tion seizes upon the front of the elbow joint as a principal locality 
and where the delicacy of the cuticle offers facilities for the parasite 
to take lodgings. So in like manner the nipple of the female is oc- 
casionally the seat of the disease, while perhaps other parts of the 
surface are nearly free from it. The skin around the base of the 
nipple becomes excoriated and quite painful, and a slight discharge 
takes place. The eruption in this locality is usually of a vesicular 
character. 
Treatment. 
Wc shall consider somewhat briefly this point of our subject; con- 
tenting ourselves with the indication of those remedies which seem 
to be most efficacious, and which are least objectionable and expen- 
sive to. the patient. 
Alkalies form the base of nearly all the parasiticides in use for 
the cure of scabies. They are the most reliable, the safest and 
least obnoxious to all parties. Sulphur has been regarded as a 
specific in this disease; but as it is in nearly all cases combined with 
lard and potash or some other alkaline ingredient, the inferences 
drawn from its use are not wholly conclusive as regards its curative 
agency. 
Alkalies not only act upon the epiderma, and destroy and remove 
its superficial portions, but are among the most deadly parasiticides 
which have yet been discovered. They are cheap, cleanly, and always 
at hand whenever needed. Nearly all the valuable preparations, 
whether ointments, lotions, or soaps, in use for the treatment of sca- 
bies, contain an alkali in some form or other. The famous pomade 
of Helmerick contains the subcarbonate of potassa; the lotion of 52 
CONTRIBUTIONS TO DERMATOLOGY. 
VIeminckx, of Brussels, used in the Belgian army, and afterwards 
endorsed and recommended by Prof. Hebra, of Vienna, contains caus- 
tic lime, and is in fact a penta-sulpliide of calcium; and Wilkinson’s 
ointment has as one of its principal ingredients the common black 
soap, or sapo viridis, which is used for domestic purposes throughout 
Germany. In our own country we have a soap much superior to the 
above in its detergent and other qualities. It is commonly made, in 
the rural districts, from the ley obtained from the ashes of the hard 
varieties of wood; and consequently contains potash in combination 
with fat or grease. This soap is used by the masses for the ordinary 
purposes of ablution, and is seldom followed by injury to the skin. 
It removes the unhealthy cuticle; and is perfectly destructive to para- 
sites of all descriptions. 
A few years since, at our suggestion, Dr. Howard F. Damon, then 
Superintendent of the Boston Dispensary, instituted a series of ex- 
tensive trials with this remedy, for the cure of scabies. The dis- 
ease was then fearfully prevalent among the poorer classes, being 
brought home by soldiers on their furloughs from the Union armies. 
Probably at no time was there ever a better opportunity among us 
for the trial of such a remedy as this. From the several hundred 
cases thus treated, Dr. Damon reports to me the most satisfactory 
results. In no instance has he known this remedy to fail when it 
has been thoroughly applied; and rarely, if ever, is there any eczema 
in consequence of the application of the common domestic soft soap 
to the skin, in the treatment of scabies. After a fair trial of this 
article, Dr. D. concurs with me fully in the opinion that it is in seve- 
ral respects superior to the parisiticides now in use, and no remedy 
is cheaper or more ready at command. The proper mode of apply- 
ing it is as follows:—Suppose the hands, wrists, &c. to be the parts in- 
volved in the eruption. The patient is to rub upon them about a com- 
mon table-spoonful of the soap, using brisk friction at the time. Let the 
soap remain on until it produces a pretty severe smarting or tingling 
sensation. It may then be washed off with warm water, and the parts 
wiped dry. The same process is to be used for any part of the surface 
if necessary. Sometimes one application is sufficient; sometimes 
two or three may be required and may be repeated every third or 
fourth evening. These will be enough to cure all ordinary cases. 
If the eruption is very extensive it will be prudent to subject only a THE ACARUS. 
53 
part of the diseased surface to the action of the soap at any one time. 
For instance, the hands and arms at one time, and the next time 
the legs or a portion of the trunk of the body. There is quite a 
difference in individuals in regard to the length of time they can al- 
low the soap to remain on comfortably to themselves. Those of pe- 
culiarly nervous temperament or very delicate skin can tolerate it 
only a few minutes, while others can bear it two or three hours be- 
fore washing it off. For infants and very young children an ointment 
containing from ten to fifteen grains of the iodide of potassium to the 
ounce of lard, and applied every second or third night, is a perfect 
parasiticide in scabies. In recent cases a single application is often 
sufficient. 
The Yleminckx solution cures the itch very rapidly, although it is 
a disagreeable remedy and very harsh for the delicate skin of females 
and young children. It is prepared in the following manner. Put 
g ij. of sublimed sulphur and g j. of quick lime into g xx. of water. 
Boil down to g xij. Stir the ingredients with a stick while boiling. 
Filter. The patient dips a brush made of bristles into the fluid and 
proceeds to paint the affected skin. As the fluid dries on, it leaves 
the surface of a yellow color from the powder which is deposited. 
The powder may remain undisturbed upon the skin for two, three or 
four hours, unless the smarting and pain become too severe. Of 
course it can be washed off at any time, if the patient is unable to 
bear it. One application is frequently enough. If its caustic action 
or that of the soft soap renders the skin raw or very tender, equal 
parts of glycerine and water, or a little cold cream can be smeared 
on. 
I propose to close this article with the following quotation from a 
brief communication in a late number of the London Medical Times 
and Gazette:— 
“ To establish a new colony, it will not suffice that a male acarus, 
however potent in himself, should step across from one person to 
another, nor that an unimpregnated female should alone. They must 
go in pairs, like the animals into Noah’s ark, or else the race cannot 
be perpetuated. But imagine a single pregnant female crossing, and 
the thing is done. As soon as she brings forth her litter the colony 
has begun. But the acarus is not adapted for these Leotard-like 
feats, and the pregnant female is always deep in the epidermis, tun- 54 
CONTRIBUTIONS TO DERMATOLOGY. 
nelling her way on, and laying her eggs as she goes. Now, as she 
tunnels, she, like all other engineers, makes air-holes through to the 
surface of the epidermis (these may be readily seen through a weak 
lens). Through these the young acari, when hatched, escape, to set- 
tle in some more or less distant part of the skin, if not disturbed 
before they are hatched. But the unhatched ova are a dust as fine 
as the pollen of a plant, and if the moist skin of the infectee only 
touch the skin of the infector, which is pierced with these little pores, 
which are full of half extruded ova, several of them are sure to stick 
to the infectee’s skin, and so (nefandum dictu) he catches the itch.” 
This affection of the shin is characterized by large and prominent 
pustules, generally but few in number, and having a hard base, with 
a dull-red areola. These pustules are models or types of the phly- 
zacia of Willan. They appear in successive crops on different parts 
of the body, but most frequently on the extremities, shoulders, and 
buttocks. They are usually discrete, although occasionally several 
arise in the immediate vicinity of each other and coalesce. When 
they reach their maturity they dry up into thick, brown and adhering 
scabs, which, when they are detached, leave behind them superficial 
cicatrices, or dark-red stains, which remain for several weeks. 
Rupia approaches in all its leading features very nearly to ecthy- 
ma. Hardy considers the two eruptions as in reality but one, and 
his views are adopted by other dermatologists. Both eruptions 
spring from causes that induce an impoverished state of the blood, 
and consequently debility of the economy to a greater or less de- 
gree ; and both pursue a similar course, and require similar treat- 
ment. 
Ecthyma is usually partial and successive; in some instances gen- 
eral in its invasion. Sometimes it continues but ten or twelve days, 
at other times it endures for many months. Willan divided the 
affection into four varieties, according to the constitution and age of 
the patient, viz.: ecthyma vulgare, ecthyma infantile, ecthyma luridum, 
and ecthyma cackecticum. These four varieties, however, can with 
Ecthyma. ECTHYMA. 
55 
propriety be described under two types or forms, that is, acute and 
chronic ecthyma. 
Acute ecthyma is most commonly developed upon the lower extre- 
mities, sometimes upon the arms, shoulders and neck; but rarely 
upon the face or scalp. It does not often give rise to very severe 
constitutional symptoms. The individual occasionally complains of 
slight febrile disturbance and sore throat for three or four days, 
while the pustules are being developed. These commence with a 
sense of pain, heat and burning in the part, followed by the appear- 
ance of small red points raised one or two lines above the surround- 
ing skin, with hard indurated bases and well-marked and vivid 
areolas. In three or four days purulent matter is formed, and the 
pustule varies in size from that of a pea to a marble at the base. 
When first- formed they are like “ blind boils.” If the eruption is 
copious and is scattered over the limbs, shoulders, back and chest, as 
it is occasionally, a good deal of irritation is set up. The patient 
is deprived of rest; the neighboring glands and lymphatic vessels 
are inflamed and abcesses form. In aged people it frequently passes 
suddenly from its simplest type to a much severer form, and a gan- 
grenous condition of the affected locality supervenes (ecthyma 
gangroenosum). Sloughs form in the centre of the diseased mass 
very rapidly—an intractable ulcer is established, and the local 
disturbance soon involves the whole system and the patient dies 
suddenly. Sometimes the purulent deposit is removed by absorp- 
tion, and the skin is restored to its natural condition after repeated 
desquamation. 
In aged persons the pustules acquire larger dimensions than in 
the young. When the eruption appears upon the latter, the consti- 
tutional symptoms, sometimes by their intensity and the reaction 
which they excite, resemble the prodromata of the eruptive fevers or 
an outbreak of herpes; but these phenomena pass away as soon as 
the pain and burning sensation in the skin begin to subside. 
On carefully examining the pustules of ecthyma, M. Rayer states 
that we recognize: 1. That in the first stage (red elevations) there 
is merely a sanguineous injection with a pyriform tumefaction of the 
epidermis; 2. That in the second there is deposited upon the sum- 
mit of these elevations, rarely upon the whole surface, and under 
the epidermis, a certain quantity of purulent serum; 3. That in the 56 
CONTRIBUTIONS TO DERMATOLOGY. 
third, which supervenes soon after, there is deposited a quasi-pseudo- 
membranous substance in the centre of the elevation which is evi- 
dently perforated ; 4. That after the escape of this matter and the 
removal of the epidermis the pustule appears in the form of a small 
cup-shaped cavity, surrounded by a hard and thick edge; 5. On 
the following days this thickened margin subsides, at the same time 
a slight cicatrix is formed beneath the crust, the centre of which is 
fixed within the point where the perforation was observed. 
Chronic Ecthyma.—This variety of ecthyma is more frequently 
met with than the acute. The eruption appears in successive crops, 
and persons of a debile or cachectic habit are particularly liable to 
be its victims. It is confined to no age, although it is the form de- 
signated by Willan, ecthyma infantile. It is true that children who 
have been poorly nourished and confined in badly ventilated tene- 
ments, are very commonly sufferers from this affection; but no more 
so than aged people, and debilitated subjects. The pustules, like 
those of the acute form, vary in size; the crusts are dark; the ulce- 
ration is sanious and yields a foetid and unhealthy pus. If the com- 
plaint is developed in an ill-fed and weakly child, the patient is very 
apt to become hectic, and after struggling a few months against the 
malign influences of insufficient nourishment, an unhealthy atmos- 
phere, and the slow but constantly advancing progress of the malady, 
it dies. 
In elderly people and in those who have injured themselves by 
improper living, the pustules are generally numerous, and extremely 
slow in reaching maturity. They are of a very deep livid color; 
are surrounded by a great extent of diffuse inflammation, and contain 
a sanguinolent, curdy fluid, rather than pus, which escapes from its 
confinement in ten or twelve days. The subcutaneous cellular tissue 
is involved, and there is a good deal of febrile action. The eruption 
then bears a close resemblance to the bullae of rupia. 
All the sub-varieties mentioned by different writers, under the 
head of chronic ecthyma, are but different stages of one and the same 
disease. 
The causes of the eruption are bad nursing, bad air, or any long- 
continued irritating applications to the skin; hence it is occasionally 
met with especially in children who have had scabies, and have been 
subjected to the external employment of sulphur and other harsh 57 
ECTHYMA 
means of destroying the parasites. In adults, over-exertion, fatigue, 
privation, debility and certain occupations—as, for example, that of 
bricklayers, grocers, butchers—and excesses of various kinds, are all 
conducive to the occurrence of ecthyma. The eruption frequently 
follows smallpox, measles and scarlatina; and last, but not least, 
in the catalogue of causes, is syphilis, either hereditary or acquired. 
The diagnosis of ecthyma rarely presents any difficulties. The 
large size, prominence, and hard base of the pustules and their isola- 
tion, are usually sufficient to distinguish them from the small, non- 
indurated, flattened pustules of impetigo which are superficial, more 
or less confluent, and yield a greater amount of viscid, purulent 
matter, and the incrustations produced by them are soft, thin, semi- 
transparent, honey-like, or yellowish. 
The pustules of acne and sycosis sometimes resemble those of 
ecthyma, but in the latter there is always a much broader base and 
areola, while in the two former the hard tubercle-like elevations 
without areolae distinguish them. 
If the eruption arise from a syphilitic cause, it is usually of a more 
chronic character with a less marked areola or none at all; often a 
coppery stain is detected; the scab is very dark with circular mark- 
ings, and there is generally a history to the case which clears up 
any doubt. 
Although ecthyma of itself is not a dangerous malady, yet when 
viewed in connection with the impaired state of the constitution 
which is but too apparent in very many subjects, the prognosis is of 
a grave character. 
Treatment of Ecthyma.—We have seen that the complaint is one 
of debility; our therapeutic treatment should consist therefore in the 
administration of remedies calculated to restore the enfeebled pow- 
ers of the constitution; and all our local measures to the diseased 
surfaces must be of a tonic character. The first object of inquiry 
should have reference to the condition of the primse via). The 
bowels should be moved by a mild purgative, and a free eliminative 
action be maintained in them. In all other respects our course 
should be essentially hygienic during the continuance of the affec- 
tion. The patient should be removed from all enervating influences, 
and should have the important benefit of salubrious air, cleanliness 
and a generous diet. If the patient is an infant, a sufficient quantity 58 
CONTRIBUTIONS TO DERMATOLOGY. 
of good milk from a wet-nurse, or the cow, is the only nourishment 
that need be sought for it. This, together with the other means 
just mentioned for improving its physical condition, will, if the case 
is of trifling severity, be all that the child will require for its restora- 
tion. If any constitutional remedial agents shall be deemed necessa- 
ry, the syrup of the iodide of iron in doses suited to the age, will 
be one of the best. The Fowler’s arsenical solution to the amount 
of one or two drops each day, may also be administered in the wine 
of iron and simple syrup. If the general health of the child im- 
proves, little trouble or anxiety need be entertained in regard to the 
eruption, which will hardly fail to disappear in proportion to the 
improvement of the general health of the child. 
If the malady is of a chronic type and is apparently due to a , 
syphilitic cause, the bichloride of mercury is called for, and may be 
given with the two-fold object of acting as a tonic upon the system and 
of annihilating from it if possible the specific cause of the eruption. 
The iodide of potassium is also another ingredient which can be em- 
ployed advantageously in the circumstances here supposed, and these 
circumstances, we are free to remark, occur quite often in the history 
of chronic ecthyma. Relapses frequently supervene in a few weeks 
or perhaps months after every vestige of the eruption has disappear- 
ed. The only course of procedure is to resume the former medication. 
It is a matter of encouragement to know that such renewal of attack 
is in most instances far less formidable than its predecessor, that is, 
if the general condition of the child has improved satisfactorily; 
otherwise the case may well inspire our gravest apprehensions. 
If the patient is an adult he must be placed under the most auspi- 
cious influences for the promotion of his general health. He must 
lead a regular life as regards all his personal habits; be well supplied 
with the most nourishing food, of which milk stands pre-eminent in 
the list—his residence to be in a salubrious situation, and he should 
practise ablution every day in warm water, with carbonate of soda 
in it at the rate of three or four ounces to 25 or 30 gallons of 
water. Treated in this way the crusts will very soon be loosened 
or entirely cast off, so that the little atonic ulcers can be brought 
into a healthy condition by means of stimulating applications. Among 
these a saturated solution of the sulphate of copper is one of the 
most efficient. The surface of the ulcers should be touched with RUPIA. 
59 
the solution once or twice every twenty-four hours, by means of a 
soft rag-mop. The acetate of lead ointment is a valuable article 
for topical use, likewise the benzoated oxide of zinc ointment of 
Bell. A saturated solution of nitrate of potash, applied three times 
a day, will promote their cure. In all cases of mild, acute ecthyma, 
the foregoing treatment is amply sufficient to bring the eruption 
rapidly to an end. 
In the chronic variety additional measures are required. For in- 
ternal use the mineral acids are important. The nitro-muriatic is 
perhaps the best. It may be administered as in the subjoined pre- 
scription: R Acidi nitro-muriatici, 3 iij.; infusionis quassim, § viij. 
M. Dose, one drachm three or four times a day, in half a gill of 
water. 
The tincture of the muriate of iron is also an excellent tonic for 
persons of dilapidated constitutions from dissipated habits. Cod- 
liver oil is to be prescribed to nearly all cases, old or young, at the 
same time with any of the other ingredients mentioned. 
The iodide of potassium is entitled to confidence, also, in this 
eruption, more especially if the patient is suffering from the venereal 
poison. He should, in fact, be treated as for constitutional syphilis. 
The local treatment of the chronic variety of ecthyma is substan- 
tially the same as that pointed out under the head of acute ecthyma. 
In cases of uncommon obstinacy some additional topical dressings 
may be needed, as weak nitric oxide of mercury ointment, or the 
unguent, hydrarg. nitratis diluted with simple ointment. 
Rupia. 
This cutaneous affection is directly germain to ecthyma. By some 
writers it is viewed as simply a variety of it. Whatever shade of 
opinion may prevail upon the subject, it seems evident, as we study 
the two maladies, that there is a very intimate pathological alliance 
between thjein. In addition, however, to what has been offered with 
regard to ecthyma, there are a few points which merit consideration 
as exclusively pertinent to rupia, of which there are two varieties— 
rupia simplex and rupia prominens—according to the severity of the 
disease and the form and thickness of the crust. The simplest form 60 
CONTRIBUTIONS TO DERMATOLOGY. 
of the eruption commences by the development of a bulla or tubercle, 
which varies in size, and is filled with a nearly transparent, serous 
fluid, which very soon loses its hyaline character by being mixed 
with sanious or purulent matter. This concretes and hardens into a 
thick, dark-brown and rough crust, resembling that of ecthyma of 
the severer form, and remains adherent to the derma for an indefi- 
nite period, unless removed by artificial means. When the incrus- 
tation is cast off, a foul and sometimes quite a deep ulcer is brought to 
view. In young children, the legs, arms, and the scalp are the situa- 
tions usually occupied by the eruption. At this period of life it produces 
severe constitutional disturbance, and is associated in most cases 
with an extremely bad condition of the system. It sometimes ap- 
pears after an attack of scarlet fever or typhus fever, or other ex- 
hausting diseases. These produce what is termed a cachectic state 
of the economy, and under these circumstances the patient becomes 
an easy prey to the ravages of the rupial affection. There is in 
some cases only one single specimen, as upon the nose, or the chin, 
or about the knee-joint. But in most instances, the eruption appears 
in clusters and in successive crops, and which cover a space varying 
from a few lines to an inch in diameter; and in some cases the 
crusts enclose an area of several inches in diameter. They are cir- 
cular in form, and, when the ulcerated surface beneath them is ex- 
posed, it appears as if cut or scooped with a punch, and a dark- 
red zone encircles the sore. 
The period of time during which the tubercle continues before 
suppuration takes place, varies in different cases. Sometimes it oc- 
curs in a few days; at other times it is delayed to several weeks or 
even months, as if the morbid process during all this interval was 
suspended or at rest. It is seldom that much pain is experienced 
from them, or that the periosteum or bone is affected, unless the 
ulcer is situated where the integument is thin, as upon the scalp or 
the front of the tibia. The character of the* ulcers differs somewhat 
according to the length of time they have been covered by the crusts. 
Sometimes they are shallow, with a smooth, shining surface; some- 
times quite deep, with a slough at their base, and the ulcerative ac- 
tion works its way beneath the skin for quite a distance beyond 
the apparent limits of the sores. When the disease attacks the 
nose, it occasionally destroys a considerable portion of the aim and RUPIA. 
61 
adjacent parts, which are covered by the thick incrustations before 
the full extent of the mischief is scarcely suspected. When the crusts 
have been removed, the ulcerated surfaces are apt to bleed upon the 
slightest touch in dressing them, unless this is done in the most deli- 
cate manner. 
The discharge is rarely pure pus, but an admixture of sero-san- 
guineous fluid, with more or less purulent matter. In very mild 
cases, the ulcers have been known to heal in a few days, but this is 
the exception to the general rule. New incrustations are formed 
every few weeks by the drying up of the secretion upon the surface 
of the ulcer; and thus a succession of crusts is kept up for a long 
time. These crusts are thicker in the middle than at the circumfe- 
rence, and, when large, they have not inaptly been compared to an 
oyster-shell or limpet-shell. When the ulcers finally heal, they leave 
behind them a dark-brown stain or lividity of the skin, which remains 
for many months before it is entirely effaced* 
Rupici Prominens derives its name from the fact that it projects 
out from the skin on which it is seated to a greater or less extent— 
varying from two or three lines to more than a whole inch, and the 
same in diameter. The eruption is developed upon the face, the 
trunk of the body, and the extremities. In a majority of subjects, 
the tubercles are few in number, but large; the secretion is usually 
abundant, thick and black; hence the crusts are particularly large, 
well-marked, conical, and prominent, as the name sufficiently indi- 
cates. They increase in size by the process of accretion, which 
takes place at the base, in consequence of the slow successive effu- 
sions of the bloody, sero-purulent matter which raises the cuticle 
and desiccates in concentric layers or rings; and thus the incrusta- 
tion augments, both in circumference and length, so that the portion 
which was at first the base of the cone becomes at last its apex. 
The cone itself is hollow. The largest specimens, if left undisturb- 
ed, usually appear on the integument covering the side of the chin. 
They are deeply set and generally very adherent. There is always 
a delicate red erythematous band or areola encircling the margin of 
the ulcer. Sometimes the eruption is confined to one locality, as 
the forehead, the inner aspect of the knees, or the thighs immediate- 
ly above the knees, the wrists, or about the elbow-joints. In other 
instances, and where the pyogenic diathesis has existed for a long 62 
CONTRIBUTIONS TO DERMATOLOGY. 
period, these formations arise in great profusion, almost entirely 
covering the face, neck, arms and legs; and in one instance within 
our observation, all the joints of the thumb and fingers of both hands 
were occupied by them. 
Where the general health of the patient is greatly impaired, as, 
for instance, from a long protracted duration of constitutional syphi- 
lis, it is no uncommon thing to find a series of these productions in 
every stage of their development—some at their maturity, some on 
the decline, and some just beginning to appear. 
The diagnosis of rupia is rarely attended with any difficulty. It 
is true, as has already been seen, that it possesses many features in 
common with ecthyma, and this is the only cutaneous affection to 
which it sustains a very near resemblance. And as regards the 
treatment, no practical disadvantage can arise, whether the practi- 
tioner should consider a given case as an ecthyma or rupia. 
We have seen, also, that the eruption now under review is pro- 
duced by great constitutional debility, and that the chief cause of 
this debility, in a great majority of instances, is constitutional 
syphilis. 
Treatment of Rtipia.—In all forms and stages of the disease, the 
constitutional treatment is of the greatest importance. Debility is 
always a predominant symptom, and we may at once commence with 
tonics. In young subjects, the syrup of the iodide of iron, in doses 
adapted to the age of the patient, is appropriate; and the tincture 
of the chloride of iron, in syrup of ginger and water, the iodide of 
potassium, quinine, and cod-liver oil, will also be requisite as reme- 
dial agents in restoring the patient to a comfortable state of health. 
The advantages of nutritious food, warm clothing, good air, cleanli- 
ness, are not to be forgotten or omitted at any time during the ad- 
ministration of medicines. 
With regard to local measures, the first thing to be accomplished 
is the removal of the scabs. Poultices, fomentations and warm alka- 
line baths will accomplish this j and the exposed ulcerated surfaces are 
at once to be dressed with stimulating applications. These may con- 
sist cither of lotions or ointments. Of the former, the black wash, 
the yellow wash, a solution of the chlorate of potash of varied 
strength, a solution of the tartrate of iron and potassium, six or 
eight grains to the ounce of water, should be used. These are all LUPUS. 
63 
stimulating in their action upon the indolent ulcers, and are 
suited to patients of any age. In some cases, where the dis- 
eased surface is very extensive and the foregoing applications fail 
to produce the desired improvement, the ulcer may be touched with 
either of the following lotions:—R. Hydrarg. pernitratis, 5 ss.; 
aquae fontanae, § iij. M. To be applied lightly every day by means 
of a soft camel’s-hair pencil. Or a saturated solution of the nitrate of 
potash may be used twice a day upon the most indolent sores, which 
may be covered afterwards with an ointment of the nitric oxide of 
mercury—one scruple to the ounce of simple cerate. No ointment 
is superior to this for general use. A slight sprinkling of pulver- 
ized chlorate of potash upon the ulcers every day for a few times 
will often bring forward healthy granulations. A like effect will 
also be produced by cream of tartar used in the same way. 
The general and local treatment for adults is to be conducted, of 
course, on the same principles as for younger subjects; the only 
difference required being in the more energetic style or method as 
regards both constitutional and topical remedies. 
Lupus. 
What is lupus ? In looking over the works of the ancient writers, 
it is interesting to observe the figurative language they often employ 
to illustrate their ideas of the forms or the peculiar characteristics of 
the diseases that attack the human system. In the present instance 
the symbol chosen is one of the most ferocious wild beasts that roam 
in field or forest, and whose very name is suggestive of destruction; 
and destruction being the salient feature of lupus, a more appropri- 
ate similitude could not be selected. 
The disease is confined to no age or sex, or class of subjects. It 
presents three principal varieties—namely, lupus erythematodes, 
lupus non-exedens, and lupus exedens. Other varieties are men- 
tioned by different authors, as lupus vulgaris, lupus vorax, and lupus 
hypertrophica, the latter originally described by Biett. All these 
forms are but different degrees or stages of the same disease. 
The general health usually remains unimpaired, even where the 
local affection continues for ten, twenty or thirty years. There is a 64 
CONTRIBUTIONS TO DERMATOLOGY. 
tissue-change which supervenes upon the local inflammation, and this 
change, together with loss of substance unlike what takes place in 
any other cutaneous disease, constitutes a distinguishing attribute of 
the complaint. 
In the first variety which we propose to consider, there is an ery- 
thematous condition of the skin, followed by loss of substance or 
atrophy in the affected part, without the formation of tubercles or 
ulceration. 
In the second variety there is a development of tubercles, follow- 
ed by destruction of tissue without ulceration. 
In the third, there is the formation of tubercles and subsequent loss 
or destruction of the skin, and sometimes of the deeper tissues also, 
by ulceration. Thus we have before us the distinctive features of 
the several forms of lupus. In each there is a devastating agency 
at work, although there is a diversity in the mode of operation. 
The disease is never contagious, and rarely traceable to hereditary 
predisposition. The most frequent locality for its development is 
the face, especially the nose. No constitutional symptoms are pre- 
sent, and rarely any pain. It sometimes happens that while the 
eruption occupies the face, nose or head, the fingers or back of the 
hands, or some other distant part, may present a similar morbid af- 
fection. It commonly appears in well-marked round or oval discs of 
deep-red color. When it breaks out on the ears, it generally com- 
mences on the posterior aspect, near the junction of the lobes with 
the lower point of the cartilage. Here it remains partially concealed 
as a small red patch, not unlike a mosquito-bite, and attracts little 
or no attention, perhaps, for several months, by which time it will 
have crept upward along the posterior surface of the whole ear, 
which becomes thickened and preternaturally red; and occasionally 
the patient experiences a slight sensation of burning and pruritus, 
and at a little latter period cannot allow that side of the head to 
rest on the pillow, or the hat or bonnet to be pressed against it, on 
account of the discomfort arising from increased heat. Occasion- 
ally, erythematous patches are developed nearly simultaneously on 
the nose, ears, cheeks, forehead and upper lip, and on the mucous 
lining of the mouth and nose. In a few weeks, or perhaps months, 
a thin, white, delicate scale forms on the diseased surface, as in pso- 
riasis. It is very adherent, although it desquamates every now and 
then in the form of a horny layer. LUPUS. 
65 
When the morbid action has continued for a long period, the dis- 
eased integument is atrophied, puckered and depressed, and is much 
thinner than natural on account of interstitial absorption, and not 
by open ulceration. If the fingers are the parts involved, the red- 
ness and tumefaction which have so long existed subside, and the 
skin is reduced to a white, hard and horny covering, and seems 
drawn tightly around the bones, like a smooth clasp. And so with 
the back of the hand of a lady whom we once saw, and on whose 
left hand the complaint had lingered from the age of 5 to 35 years. 
The whole surface was perfectly bloodless, and white and polished 
as parian marble. The disorganized skin was sealed down firmly 
to the carpal bones, and the ring and little finger were bent immova- 
bly upon the palm; the parts thus disfigured seemed at first view to 
have suffered from the effects of a severe scald or burn. This pa- 
tient had been afflicted also, for some eight or ten years, with lupus 
non-exedens on the nose. 
When the disease attacks the cheeks or nose, the inflammation, in- 
duration and hypertrophy of the affected part produce great defor- 
mity. There is a sort of knobby or lobulated appearance occasion- 
ed by the development of tubercles, which sometimes increase in 
numbers with great rapidity and coalesce. As the morbid processes 
begin to decline and the disease advances towards a cure, the red- 
ness and swelling gradually subside, and the skin assumes a smooth, 
shining appearance; there is loss of substance, and the portion of 
integument which was the seat of the lupoid action sinks below the 
plane of the adjacent surface. And if the nose is the unfortunate 
organ on which the malady plants itself, it looks sharpened or notch- 
ed, as if the soft parts had been pinched or irregularly pared off, 
the bones and cartilages become prominent, and a remarkable cica- 
trix and deformity remain, which no surgical operation can repair. 
In some cases there is, for a very long period, repeated exfoliation 
of thin, white, dry, laminated scales from the cicatrized surface after 
every other morbid process has ceased. (This is the scrofulide 
erythemateuse of Hardy.) 
Lupus non-exedens.—This generally commences at an early period 
of life, and is usually represented by the development of a few dis- 
tinct tubercles, varying in size from a pin’s head to that of a pea; 
they are slightly flattened on their summits, somewhat elastic and 
boggy to the touch, and if pressed or broken with a probe, or other- 66 
CONTRIBUTIONS TO DERMATOLOGY. 
wise disturbed, they readily bleed. They often remain in a dormant 
state for months or even years without producing any inconvenience 
to the patient, except as regards looks; and show no disposition to 
increase until, perhaps, their activity is awakened by some unappre- 
ciable cause or circumstance, when they suddenly enlarge at the cir- 
cumference and multiply in number, and thus by their aggregation 
and fusion they form a well-defined patch of a pale, dull-red or mot- 
tled color of various extent, and circular, oval or tortuous in outline. 
At length the patch is covered with scales or crusts—somewhat like 
those seen in eczema. These are adherent in their centre to the 
summit of the tubercles or nodules, while their edges are free and 
curled up. Cuticular desquamation, however, takes place, and is re- 
newed at different intervals. 
The disease seems to have a preference to some portion of the 
face, and the nose is by far its most frequent habitat. It sometimes 
attacks the back and extremities, especially the lower. Sometimes 
the morbid action commences on the upper lip, which soon becomes 
excessively tumefied, and gives rise to great disfigurement. The 
lower lip is very seldom the seat of the disease. The central por- 
tion of the patch often heals, and the cicatrix is decidedly lower than 
the peripheral portion, which is studded over with a ringlet of tu- 
bercles. These coalesce, and form, as it were, a separating wall 
between the morbid and healthy skin. The area of the diseased 
action enlarges very slowly, and if seated on the integument cover- 
ing the ossa nasi, the process of expansion, which usually extends 
in nearly equal ratio in all directions, encroaches on the lower eye- 
lid. Eversion takes place from the contraction of the integument, 
and the mucous surface of the conjunctiva is exposed to the attrition 
of the air; and there is a constant flow of secretion, greatly to the 
annoyance of the patient. Laterally, the complaint advances far 
down upon the cheeks; meanwhile the process of healing is going 
on in the central part, which clears away and cicatrizes, but without 
true ulceration. There is loss of substance by absorption, and the 
thin skin is slightly puckered and very adherent to the bones. Its 
sensibility is much enfeebled or totally lost, and it never regains its 
original appearance or resiliency. When the devastations are com- 
pleted, the individual often presents a most unique and hideous de- 
formity. Nearly the whole of the cheeks, lips and chin is sooner or 
later covered with a succession of fresh tubercles, which run toge- LUPUS. 
67 
thor, and the patient looks as if his face was covered with a mask. 
This is the lupus with hypertrophy of Biett. It is often developed 
in connection with the erythematous variety, or with a lupoid ulcera- 
tion of the mucous membrane within the buccal cavity or the nasal 
fossae. In some instances, the disease commences in the latter region 
and produces at first a simple redness on the external integument, 
with slight thickening of the aloe, while it eats its way through the 
cartilaginous septum and higher up in the direction of the turbina- 
ted bones. Such is the strange and fitful course pursued by this 
complaint in very many cases. 
Lupus exedens.—This form of lupus is more frequently met with 
than any other. It commences by the development of one or more 
tubercular masses, which are characterized by greater hardness and 
density in their structure, and less transparency than are present in 
those of lupus non-exedens. Their tendency to ulceration becomes 
apparent at an early day, and progresses with marked activity in 
many instances, while in other cases its march is very slow. When the 
former tendency prevails and the complaint attacks the nose, this 
organ is sometimes entirely destroyed in four or five weeks. The 
soft parts, the cartilaginous structure, and sometimes the osseous, 
are swept away by this peculiar process of destruction in spite of 
all efforts to arrest its voracity. 
The disease may attack other portions of the surface at the same 
time that it affects the nasal organ—as the entire scalp or face, the 
back of the neck, between the shoulders, on the hands, fingers, toes, 
&c., and may proceed to the destruction of all the soft tissues that lie 
within its path; and in some instances not sparing even the bones. 
Ordinarily, the disease, commencing as a small, hard tubercle, re- 
mains nearly quiescent for some considerable time, and then passes 
into a suppurative stage and is soon covered with a thin greenish- 
brown scab, and remains, perhaps, circumscribed to a single spot. 
Other tubercles appear in the immediate vicinity at various periods, 
and undergo the same changes. The patient picks off the soft and 
yielding crusts, beneath which a light yellowish fluid may be con- 
cealed, and when this is wiped away an excavated ulcer, more or less 
deep, may be exposed to view; or, instead of any secretion, a red 
pulpy surface may be left, which bleeds on the slightest touch. This 
ulcer becomes concealed by the formation of another scab larger 
than the first, and formed by the drying up of the semi-purulent or 
foetid, ichorous matter poured out upon the diseased surface. 68 
CONTRIBUTIONS TO DERMATOLOGY. 
The surface of the ulcer of lupus exedens is ragged, the edges 
thick and red, covered with a white exudation of lymph and with 
small, unhealthy granulations. There is a frequent attempt at cica- 
trization, which may and does take place to some extent; but the sore, 
once established, does not readily close. It may give promise of 
being healed soon, when all at once the ulcerative process seems to 
have acquired a fresh impulse. 
However severe and extensive the ravages of lupus exedens may be, 
it is seldom that any pain is experienced during the whole course of the 
malady, and in this particular, as well as in many others, it resembles 
constitutional syphilis. Sometimes there is itching in the part, espe- 
cially towards night, and after certain articles of food have been 
taken; and in sudden changes of weather the patient experiences a 
temporary uneasiness, but scarcely amounting to absolute pain. 
When the ulcer of this variety of lupus heals, the resulting cica- 
trix is of a pearly white, with streaks of a faint purplish tint, and 
corrugated bands running over it, as mentioned in connection with 
the previous disease. It is no uncommon event for the complaint to 
break out afresh at some future day at some point within or near 
the boundaries of this cicatrix, whatever line of local or constitu- 
tional treatment may have been adopted. 
The consequences of lupus exedens vary with the part on which 
it is situated and the period at which it is subdued by treatment. If 
seated on the nose and cured early, a slightly notched scar remains, 
and the tip of the organ is pointed and irregular. If on the cheek 
or ear, and has been cured before it spread extensively, the remain- 
ing scar does not occasion much deformity. These unimportant 
blemishes, however, are rare compared with the more frequent and 
frightful deformities which the malady generally produces, especially 
if of a syphilitic origin. In such cases it owes its terrible severity and 
consequences to the superaddition of a specific poison that pervades 
the constitution. It may attack the forehead or nose, and appear 
simultaneously on the extremities, the front of the neck, the buttocks, 
or elsewhere on the trunk of the body, in the guise of what are 
called serpiginous ulcerations. The skin suffers first and generally 
the most; the cartilages come next, and finally the osseous frame- 
work of the nose and roof of the mouth are swept away. 
Lupus is little liable to be confounded with any other disease that 
invades the skin. The tubercles, which are its earliest representa- LUPUS. 
69 
tives, are of a livid, dull red color, pursue an indolent course and 
are usually confined to one spot or district, as the nose, lips, cheeks, 
ears, &c. Sometimes the complaint commences as a single tubercle. 
At a variable period the tubercles pass into a state of ulceration. 
This ulcerative process soon spreads beyond the limits of the origi- 
nal tubercles. Slight, scaly crusts are formed. These are quite ad- 
herent, but break down easily from trifling pressure. At length 
attempts are made at repair in the shape of unhealthy-looking cica- 
trices. The complaint is unaccompanied by any constitutional 
symptoms of the slightest importance. These are pathognomonic 
features. 
Pathology.—In regard to the new-formation of connective tissue 
which constitutes the essence of the disease, Wedl states as the results 
of his investigations that it is at first very limited in extent, and 
accompanied with injection of the vessels and tumefaction. It grad- 
ually extends, and produces a consecutive atrophy of the organs in 
which it spreads. In the cutis the hair falls out, and the sebaceous 
glands and papilla shrink; in a word the cicatriform, smooth aspect 
of the skin, above noticed, is produced. In this atrophied condition 
the latter is ultimately perforated by the new growths. A cicatriform 
contraction, moreover, may remain at one spot, whilst the perfora- 
tion of the skin takes place at another. The new-formation of con- 
nective tissue may, also, extend into the adipose and muscular 
tissues, or so far even, as to affect the bones themselves, and to inter- 
fere with the nutrition of the elementary organs, which become as it 
were supplanted by the new-formation, but not dissolved. The new 
connective tissue may suffer involution in many places, where the 
conditions for its further development are wanting; but it is not sub- 
ject to any genuine or spontaneous, retrograde metamorphosis, ac- 
companied by a softening of the new-formed substance. The pus 
which is so commonly formed in lupus, should by no means be 
regarded, as it has been, more especially by the older writers, as a 
product of the breaking up of the newly organized substance, or of 
the normal elements of the tissue; a view, which, according to 
opinions at present received, must be wholly rejected, inasmuch as 
the pus is itself a new formation out of a blastema, which, in the 
present case, as in many other instances, is associated with the new- 
formation of connective tissue. 
Causes.—Syphilis is one of the most frequent causes of this com- 70 
CONTRIBUTIONS TO DERMATOLOGY. 
plaint, although many individuals who are afflicted with lupus, furnish 
no evidence in their history that their disease is in any way or degree 
derived from the venereal taint. Scrofula is named by various 
authors as the parent of lupus; and yet a scrofulous taint in the 
system is a myth in the opinion of many able writers. If we admit 
its agency in the production of lupus we must do so on a purely hy- 
pothetical basis. 
Lupus is much more common in women than in men; and this fact, 
in our judgment, seems to take away all foundation for the theory in 
regard to the ideal relationship between lupus and scrofula. 
The influence of sex and age is very marked as among the pre- 
disposing causes of the several varieties of lupus. Of 170 cases 
collected and reported by Mr. Naylor,* Assistant Surgeon to the Hos- 
pital for Diseases of the Skin in London, during the years 1861, 
1862, and 1863, 131 were females and 39 males. These figures 
represent lupus in the aggregate only, a much greater difference being 
noted in some of its varieties. Thus in lupus exedens the ratio is 
5 to 1 between the two sexes, and higher yet in the two other varie- 
ties. Lupus exedens as a rule is developed primarily between the 
ages of 10 and 30, becoming more rare after the latter period, and 
seldom commencing before the seventh year. 
Lupus arising from syphilis takes a wide range in its period of 
development, beginning as early as the fourth or fifth month and as 
late as the seventieth year and upwards. Lupus is not specially in- 
fluenced by occupation, or locality. We have known quite a number 
of cases following the receipt of some slight injury to the part as the 
immediate cause of the complaint; as a blow, a scratch, a spark of 
hot cinders, &c., impinging on the site where the tubercle appeared 
soon after the accident. 
There is another fact connected with the etiology of the disease 
which is difficult of solution, and that is, that it is seldom seen in the 
upper classes of society. Is the disparity due to a better quality of 
food, better air, greater cleanliness, or is it not influenced by these 
circumstances ? The affirmative would seem to be the true answer. 
The prognosis is not always very satisfactory. In recent cases, 
or those of quite limited extent, the prospect of permanent recovery 
is encouraging; but in cases where the morbid habit has existed for 
* Diseases of tlie Skin, by George Naylor, F. It. C. S., London: 1866; p. 165, LUPUS, 
71 
years and spread over a large field, great assiduity, care and skill 
are requisite to accomplish a cure of the existing evil; and when this 
is effected the probabilities are pretty nearly balanced as to whether 
or not the malady will reappear at some future day. This contin- 
gency, however, affords no reason for the neglect or omission of any 
remedial measures which in the judgment of the medical adviser the 
case demands. 
Treatment.—There is no specific course to be pursued either as 
regards constitutional or local remedies. We must be governed by 
general principles of medical science. The health of the patient 
rarely ever suffers from any of the varieties of lupus, except it be 
from constitutional syphilis. If the latter evil is engrafted into the 
system the lupoid development is to be considered in connection 
with the constitutional malady and “part and parcel of it; ” and all 
internal remedies must be selected from among those which are in 
best repute for secondary or tertiary syphilis, as the case may be. 
The patient should be under the best hygienic influences at all times. 
Arsenical preparations have often been administered for the cure 
of lupus, but no well-authenticated reports in favor of them have 
been recorded in medical or surgical works, and it is but just to re- 
mark of them that they possess no claim to confidence in the disease 
under consideration. Mr. Wilson is inclined to recommend Dono- 
van’s solution in doses of ten or fifteen drops three times a day at 
meal time. Few patients can tolerate this amount of the solution 
for any length of time. We so judge from frequent reports from 
them, and we have ceased to prescribe it in any quantity. In its 
stead we prefer very small doses of the bichloride of mercury—say 
the tenth of a grain morning and evening. It should be taken with 
meals, in the form of pill, or solution with the compound tincture of 
cinchona, or compound tincture„of cardamom. The cod liver oil is 
just now a popular article in lupus. The daily quantity recommend- 
ed by different surgeons ranges from half an ounce to one or two 
pints! 
Nitric acid, nitro-muriatic acid, the various chalybeates, the iodide 
of potassium, the chloride and carbonate of ammonia, and an unlim- 
ited number of mineral waters—all have their advocates. What- 
ever course of constitutional treatment, in the judgment of an intel- 
ligent physician, may be indicated with a view to restore or preserve 72 
CONTRIBUTIONS TO DERMATOLOGY. 
the integrity of the several vital organs and their functions, will be 
the proper one. And it will be labor lost if he looks here or there 
after specifics. 
The local treatment must be our main reliance; and with this there 
will be need of long and patient perseverance in a majority of cases. 
In erythematous lupus, if the efflorescence is quite limited, one of 
the best local applications to commence with is a compound tincture 
of iodine of the following strength:—R. Potassii iodidi, 5 ijss.; iodi- 
nii, B ij.; Aquas fontanae, § j. M. A portion of this is to be applied 
twice a day for two or three days by means of a camel hair pencil. 
By this procedure the cuticle will be completely detached, and when 
this takes place the raw surface is to be covered with lint saturated 
with liquor plumbi diluted with an equal quantity of water. If the 
diseased surface is very extensive it may not be advisable to remove 
the cuticle from the entire patch at one time. The nitric acid very 
much diluted may be substituted for the lead wash if no benefit results 
from the use of the latter. If there is severe pain or smarting at 
any time, a lotion containing prussic acid can be employed with ad- 
vantage in connection with a solution of the borate of soda. Gen- 
erally speaking there is more discomfort experienced by the patient 
towards evening or a little later in the day than at any other time, 
from the smarting and burning. At such times the subjoined formula 
fora lotion should be ordered: R. Sodas sub-boratis, 3ij.; acidi 
liydrocyanici diluti, 3 ij. M. Lotion. Rags saturated with this may 
be applied to the lupoid surface. 
The benzoated oxide of zinc ointment, with three grains of sul- 
phate of morphia to each ounce, is likewise a suitable ingredient 
with which to dress the parts. 
If the scales are very thick they can usually be detached readily 
by means of a strong solution of potassa fusa, or the carbonate of 
soda, and afterwards the raw surface is to be dressed with the lead 
water, or either of the other agents above mentioned. By these 
means the disease will often abate in severity. Other local measures 
are worthy of a trial also: such as the iodide of sulphur ointment, 
15 grains to the ounce of rose ointment; the iodide of mercury oint- 
ment, one scruple to the ounce, to be applied every day or every 
other day; or the iodide of lead ointment, one drachm to the ounce. 
This last may be applied constantly. LUPUS. 
73 
Lupus non exedens.—The tubercles of this variety of the malady 
can be destroyed by means of several kinds of caustic, and a healthy 
action excited. Squibb’s “ argenti nitras fusus,” strong nitric acid, 
the acid nitrate of mercury, the chloride of zinc and the potassa fusa, 
are about the only ones that the surgeon need employ. Squibb’s 
preparation of the nitrate of silver is cast into sticks about an inch 
in length and sharply pointed at one end. These sticks, or "points” 
as they are familiarly called, do not usually break very readily. 
They contain five per cent of chloride of silver superadded to the 
composition of the ordinary nitrate of silver—hence their hardness 
and superiority. Another advantage is that they always keep pointed 
while using them. 
If the tubercles are situated on the cheeks, on the bridge of the nose, 
or the scalp, and the diseased structure is soft and boggy, the nitrate 
of silver points can be employed to plough through as it were the en- 
tire mass of tubercular formations, and thoroughly and effectually 
break them down so that they may not re-appear. If the complaint 
is very extensive, only a part should be attacked at any one time. 
If the alse nasi are to be treated, the nitrate of silver may not be 
the most suitable. It is somewhat inconvenient and a little difficult to 
employ it in this locality on account of the yielding and moving about 
of the parts when pressed upon with the force requisite to break down 
the tubercles. The pernitrate of mercury or the chloride of zinc per- 
haps will be found more convenient and equally effectual. The pain 
produced is about equal, whichever of the two is employed. 
If the tubercles are situated on the ear, the silver can be passed 
directly through the whole mass and thoroughly break it up. There 
is generally quite free bleeding, and no small portion of the nitrate 
is mingled with the blood and wasted without coming in contact with 
the morbid growths. 
After the application of the caustic the surface is to be washed 
thoroughly in cold water, and water dressing used. Sometimes the 
ear thus operated upon swells enormously, and it is well to apprise 
the patient that considerable inflammation will supervene on the use 
of any caustic agent, whatever it may be. A warm soft poultice will 
now be required. In five or six days a slough will be detached, and 
a raw surface with a more or less healthy aspect will be brought to 
view. The repetition of a caustic may again be needed ; but instead 
of the silver a thin coating of the chloride of zinc, or nitric acid, or 
the pernitrate of mercury, no matter which, will be followed by the 
development of healthy granulations with more certainty than would 
attend the employment of the former caustic. The base of the lupoid 
surface is in an atonic condition, and the application of the silver is 74 
CONTRIBUTIONS TO DERMATOLOGY. 
of less promise than either of the other three just mentioned. For 
the rapid and certain destruction of the tubercular masses the ni- 
trate of silver is the most efficient weapon, and here ends its superiority. 
Very likely other tubercles will spring up at some point in close proxi- 
mity to the previous ones, in which case the silver will again be called 
for. 
Sometimes when this variety of lupus is situated on one of the fin- 
gers or on the back of the hand of a hard laboring man—a fisherman, 
a blacksmith, a shoemaker or farmer—there will be a few tubercles 
present while other portions of the skin will be thickened with an 
unorganized mass of papillae, or dry, hard, horny spines, closely crowd- 
ed together and sticking out above the adjacent skin perhaps the 
tenth of an inch. These cases occur, but they are rare, and exceed- 
ingly slow in their growth. The best local application to these 
patches is the potassa fusa ; and several days will be required for 
the action of this caustic to work its way down to the derma. When 
this is reached and the debris is removed, the exposed surface should 
be touched with a delicate coating of the chloride of zinc or acid nitrate 
of mercury or nitric acid. The tubercles are, as in all other instances 
and places, to be destroyed with the nitrate of silver points. 
If the hypertrophied patch should be free from irritation and at the 
same time considerable cuticular desquamation overspreads the sur- 
face, acetic acid, diluted with two parts of water, will be found a 
suitable application. 
The foregoing is about all the treatment which lupus non exedens 
admits of, wherever it may be situated. 
Although success may for a time attend our efforts in reducing the 
disease to the lowest point possible, it will be well to apprise the pa- 
tient that the tubercles will be very likely to re-appear ; for the history 
of lupus abundantly proves that there is no variety which shows so 
frequent tendency to recur as the tubercular, and it is rarely in the 
power of medicine or surgery to destroy this tendency. 
Sometimes the patient suffers from an attack of erysipelas during 
treatment, especially if the face is the part diseased. This occur- 
rence has been known to act as a healing process to the lupoid 
affection and apparently to diminish the chances of a recurrence. 
In the local treatment of lupus exedens, the first step is to clear 
away any scabs or incrustations that may have formed; then wipe 
away the ichorous or purulent deposit or blood that lies upon the ul- 
cerated surface, which may then be touched with a sharp caustic. 
Various caustics have been recommended and have proved efficient in 
different hands. Hebra is partial to the nitrate of silver. In recent 
cases of small extent, or when the granulations are soft and readily LUPUS. 
75 
broken down, this caustic is sufficient to accomplish the object de- 
sired ; or when solitary tubercles spring up within the area or just out- 
side of the diseased surface, as they are very apt to do, the silver is 
well suited to accomplish their destruction, which will very likely 
be followed by the healing up of the part which was the site of the 
tubercle. But where the surface is free from tubercles or the re- 
mains of tubercles, and is simply a lupoid ulcer, the nitrate of silver 
has proved, in my experience, less effectual than the acid nitrate of 
mercury or the chloride of zinc.. Generally, this lupoid surface is 
seen dotted over with very minute granular bodies, as if a process 
of healthy granulations had been commenced, but arrested in their 
development. Such a surface is quite hard to the touch, much more 
so than a normal healthy granulating surface, and if an attempt be 
made to reach the bottom of this morbid growth with the silver, it is 
apt to be a failure. A thin slough is produced ; but in five or six 
days the surface which yielded it will present an appearance identical 
with that exhibited before the application of the caustic in question. 
This mode of procedure, of course, is quite ineffectual, however long 
continued. Nothing like the desired recuperative action is excited. 
With the acid nitrate of mercury, or the chloride of zinc, the depth 
to which they can be made to reach is almost unlimited ; and yet their 
judicious application is free from danger, although not free from 
pain. If a large surface is diseased, only a small part should be sub- 
jected to the caustic at any one time. In two or three days, another 
section should be treated in like manner, and so on as fast and as far 
as the patient can tolerate. If the zinc is used, it should be in a 
state of perfect deliquescence. It is then of about the consistence 
of glycerine, and is to be applied with a camel-hair brush. Some 
writers advise that it be made into a paste with flour and glycerine ; 
but when thus mixed it runs in every direction when applied to the 
skin, to say nothing of its comparative weakness in consequence of its 
union with the other two inert substances. 
If the acid nitrate of mercury is selected, it is to be applied with 
a camel-hair brush, in the same manner as the chloride of zinc. If the 
strong nitric acid is preferred, it is to be made into a paste with 
sublimed sulphur, and applied by means of a glass rod or a wooden 
spatula, and may be allowed to dry on the part. 
After the caustic is applied, the part is to be coated over with 
collodion. This dries at once, and serves to mitigate the pain. No- 
thing by way of interfering with the eschar should be allowed. 
Hydrargyri Iodidum Rubrum.—M. Cazenave considered this the 
best topical application that could be employed in lupus. He used 
it in thin layers every six or eight days to small portions of the dis- 76 
CONTRIBUTIONS TO DERMATOLOGY. 
eased surface at a time, in the form of a caustic ointment, made of 
equal parts of the iodide, oil and lard. Dr. Tilbury Fox, of London, 
in his valuable Treatise on Skin Diseases, regards the biniodide as 
superior to any other external application in bad cases of lupus. Ilis 
formula is:—R. Ilydrargyri biniodidi, 5*-5 glycerinas, %i. M. I 
have tried this last prescription in three cases of lupous ulceration. 
It improved the condition of the affected parts, and in a few weeks 
cicatrization took place in a satisfactory manner. The action produced 
by it appeared to be quite similar in these cases to that of the chloride 
of zinc and the liquor hydrargyri pernitratis. 
Thus it will be seen that a variety of remedies have been tried, 
and have had their advocates from time to time, in the treatment 
of the malady under consideration. In some instances, the lesion is 
perfectly cured in a few weeks, and never returns; in others, the 
success is only apparent, for in a few weeks or few months, the abnor- 
mal action reappears, the patient exhibits unmistakable signs of a 
depressed vitality and vitiated condition of the blood ; and, notwith- 
standing the most judicious efforts put forth for his recovery, the dis- 
ease advances slowly to a fatal termination.