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LECTURES ON EKZEMA
AND EKZEMATOUS AFFECTIONS.
LECTURES ON EKZEMA
AND EKZEMATOUS AFFECTIONS,
AN INTRODUCTION
ON THE GENEEIL PATHOLOGY OF THE SKIN
AN APPENDIX or ESSATS AND CASES.
ERASMUS WILSON, P.E.S., F.E.O.S.
FBoraaoB or DnuUTOuut is tbb botal c»llbob
LONDON:
JOHN CHURCHILL AND SON
NEW BURLINGTON TTREETr.
MDCCCLXX.
fS-/. ■wx, I^S
WTMAK AMD tONB, OftBAT QUBKN BTBBBT, LONDON W.C.
I
PREFACE.
The Lectures which form the chief matter of
the accompanying pages were published in the
Journal of Cutaneous Medicine ; while the Essays
and cases constituting the last chapter were partly
published in the same journal and partly in other
journals. Both subjects are now brought together
in one volume, for convenience of reference and
to illustrate more fully the views and opinions of
the Author. The importance of the disease,
Eezema, both in a social and in a scientific sense,
is now universally recognized : in the former cha-
racter it claims our most careful observation to
master a knowledge of its nature and cure ; and
in the latter it deserves to be regarded as the
keystone of Dermatology.
In addressing a learned and scientific profession
the Author feels that there is no necessity for ex-
cusing the orthography of the word Ekzema which
he has adopted. The word is Greek ; the spelling
is also Greek : and therefore he is doing no more
than simply adopting the language of the fathers
of medicine from whom the term has descended.
CONTENTS.
CHAPTER I.
Anatomy of the Skin, 1. — Physiology of the Skin, 1 1. — Pathology
of the Skin, 14. — Diagnosis of Cutaneous Disease, 93. —
Etiology of Cutaneous Disease, 95. — Therapeutics of
Cutaneous Disease, 106. — Classification of Diseases of the
Skin, 119.
CHAPTER II.
Ekzema, 141. — Definition of Ekzema, 152. — General Forms of
Ekzema, 152. — ^Local Forms of Ekzema, 162. — Constitutional
Relations of Ekzema, 175. — ^Diagnosis, 176. — Etiology, 178.
— Prognosis, 193. — ^Treatment, 195.
CHAPTER III.
Ekzkmatous Affections, 218. — Leichen, 220. — Impetigo, 229. —
Scabies, 232.— Diagnosis, 238.— Cause, 240.— Prognosis,
241.— Therapeutical Treatment, 242.
CHAPTER IV.
Essays, Notes, and Cases illustrative of Ekzema. — Ekzema
infantile, 247. — Statistics of Ekzema infantile, 265. —
Nature, Varieties, and Treatment of Ekzema, 280. — Patho-
logical Phenomena of Ekzema, 305. — Etiology of Ekzema,
325. — ^Anomalous Cases of Ekzema, 356. — Histology of
Ekzema, 376.— Therapeutics of Ekzema, 379. *
Index ... ... ... ... ••• 383
ON
EKZEMA AND EKZEMATOUS AFFECTIONS.
<«{o»
CHAPTER I.
AKATOMT, PHTSIOLOGTy PATHOLOOT, ETIOLOGY, AND THERAPEUTICS
OF THE SKIN ; AND PBINCIPLES OF CLASSIFICATION OF
CUTANEOUS DISEASES.
Anatomy of the Skin.
The Skin is the external surface membrane or in-
tegument of the body, as is the mucous membrane
the internal integument. It is composed of two
layers ; an internal layer, the derma ; and an external
layer, the epidermis.
The Debma, or Cobium, may be regarded as an
adaptation or modification of the surface tissues of
the body to suit a particular purpose ; by its internal
face it is continuous with the superficial subcutaneous
or areolar tissue, while its external face has received
the name of limitary or basement membraney limitary,
because it is the boundary of the vascular tissues ;
and basement, because it constitutes the base on
which the epidermis rests. The term " membrane '*
applied to the limitary and basement face of the
derma, must be accepted with some reserve, as the
presence of a separate layer has not been identified ;
and the most simple idea that can be given of it is,
to regard it as the limit of the special organization
of the derma.
B
2 ANATOMY OF THE SKIN.
If we subject the derma to examination from its
internal surface to its exterior, we find it at first
presenting the structure of a coarse network, the
pars reticularis J and the network becoming gradually
finer and finer as we follow it outwards ; nearer the
external surface it resembles the tissue of a fine
sponge ; and most externally of all, it is transparent
and homogeneous, or indistinctly fibrillated. More-
over, quite at the external surface it is raised into
minute prolongations of its substance which are
termed papillary and which, with the basis from
which they arise, constitute collectively the pars
papillaris.
A further examination of the external face of the
derma exhibits not only papillary prominences, but
also numerous perforations, which are the mouths
of tubuli, stretching more or less deeply into the
substance of the corium. The apertures of the per-
forations are the pores of the skin, and the tubuli
its follicles ; and the follicles are partly devoted to
the formation and maintenance in position of the
hairs, and partly to the excretion of the glandular
products of the skin. Moreover, observation of
the external face of the derma demonstrates to us
the existence of two surfaces, one of which is
apparent, namely, the papillary surface^ and the
other hidden or occult, namely, the follicular and
glandular surface.
We may next inquire into the structural compo-
sition of the derma, which we shall find to consist
of white fibrous or dense connective tissue, muscular
tissue, vascular tissue, nervous tissue, fatty tissue,
and loose and filamentary connective tissue. The
most abundant of these is the white fibrous tissue,
which is the chief constituent of the pars reticularis,
enters largely into the composition of the stroma of
the upper or areolar portion of the corium as well
as of the pars papillaris, and is the material of
construction of the papillsB. Mingled with the
AXATOMY OF THE MEMA. 3
white fibrous tissue is a considerable proportion of
yellow fibrous or elastic tissue ; and less abundantly
than the latter, and in some situations more than in
others, the unstriped muscular fibre or muscle of
organic life. The latter is found in distinct bundles
at the base of the areola of the nipple, in the
scrotum, and in connection with the hairs, giving
rise by its association with the latter, to those pro-
minences of the pores of the skin which have
suggested the term, cutis anserina, or goose skin.
The vessels of the skin enter into and make their
exit fi:om the structure of the corium through
canals, of which the meshes of the pars reticularis
are the apertures ; in these canals they are asso-
ciated with the nerves, and the vaso-neurous
fasciculus is surrounded and protected by loose
connective tissue, supporting in its meshes minute
lobules of adipose tissue. Within the canals of the
Ears reticularis, the arteries and the nerves give off
ranches, and the subdivisions of these branches,
ending in capillaries and fibrillaa, constitute a ter-
minal plexus which is spread out horizontally in the
pars papillaris, which sends outwards coils and loops
and filaments into the papillae, and inwards vascular
and nervous plexuses to surround the follicles.
We are thus made aware that the vascular and
the nervous plexuses of the skin are not simply
horizontal, but that they are also centrifugal or
papillary, and centripetal or follicular; the surface
of a follicle being identical in point of organization
with the surface of the derma. And the latter fact
is made more obvious, when we recognize in the
mammary gland, the colossal development of a
cluster of sebiparous glands, and in the alimentary
canal, a compound follicle open at both extremities,
and having secondary and ramified follicles opening
upon its surface, one of these follicles being the lungs
and others the liver and the pancreas. The horizontal
and the vertical vascular plexuses of the skin have
B 2
4 ANATOMY OF THE SKIN.
an important relation to its states of hyperaemia
and congestion ; hyperemia of the horizontal plexus
being indicated by a general suffusion, and hyper-
semia of the vertical follicular plexus by punctation.
It is to be mentioned also, that in the organization
of the papillae cutis of the palmar surface of the
hands and fingers, and of the plantar surface of the
feet and toes, certain of the papillae are simply
nervous, and contain no capillary loop, while the
majority are vascular. The nervous papillae are
especiaUy destined for the faculty of touch, and the
oval-shaped nervous mass which they envelop has
been termed by Wagner, to whom we are indebted
for its discovery, corpusculum tadus ; and by
Kolliker, axile corpuscle. Moreover, the nervous
papillae are met with in greatest number where the
faculty of tactile sensation is the most acute ; as, for
example, on the pulps of the fingers and the palmar
surface of the hand.
Having, then, before us, the general idea of the
position and structure of the skin proper, or derma ;
its relations externally and internally ; the modifica-
tions presented by its surfaces, a coarse network on
one face, and smooth and papillated on the other ;
perforated in both directions by tubular passages,
those from the interior to give transit to vessels and
nerves, and those from the exterior to serve for the
current of secretions and the support of the hairs ;
composed intrinsically of connective, elastic, muscu-
lar, and adipose tissue ; traversed by blood-vessels,
lymphatic vessels, and nerves ; — we may further
note that the derma or corium is modified in the
different regions of the body, in respect of all the
conditions which we have just reviewed, in order to
accommodate the special circumstances or functions
of the region or of the part. In one situation it is
loosely, in another it is tightly, bound down and
adherent to the parts on which it rests. The pars
reticularis may be remarkable for coarseness in one
ANATOMY OF THE EPIDERMIS. 5
situation and for fineness in another ; the papillas in
certain parts are long and numerous, in others they
are scanty and diminutive. The pores and the ex-
cretory tubuli are large and abundant in one place,
small and scattered in another ; and the proportions
of the difierent constituents of the skin vary con-
siderably, both in relative and in actual quantity.
In one situation there exists an abundance of con-
nective tissue ; in another a remarkable quantity of
elastic or muscular tissue ; in this the vascular, in
that the nervous supply predominates ; and all these
variations must be present to the mind in aid of our
diagnosis and prognosis of cutaneous disease.
Moreover, in the pursuit and investigation of the
pathology of cutaneous disease, to which the present
sketch of the anatomy of the dermal textures is
nothing more than ancillary, we shall have occasion
to note the pltis or the minus of the conditions at
present under consideration, as among the -most
interesting of the features of our studies. We shall
meet with instances in which the skin is too tightly
and in others too loosely boimd down to the struc-
tures beneath it ; in which the papillae are monstrous,
or atrophied, or absorbed ; in which the pores of the
follicles are too large or too small ; and in which the
connective, the vascular, and the nervous tissues are
at a minimum or in excess.
Next in importance to the derma is the epidermis,
the covering by which the derma is invested ; that
serves the derma as an organ of protection and
defence ; that yields with its motions, and accommo-
dates itself to the several conditions of health and
disease of the more highly organized structure upon
which it lies embedded ; that in health is the in-
separable bondsman of the pars papillaris, while in
disease it has a tendency to break from its bondage
and desert its relationship and its functions.
The Epidermis is also termed the scarf-skin and
6 ANATOMY OF THE SKIN.
the scurf-skin, as though it were the scarf thrown
over the unprotected derma, or from its known con-
stitution of minute scales, which, by their separation
and accumulation on the surface, constitute the
scurf; but to us it seems more than probable that
the former of these terms takes its origin from the
latter, and, as a consequence, that the word scurfs
skin is the most correct. Another of the synonyms
of the epidermis is derived from the Latin cutisj
namely, cuticle; the terms derma and cutis, and
epidermis and cuticula, being mutually synonymous.
The epidermis is the homy and albuminous layer
which covers the surface of the derma, and protects
it from the injurious agencies of the external world ;
the same layer holding similar relations to the
mucous membrane is termed epithelium, and just as
the derma is continuous at the apertures of the
body with the corium of the mucous membrane, so
the epidermis is continuous with the epithehum, the
epidermis and the epithelium together constituting a
perfect sheath or varnish to the whole surface of the
individual, both internally and externally. The epi-
dermis is many times thinner than the derma, but,
like the latter, it presents an internal and an external
surface. The internal surface is moulded on every
irregularity of the derma, forming sockets for its
papillae and sheaths for its follicles ; while the exter-
nal surface is more or less influenced in appearance
by the evenness and unevenness of its bed ; on one
part where the papillse are few in number and
minute, being almost flat, and in another, such as
the palm of the hand, where the papillaa are nume-
rous and arranged in parallel ridges, being uneven
and ridged.
Another peculiarity of the epidermis is deduced
from its deficient elasticity as compared with the
derma. The latter, although highly elastic, is
necessarily thrown into wrinkles and folds by the
movements of the body, and the creases or lines of
ANATOMY OF THE EPIDERMIS. ^
motion^ as they are termed, are more or less permaBent.
The epidermis conforms to this condition of the
derma, and exaggerates its results, the hollows and
the prominences of the lines of motion, as repre-
sented by the epidermis, being deeper and more
strongly marked than those of the derma ; and,
certain of the minuter lines of motion of the skin,
which are scarcely perceptible in the derma, being
conspicuous in the cuticle. Such, for example, are
the lines which radiate from the pores of the
follicles, and are produced by the intrinsic move-
ments of the corium, namely, such as result from
the action of its special muscular structure; for
example, those concerned in the state of erection
of the pores termed cutis anserina.
The epidermis, besides being the enveloping
sheath of the derma, is a cell-tissue of the most
primitive structure, endowed with a self-maintaining
and self-producing power, undergoing development
and growth, possessing a borrowed and an inde-
pendent vitality, living and performing the destined
functions of cell-life, elaborating a soft albuminous
material into a homy tissue, and converting albu-
minous and proliferating cells into thin homy and
compactly condensed scales ; while in the follicles
and glands it assumes the character of the active
agent of secretion of the special products of those
glands ; eliminating sebum in one situation, sweat in
another, and milk in a third.
If we subject the epidermis to the same form of
examination as that to which we have already sub-
mitted the derma, we find it to present on its
internal surface a soft cell-tissue, the pars cellularis
or rete mucosum ; and on its external surface a dense
semi-transparent and firm portion, the pars cornea^
or horny layer. In bulk, the horny layer is several
times thicker than the soft or mucous layer ; the
latter being the immature or formative portion of
the cuticle, consisting of cells with nuclei and
8 ANATOMY OF THE SKIN.
granules ; the former the perfected structure ; the
process of elaboration and horny transformation of
the cells being completed in the lowest stratum of
the membrane. Above this, the horny portion, as
a consequence of its manner of formation, is finely
laminated, and the detrition of the laminas on the
external surface produces the fine scales which have
suggested the terms scurf and scurf-skin.
It is in the soft under- stratum of the epidermis,
the rete mucosum, that the pigment of the skin is
deposited ; but the pigment, in consequence of the
preponderance of albumen, the production of horn,
and the exhaustion of fluid, is more or less counter-
balanced in the horny layer ; hence the horny layer
of the cuticle of the negro is whitish or greyish in
appearance, and difiers but little from that of the
European. The rete mucosum is continuous with
the cellular epithelium of the follicles and glands ;
and the cells of the rete mucosum and those of
the epithelium may be regarded as identical in
structure.
Like the derma, the epidermis is also perforated
with tubular passages, which correspond with the
pores of the skin, namely, the openings of hair-
follicles, the sebiferous follicles, and the sudoriferous
ducts. The former of these openings pass through
the epidermis in a direct line, but those of the
sudoriferous tubuli form a spiral coil, and both
carry with them into the mouth of the follicle a
conical process, or plug of the rete mucosum. It
was the ignorance of this fact that committed
certain of the older physiologists to the belief that
the cuticle was not permeable; for when they
separated a portion of the membrane, and poured
mercury on its internal surface, the mercury could
by no means be made to find a way through, the
little conical plug and its prolongation being an
effectual barrier.
Like the derma, the epidermis is modified in
FOLLICLES AND GLANDS. 9
different regions of the body to suit the especial
functions of the part. It is thin on the eyelids, the
scalp, the inner side of the limbs, and the scrotum ;
while it is thick on the outer side of the limbs, and
remarkable for its thickness on the palm of the
hands and sole of the feet. Moreover, at the ex-
tremity of the fingers and toes it is modified in an
especial manner to constitute the nails. Under the
influence of a morbid state of the economy, the epi-
dermis may be increased or diminished in quantity
and texture : it may be too dry or too moist ; too
flexible or too rigid ; it may separate from its ad-
hesion to the derma and give rise to vesicles and
bullae ; or it may break up into laminae, and present
us with the varied phenomena of squamae and de-
squamation.
The FOLLICULAR and the glandular element of com-
position of the skin, in the next place, claims our
attention. The follicles and the glands are a simple
modification of the derma and the epidermis to suit
a particular purpose ; that purpose being the elabo-
ration of a peculiar product, in one part and in one
region known as the sebaceous matter, or the sebum,
in another as the sudatory secretion, or the sweat.
The agents of these secretions are the tubuli which
have been already described as perforating the
derma from without, which in the one instance are
prolonged to the lower stratum of the pars areolaris
and end in a small coiled-up mass, the sudoriparous
gland ; and, in the other, ramify in the stroma of the
upper region of the derma, and constitute a small
ramified and lobulated organ, the sehiparous gland.
Besides these tubuli there is a third kind, which is
straight in its course, which descends in the derma
to a varied depth, sometimes extending beyond the
lower face of the pars reticularis, and whose chief
purpose is the support and maintenance in position
of the hair, the hair-follicle. Furthermore, it may
lO FOLLICLES AND GLANDS OP THE SKIN.
be mentioned that wherever hair-follicles exist, the
sebaceous follicle or gland is an offshoot from the
upper part of that follicle.
In structure, the hair-follicles, the sebiparous fol-
hcles or glands, and the sudoriparous tubuli and
glands are identical ; all are faced by the derma and
lined by a continuation of the epidermis termed
epithelium, and all have a laminated condensation
of the tissues of the derma around their cylinder,
which is termed their coats. They also, like the
structures heretofore examined, have their peculiar^
ities which adapt them especially to the wants of a
particular region. The hair-follicles have an oblique
position in the skin, are large in certain situations,
and wanting altogether in others, such as the palm
of the hand and sole of the foot. United every-
where with sebiparous glands,— which form a kind
of frill around the neck of the largest follicles, which
depend in pairs like clusters of grapes from the neck
of those of the scalp, and which are single in con-
nection with the smaller folKcles, — the hair-follicles
of the minuter hairs become secondary to the sebi-
parous follicles and glands, as on the nose and in
the meatus of the ears. In these latter situations
the sebaceous follicles and glands are remarkable
for their bulk ; while in the palmar and plantar sur-
face of the hands and feet they are wanting alto-
gether, and give place to the sudoriferous tubuli
and sudoriparous glands. Nevertheless, the differ-
ences in the three sets of organs in their most highly
developed form are sufl&ciently characteristic; a
simple straight tube, the hair-follicle ; a tube con-
voluted at its extremity, the sudoriparous gland ; and
a more or less ramified and lobulated organ, the
sebiparous gland. So also, and to an equal extent,
do the functions of the three organs differ ; the one
a mechanical support, a sheath to the root of the
hair ; the second, the producer of an aqueous secre-
tion with acid reaction ; the third, the source of the
PHYSIOLOGY OP THE SKIN. II
fatty element of the skin, bedewing its surface with
an oleaginous moisture, giving brightness and bril-
liancy to the surface and to the hair, and protecting
them both from the evils of attrition and the irrita-
tion of the atmospheric elements.
The remaining constituent of the skin, namely the
hair, brings before us another interesting feature of
the animal economy ; developed from the fundus of
its follicle through the agency of a papilla, the hair
presents us with the analogue of a tooth : as the
pulp of the tooth is converted into the fibrous den-
tine of that organ, so the hair-papilla or hair-pulp is
transformed into the fibrous structure of the hair ;
the central embryonic cells of the hair-papilla are
marked in the centre of the hair-cylinder by the
medulla or pith ; on the exterior of the fibrous sub-
stance of the hair is the transparent representative
of the enamel, in this instance the cuticle of the hair,
and exteriorly to the latter, the corrugated surface
represents, according to Huxley, the parallel of the
persistent capsule of the tooth. We are struck by
the unexpected importance of the hair in the animal
kingdom, and our astonishment increases when we
find that a hair, a tooth, and an eye, are each a
simple adaptation of the same primitive organ,
altered in its form by special development to suit a
special place in the organization, and fulfil a special
office.
Physiology op the Skin.
The Physiology, or consideration of the uses of the
skin, brings to our notice its various qualities of
complexion, texture, smoothness, and sensibility. A
healthy complexion of the skin is one of the most
striking of its characters, but not the most easy to
describe, and in this, as in many other examples of
I
12 PHYSIOLOGY OF THE SKIN.
medical diagnosis, the eye of intelligence and expe-
rience comes to our aid. We know the delicate tints
of white, of yellow, of blue, and of brown, of the
dermal tissues, and we recognize as the healthy
complexion, the lighting up of these tissues by the
arterial and partly by the venous blood. To the
Dermo-pathologist there is no better test of the
health of the body than the appearance of the skin ;
and to him the complexion of the face affords pow-
erful aid, in addition to his scrutiny by means of
the tongue, the pulse, and the inward sensations of
the patient; the muddy, the yellow, and the greenish
tints of the complexion betoken mal-assimilation ;
while an accumulation of the duskier hues, raises a
suspicion of the solar plexus and its dependent
viscera being the source of disorder.
Normal texture of the skin is evinced by a healthy
firmness, a medium thickness, and a proper elasticity
of the integument, and, like the complexion, is to be
tested by negative rather than by positive signs. It
is neither too soft nor too thin, neither is it flabby
nor wrinkled, but it possesses those incomparable
qualities which we associate, with much reason, with
a healthful condition, which in fact represent the
normal standard of health. So also a healthy smooth-
ness of the skin is an important indication of its
proper nutrition and renovation. An excess of
smoothness may result from a morbid change such
as interstitial deposition or effusion ; while a want
of smoothness may be the consequence of unhealthy
elaboration on the part of the cell-tissue of the epi-
dermis ; or of imperfect secreting function of the
sebaceous and sudatory glandular apparatus.
There is no better test of the normal or abnormal
condition of the skin than its state of sensibility, and
an aberration of sensibility may be regarded as a
proof of its deteriorated function. We have exam-
ples constantly before us of morbid sensibility ; the
body is unable to bear the chill of the morning bath,
COMPLEXION AND SENSIBILITY. I 3
SO necessary to the health of the economy ; the skin
of the face is irritated by the action of soap, so
necessary for its cleanliness and comfort. Every
day we are constrained to modify our directions or
our treatment to suit the abnormal sensibilities of
our patients. The morbid sensibility of the skin
may assume the positive character of pain, or it may
be the seat of itching, tingling, burning, creeping,
piercing, shooting, &c., and the form of pain is
sometimes sufficiently characteristic to enable us to
determine the nature of the disease ; the tickling
itchiness of scabies is pathognomonic ; so also is the
prickling, tingling, and burning of herpes ; so like-
wise are the creeping, stinging, and darting pains of
prurigo, the throbbing and burning tingling of urti-
caria, and the fierce and concentrated itching of
papular and indurated ekzema ; nor are examples of
decided neuralgia absent from the cutaneous tissues :
it may be a dermatalgia of the normal tissues, or it
may be a dermatalgia of morbid tissues, as in the
instance of ekzema neurosum.
The nervous sympathies of the skin are manifested
in the blush of emotion ; the flush of heat associated
with taking food when the stomach is weak and the
digestive organs impaired ; and the hyperasmic con-
gestions excited by irritability of the abdominal
organs, and especially by those of the uterine and
the reproductive system. That very troublesome
disorder, urticaria, is an illustration of the morbid
sympathies existing between the digestive organs
and the general surface of the body ; and that not
less annoying but more enduring affection gutta
rosea, between the same organs and the skin of the
face. While the direct influence of the nervous
system on the skin or neurosis, is evinced in the de-
velopment of the vesicles of herpes.
To the physiological operations of the integument
belong in like manner the disorders of secreting
functions, the derangement of the sebaceous and
14 PATHOLOGY OF THE SKIN.
sudatory secretions; alteration of pigment-formation
and distribution, and morbid changes in the epi-
dermis, the nails, and the hair.
Pathology of the Skin.
The Pathology of the skin opens up to us an in-
vestigation replete with important and varied pheno-
mena ; and our interest in the subject is increased
by having the morbid operations, as it were, spread
out immediately under our eye and within the reach
of our hand. We may distinguish diseases which
are especially affections of the derma; others which
are aflrections of the epidermis and nails ; and others
again which are affections of the glandular appa-
ratus. While the disorders of the derma may result
from simple inflammation^ they may involve sepa-
rately the nerveSi the hlood-vessels^ and the blood;
they may be derangements of develomaenty nutrition^
and growth; or they may exhibit the pathological
condition of metamorphosis of tissue.
Inflammation of the derma may present itself as a
simple redness or erythema ; as a rising of the fol-
licles of the skin constituting papulae^ or larger
masses termed tubercula ; as minute blisters termed
vesiculoe^ or large blisters, named bullce ; as vesicles
containing pus, or more correctly as pustules ; and
as detached laminas or scales of epidermis termed
squamce' ; and to these states or lesions^ as they are
technically called, may be added stains or maculasf
which may be left behind by the inflammatory pro-
cess. These pathological lesions may exist sepa-
rately, or they may all, or nearly all, be present at
the same time ; and they are sufficiently conspicuous
and decided to have been fixed upon by Willan as
the signs or types of his eight orders of cutaneous
diseases.
PATHOLOGICAL LESIONS. I 5
Ebythbma, according to Willau, or rather, Exan-
thema or rash, is represented by " superficial red
patches variously figured and diffused irregularly
over the body, leaving interstices of a natural colour,
and terminating in cuticular exfoliations."
Papula, or pimple, is " a very small and acumi-
nated elevation of the cuticle, with an inflamed base,
very seldom containing a fluid or suppurating, and
commonly terminating in scurf."
TuBEROULUM or tubcrcle is a " small hard super-
ficial tumour, circumscribed and permanent, or
suppurating partiaUy."
Vesicula, or vesicle, is " a small orbicular eleva-
tion of the cuticle, containing lymph, which is some-
times clear and colourless, but often opaque and
whitish, or pearl-coloured ; it is succeeded either by
scurf or by a laminated scab."
Bulla, or bleb, is " a large portion of the cuticle
detached from the skin by the interposition of a
transparent watery fluid."
PusTULA, or pustule, is "an elevation of the cuticle
with an inflamed base, containing pus."
Squama, or scale, is " a lamina of morbid cuticle,
hard, thickened, whitish, and opaque."
Macula, or spot or stain, is " a permanent dis-
coloration of some portion of the skin, often with a
change of its texture."
The definitions of Willan are distinct and lucid,
and are still employed in the sense in which they
were used by that eminent man, with the exception
of the last ; the macula9 of the present day applying
simply to stains of temporary existence, such as the
congestions of small-pox, and the discoloured
sequelaB of lepra and dermatosyphilis ; while the
maculae of Willan, namely the ephelidje, the naavi
and the spili, are distributed in accordance with
relationships, such as are. determined by a more
advanced school of pathology.
1 6 PATHOLOGY OF THE SKIN.
The Signs of inflammation of the skin, or derrm^
titis^ as of inflammation in general, are, redness,
pain, heat, and swelling. In simple redness we have
to distinguish between that which is slight and
transient, a mere filling of the capillaries with blood,
or hyperaemia ; and the more permanent redness,
accompanied with other changes in the tissues of the
skin, which constitutes dermatitis. The limits be-
tween the physiological and the pathological are
barely discernible ; the blush of emotion is scarcely
to be distinguished from the blush of transient
erythema or urticaria, and the too frequent repeti-
tion and the permanence of the blush becomes a con-
firmed erythema, as in gutta rosea. The patho-
logical blush is termed erythema and exanthema
and also erysipelas ; but these terms, although
signifying nothing more than redness, have special
meanings attached to them in their practical applica-
tion and use.
The redness of the skin ofiers considerable variety
of character ; it may be universal or partial ; it may
also be uniform or punctated ; and it may vary in
its tint, from the bright scarlet of arterial blood to
the purple and the blue or the livid, of venous
blood ; or to the lurid and the sombre hue of morbid
blood. An uniform sufiusion results from the
equable congestion of the papillary layer of the
derma, the surface capillary plexus ; while congestion
of the follicular or vertical capillary plexus gives
rise to a punctiform redness, which may exist
independently, or be a part of the uniform redness.
In erythema and erysipelas the redness is uniform ;
while in one variety of roseola, as also in the exanthe-
matous fevers, namely, rubeola, scarlatina, and
variola, it is punctated. The latter diseases may
also be taken as the best examples of variety of red-
ness ; scarlatina and variola being remarkable for
the brightness of their hue, while rubeola is ruby or
raspberry coloured, and roseola rose-coloured or
PATHOLOGY OF HYPEBiBMIA. l^
crimson, a tint that verges upon purple. In a torpid
state of the circulation of the skin these tints are
depressed to the purple and the livid, and especially
in those forms of hyperaemia which, like kyanosis,
are associated with a mechanical interruption of the
circulation. The alterations of redness dependent
on morbid blood, are illustrated by the muddy hues
of dermatosyphilis, those forms of discoloration
which have received the name of copper-coloured.
Hyperaemia, or distension of the vessels with
blood, must necessarily be associated with some
degree of swelling of the skin : the swelling may be
slight, so as to appear hardly appreciable, or it may
be strongly marked, and a distinguishing symptom.
Swelling, however, is no test of the degree of force
of the hyperaBmia, but is dependent sometimes on
the region of the body affected, sometimes on con-
stitutional predisposition or temperament, and some-
times on the nature of the disease. An erythema
in the palpebral region will generally be attended
with more or less tumefaction ; one form of erythema
is remarkable for its tumescent character, erythema
tumescens ; there is a general state of swelling of
the skin in rubeola, scarlatina, and variola ; and a
special tumefaction in erysipelas. The sweUing of
the dermal tissues is sometimes remarkable for its
rapidity and suddenness, as in erythema tumescens,
and after the bites or stings of certain insects ; and
sometimes it is slow and gradual. In general, it is
due to the escape from the vessels of the serous
element of the blood; but in certain cases, as in
erythema nodosum and tuberculosum, and especially
in urticaria, is dependent in part on spasm of the
muscular structure of the skin. Where exudation
into the aflfected tissues is the cause of the swelling,
as in erysipelas, the skin is apt to assume a peculiarly
transparent appearance, as though it were tensely
injected with a transparent fluid, and to resemble
brawn. The brawn-like transparency and texture
c
1 8 PATHOLOGY OP THE SKIN.
of some forms of erysipelas is very remarkable, and
similar brawn-like blotches are met with in elephan-
tiasis ansesthetica. Again, it is not uncommon for
the accumulated fluids of the tissues to be discharged
upon the surface of the derma, and to raise up the
epidermis into vesicles and bullae; in this pheno-
menon we find explained the vesicles of miliaria,
and especially of ekzema and erysipelas ; the latter
constituting the erysipelas bullosum.
Increased temperature, or heat of the skin, is not
a conspicuous sign in connection with the pathology
of the dermal tissues ; in a few instances we have
noted a rise in the thermometer of a few degrees in
ekzema and erysipelas, and also in scarlatina and
variola; but, in general, the sensations of heat
experienced by the patient are forms or modifica-
tions of pain rather than an actual augmentation of
temperature. Occasionally, when the patient has
complained bitterly of heat, the sensation to the
hand of a healthy person is one of cold ; the feeling
of extreme heat in scarlatina and variola is relieved
by excluding the atmosphere ; and the heat of the
zona ignea, or herpes zoster, is a mere modification
of sensibility. In like manner the chills and flushes
of heat which are associated with certain forms of
hyperaemia, must be looked upon as contrastive
sensations rather than as actual variations of tem-
peratui*e.*
Pain in the skin, and accompanying cutaneous
eruptions, presents a great variety of character : —
the most common manifestation of painful sensation
• " Under certain conditions,'* says Liebig, " a chill is felt in-
wardly without the temperature of the body diminishing on that
account, and warmth is experienced without there being an in-
crease of heat. These sometimes point to a state in which certain
nerves tfirow offmore vxxrmtfi than they receive, or receive mare
than they ilirow off. The sensation serves only to announce an
inequality, which, if it be slight and passing, can, by various
stimulants, be easily removed. If it be lasting, it is looked upon
as a symptom of illness.''
MORBID SENSATION OP THE SKIN. 1 9
is pruritus, and in addition to pruritus there may be
a morbid sense of heat and cold, burning, tingling,
pricking, darting, shooting, creeping, sometimes
weight and throbbing, and sometimes soreness and
aching. The pruritus also has its shades of modifi-
cation; it may be tickling and not seriously un-
pleasant, such is the itching of scabies ; it may be
tingling, as in urticaria ; burning and shooting, as
in herpes ; or pungent and irritating, as in ekzema.
There is reason to beheve that these modifications
are in some degree influenced by the extent of
nervous tissue involved in the disease : in scabies
and erythema the papillary surface only is affected ;
in urticaria, deeper filaments of the cutaneous
nerves ; in herpes, as we know, the affection of the
nerve extends further along its course and even to
its trunk ; while ekzema is complicated with graver
changes in the tissues of the skin. If James I.
could advocate the monopoly of scabies by kings and
purple blood, on account of the delights of scratch-
ing, he would be little inclined to extend his protec-
tion to the fierce itching of' ekzema; which the
Romans called scabies, and the Greeks psora, from
the tearing and laceration to which it gave rise to
assuage the pruritus. The itching of ekzema now
and then excites a state of frenzied suffering, and
some of those who have writhed under an allied
disorder, namely prurigo, have compared their tor-
ments to being broiled on a gridiron ; to being eaten
up by ants ; and to being pierced all over with
halberds. Occasionally we find actual pain substi-
tuted for itching, as in ekzema neurosum, and then
the sensation is one of being denuded of skin, or
of exposure of the bare nerve ; the slightest touch
occasions the most intense suffering, and the
application of remedies is almost impossible.
c 2
1
20 PATHOLOGY OF THE 8KIK.
In our preceding lecture we took a survey of the
territory which we propose to investigate ; we studied
the map of the region whose natural intricacies it is
our business to explore ; we took a general review
of the disturbances that might by possibility arise,
that we may prepare ourselves with the means of
regulating and controlling such disturbances and
disorders whenever they occur. • We looked upon
the integument as composed of a derma, an epider-
misy and a subcutaneous areolar and connective
tissue, and in each of these three divisions of its
structure we met with separate points for con-
sideration ; in the epidermis we found a formative
growing layer, the rete mucosum, and a perfected
norny layer ; in the derma we discovered a follicular
and a glandular structure, together with vessels,
nerves, connective tissue, and muscular tissue ; and
in the subcutaneous web we noted the presence of
connective tissue, adipose tissue, and the cascal ends
of the larger hair-foUicles. But however much we
might be disposed as physiologists to admire the
beauties of structure and adaptation of the cutaneous
organ, in its whole and in its parts ; yet as patho-
logists, and especially as dermo-pathologists, our
view of the integument is necessarily associated with
the contemplation of its possible abnormal and
morbid derangements. Instead of being smooth and
clear and flexible, the horny layer (lamina cornea) of
the epidermis in a pathological state, may become
rough, opaque, and brittle ; the rete mucosum
(lamina mucosa) may be altered in colour and in
structure ; and the several components of the derma
and of its subcutaneous layer may be changed in
their appearance and function.
We have considered the chief of the pathological
changes aflTecting the derma, under the heads of
redness, swelling, heat, and pain ; the rubor, tumor,
calor, et dolor of simple inflammation. We recognize
in redness the distension of the capillaries with
PATHOLOGY OF SWELLING. 21
blood ; we noted the differences of character pre-
sented by the redness when the hyperaemia occupied
the peripheral surface, and when the follicular in-
flexions of the derma, in the former case producing
a general suffusion, as in blushing ; in the latter a
punctation, as in measles. We remarked on the
variety of the tints of redness, from the scarlet of
scarlatina, through the ruby hues of rubeola, to the
purple and the livid of kyanosis ; we took under our
consideration the abnormal coloration of dyskrasia
as illustrated by dermatosyphilis ; and we may add,
further, to these modifications of colour, that which
results from the exudation of blood from its vessels,
as in the instance of purpura and contusion.
SweUing, in various gradation, we found to be a
common associate of cutaneous disorder, in some
measure resulting from distension of the capillaries,
and the consequent accumulation of blood in the
skin ; but in a greater degree from the absorbent
action of the cell-elements of the derma. The
presence of swelling betokens a state of disturbance
of activity of the cell-elements of the tissues affect-
ing their nutritive function ; and, under the influence
of such disturbance, they absorb with rapidity and
eagerness the fluids brought to them by the blood-
vessels, and become distended and enlarged, the sum
of their enlargement being the measure of the
amount of swelling produced.* In physiological
hyperaemia, as in blushing, there is doubtless a
transitory state of swelling of the skin ; and we
know that by a repetition of such flushes a per-
manent enlargement of the capillary vessels, or, as
* The researches of German Pathologists tend to show that
the presence of an excess of nutrient material in the tissues leads
both to hypertrophy and hyperplasia of their elementaiy consti-
tuents ; cells are swollen, their nuclei being enlarged ; new cells
are dereloped; and the cells of connective tissue shoot forth
ramifications which exceed the normal boundary of distribution
of that substance.
22 PATHOLOGY OF THE SKIN.
it is termed, angeiektasia, is produced, which is often
accompanied, as in gutta rosea, with enlargement
and thickening of the corium of the skin. In that
more extensive and prolonged flush of the skin which
accompanies the exanthemata, the swelling is general,
and, as we know to be the case in variola, often so
considerable as to distend the head and features to
a frightftd degree.
There can be no doubt but that swelling is very
much modified by the sthenic or asthenic condition
of the cell-elements of the tissues, and that the
sthenos or asthenos of the latter is to a very con-
siderable degree under the influence of the tone or
power of the constitution. In a mild example of
variola, or scarlatina, with abundant hyperaemia, the
swelling may be moderate, while in another case,
where the constitutional powers are depressed and
the tissues participate in the general weakness, the
fiweUing may be excessive, although the hypersemia
is only slight. To these causes must be attributed
the excessive swelling which accompanies erysipelas ;
and the frequent association of extensive swelling
with chronic afifections in which both the tone of
the system and of the cell-elements of the part is
reduced. Wherever much connective tissue prevails,
to the exclusion of blood-vessels, as in the eyehds
and scrotum, there swelling is a common and strik-
ing occurrence; or, where the circulation is weak
from peripheral position, as in the nose and
extremities. While, on the other hand, there are
certain forms of swelling, such as that which ac-
companies erythema tumescens, wherein the cell-
elements of the tissues would seem to be chiefly in
fault. We have an example of swelling dependent
on a local asthenia in the very considerable tumefac-
tion that usually accompanies the sting of a wasp,
and sometimes the bite of less-venomous insects ;
but at the same time we know full well that any
extraordinary tumefaction is always associated with
PATHOLOGY OF ABNORMAL SENSATIONS. 23
some degree of asthenia of the individual, and we
note the occurrence of extreme swelling as an
unusual phenomenon.
The conclusion to be drawn from these examples
would therefore appear to be that while tumefaction
is undoubtedly due, as its proximate cause, to an
excessive absorbent action on the part of the cell-
elements of the tissues ; yet that that excessive
action, if not asthenic from the first, speedily
becomes so ; and that its sthenic or asthenic cha-
racter is under the immediate influence and partakes
of the nature of the general constitution. Upon
the same data we are permitted to frame the theory,
that in proportion to the debility of the cell-elements
will be the more aqueous quality of the fluids
absorbed, the retinence of the aqueous condition,
and the nearer the approach of the swelling to the
state of oedema. While, on the other hand, the
assimilation of the ingested fluid, and the expulsion
of its excess, will demonstrate the existence of a
more vigorous cell-power, and lead to a more speedy
dispersion of the tumefaction.
We moreover remarked, that the sensations of
heat in the morbid skin were in general greatly dis-
proportioned to the actual temperature, in conse-
quence of the heightened sensibility of the organ ;
this is remarkably the case in herpes, the zona ignea,
and sometimes also in ekzema. In the latter disease
we have noted the temperature of the skin as high
as 103^ while in scarlatina and erysipelas it some-
times reaches an elevation of 104® or 105°; and in
anaesthetic elephantiasis it has been found, in the
hands, as low as 68^ and rarely higher than 90°.
Under the head of pain we enumerated a goodly
list of morbid sensations ; but we may farther
illustrate this point by mentioning the following
catalogue of painful sensations drawn up by a
patient sufiering under dyssesthesia. At various
times she experiences dull pains in the skin, acute
24 PATHOLOGY OP THE SKIN.
tranBient pains, shooting, darting, pricking, smart-
ing, tingling, itching, crawling, and burning pains,
with sensations of throbbing, quivering, trickling,
shivering, and trembling ; sometimes the skin has a
sore or rubbed feeling, and is always unnaturally tender
and sensitive, and more sensitive to slighter stimuli
than to those of a severer kind. This strange record
of suflfering is attributable to hysteria, the common
parent of abnormal feminine disturbance ; but we may
be permitted to question the degree to which the uterus
is answerable for such abnormal symptoms ; they
sometimes occur in men, in which case hysteria is
clearly out of the question ; but the real cause is, in
fact, disturbance of function of the coeliac centre of
nervous plexuses ; hence a more appropriate and
correct name than hysteria would be cosliaca. The
term coeliaca would be applicable to men as well as
to women, and would better express the nature of
the pathological derangement ; since hysteria is, we
believe, as often an eflfect of a central nervous irrita-
tion as the cause of a radiation of morbid sym-
pathies. In the case to which we have just referred,
the patient was a lady of strong mind and good
common sense, and her nervous sufferings were a
source of as much surprise and vexation to herself
as they are to those around her. Her illness began
by a nervous shock, fright, and affliction ; the seat of
injury consequent on these causes was doubtless the
solar plexus, and from the solar plexus as from a
centre her morbid sensibilities took their Yise ; the
uterus suffered with the other abdominal organs, and
more particularly with the alimentary canal ; but the
latter affection, and the consequent hysteria, were
in reality a secondary result. Among the rest of
the morbid sensations which this lady experienced,
was the consciousness of the movement of the blood
through its vessels, and an inward sense that
occasioned involuntary fright and alarm.
From the more general signs of pathological
EKZEMA AND PSORA. 25
derangement of the skin already mentioned, namely,
redness, swelling, heat, and pain, we may next pro-
ceed to the particular and special signs, which are
usually termed lesimis ; and we cannot do better
than study the pathological lesions of the integu-
ment side by side with the commonest and most
universal of diseases of the skin, namely, ekzema,
Ekzema. as a word, simply means eruption, and it
may be truly said that it is the eruption of the skin ;
as the most common of the eruptions it is that
which comes the most frequently under our observa-
tion, and is therefore the one to which we can most
readily refer, the most easily study, and with which
we can with the greatest facility compare other forms
of cutaneous disease. The word ekzema was given
to this very common eruption by the Fathers of
Medicine, namely, the Greeks; but they also had
another name for it, which expressed one of the
most prominent of the characters or qualities of the
disease, — namely psora^ and we must endeavour to
pronounce the p as well as the s in this word to give
it its proper eflFect. Now psora means the itchy
because of its itchiness, because, in fact, of the
necessity, which is induced by its itchiness, to rub
and to scratch ; the word psoein means to rub, and
psoriaein to have the psora or itch. This is the
language of Hippocrates, who dates back five
hundred years before the Christian era ; and these
words are as applicable to the disease in question
at the present hour as they were in the time of our
great predecessor. But let us pursue the matter a
little further. " Familiar to our ears as household
words " are the terms ekzema and psora, and so also
is another word, psoriasis ; but until now it may not
have been known to you that ekzema and psora have
the same meaning, and are in Set synonymous ; that
ekzema announces the eruption only, whereas psora
represents the most marked of its symptoms^ its
psoric or itchy tendency. By-and-by, we shall have
26 PATHOLOGY OF THE SKIN.
to point out to you that ekzema or psora presents
two very marked and distinctive forms, represented
by the words humidum and siccum ; namely ekzema
humidum, ekzema siccum, or psora humida and
psora sicca. The moist form is distinguished by
moisture or discharge, and the dry form by dryness
and a consequent exfoliation of the cuticle in small
scales ; ekzema siccum, or psora sicca, is therefore
squamous as well as being itchy, and in these two
qualities combined wq find the explanation of the
word psoriasis ; psoriasis, in fact, being the squamous
form or stage of psora, of which the word is an
obvious derivative. It is important to remember
this, because the word psoriasis has been generally
misapplied since the time of Willan, and the evil has
been increased of late years by the assignment of the
term to the lepra of the Greeks, the lepra vidgaris
of Willan. We also beg to remind you that the a
in psoriasis should be pronounced long, namely,
psoriasis.
But we must say a few words more with regard
to ekzema before we commence to observe it more
carefully. It may seem to you that we attach too
much importance to the meaning of a word ; but,
gentlemen, we must ask you to accept in faith that
which we now declare to you ; we have not laboured
at the study of cutaneous medicine for thirty years *
without having come to certain positive conclusions,
and conclusions which we believe to be founded in
truth. One of the first articles of cutaneous faith
that we call upon you to subscribe to, if you would
in future be ranked as our disciples, is, that ekzema
and psora are identical, and that psoriasis is a stage
of psora. When the time comes, we shall be equally
able to prove to you that that other disease which is
now so commonly termed psoriasis by the Foreign
schools, is not psoriasis, but is really the lepra of
the Greeks, the lepra vulgaris of WiUan. But
we have other masters besides the Greeks, and
SCABIES AND IMPETIGO. 27
masters whom it is our delight to honour, — ^namely,
those worthy successors of the Greeks, the Eomans.
Greatest among the Roman physicians was Celsus ;
and Celsus designates psora and ekzema by the
terms scabies and impetigo; scabies derived from
scdberef to scratch — ^itself a derivative of scaphein^ to
dig as with the nails in scratching — is the analogue
of psora ; while impetigo, ab impetu agens^ a break-
ing out with impetus, corresponds with ekzema ; and
all the four terms apply to the same disease. At the
present time, however, we dispose of these four
terms differently ; ekzema we retain as the type of
psoric affection ; impetigo, we apply to a pustular
ekzema ; scabies, we restrict to the ekzematous
eruption, excited by the acarus scabiei ; psoriasis
we give to the dry and squamous ekzemata, especially
when associated with thickening and cracking of
the skin and much pruritus ; and psora we discard,
as having no special occasion for its use.
Gentlemen, we offer you no excuse for this digres-
sion from our subject ; we have led you over classic
ground, and through a territory in which disputed
questions prevail, but we have endeavoured to
guide you with the lantern of knowledge to the
temple of the veiled goddess whom all true wor-
shippers of science most venerate ; and we conclude
our episode by informing you that although in
cutaneous medicine we are ungracious enough to
have rejected the ancient term psora^ yet that we
retain it in our popular language in the simple and
forcible expression sore.
Well, gentlemen, if we have a subject before us
suffering from ekzema, we shall inevitably find red-
ness or hyperaemia more or less extensively distri-
buted; we shall have swelling or thickening from
infiltration of the affected skin ; we shall possibly
discover an elevation of temperature ; and we shall
pretty certainly be made aware of pain^ commonly
in the character of burning or scalding, itching,
28 PATHOLOGY OP THE SKIN.
and probably tingling and pricking. But besides
these morbid states or lesions, the common signs
of inflammation of the skin, we shall meet with
other signs of disorder, namely : — minute elevations,
which are termed papulce or pimples ; or small
elevations filled with a transparent albuminous
fluid, namely, vesiculce or vesicles ; maybe with small
vesicles filled with pus, vesico-pustules, or simply
pustules; then we shall find excoriations exuding
a viscous albuminous fluid, sometimes transparent
and sometimes purulent ; or the thickened skin may
be fissured with chaps ; or there may exist cover-
ings of different kinds to the inflamed corium,
sometimes assuming the character of crusts or scabs^
and sometimes of small scales undergoing constant
desquamation. Again, we may observe, in conjunc-
tion with these lesions, scratches denoting the opera-
tion of the nails for the relief of itching; and
lastly, macular or stains left on the affected part
after the healing of the skin.
Now all these lesions may be present at successive
periods on the same person and in the same disease,
for example, ekzema ; and if we look at them a
little more closely, we may see reason to arrange
them into two groups, namely, such as are of
earliest appearance, or primary; and such as are
subsequent, or secondary. For instance, the red-
ness, the papule, the vesicle, and the pustule are
primary; while the desquamation, the excoriation,
the fissure or chap, the crusts, the scabs, the
scratches, and the stains are secondary. But
besides these lesions, which are all present in
ekzema, there are a few more which belong to other
forms of disease, and therefore we shall assemble
all that are usually recognized — under the two
heads, primary and secondary, and consider and
describe them seriatim.
PATHOLOGICAL LEIOSNS. 29
Pathological Lesions. — The primary lesions of
the skin, or signs of a morbid state, are as
follows : —
Rubor. Pustula. Tuberculum,
Papula. Bulla. Tuber.
Yesicula. Squama. Macula.
And the secondary lesions are : —
Desquamation. Fission.
Excoriation. Ulceration.
Induration. Cicatrisation.
Incrustation. Discoloration.
RuBOE, or REDNESS, is the state of colour of the
skin produced by the abnormal distension of its
vessels with blood. It may be simply functional
and uncomplicated by any change in the vessels
themselves, or it may be structural and depend upon
a permanent state of enlargement or hypertrophy
of the vessels, or alteration of their coats. Func-
tional redness may be present as a mere transient
blush, or physiological hyperaemia, or it may repre-
sent many degrees of intensity of pathological
hyperaBmia and constitute an exanthema or an
erythema. Structural redness, on the other hand,
may be due to a permanent enlargement of the
vessels of the skin, termed angeiektasia and vas-
cular naevus ; or it may result from lesion of the
coats of the vessels and the escape of the blood
into the parenchymatous tissue, as in purpura, and
also in contusion of the skin.
Pathological redness also presents as phenomena,
— that it may subside without alteration of nutrition
of the skin, as in some of the slighter forms of
erythema, or that it may induce a suspension of
nutrition of the epidermis, and in this way give
rise to exfoliation and desquamation of the cuticle ;
or it may be associated with exudation and hyper-
30 PATHOLOGY OF THE SKIN.
nutrition of the cell-structure^ causing thickening ;
or, finally, it may become chronic and accompany
the secondary series of morbid processes, and be in
itself a secondary lesion. You remember, gentle-
men, that it was upon redness that Willan founded
his definition of exanthema or ra^h, — namely, that it
consists " of red patches on the skin, variously
figured, in general confluent, and diffused irregularly
over the body, leaving interstices of a natural
colour.'* In this definition, however, it is clear that
Willan had in his mind the rash accompanying the
exanthematous fevers, — ^namely, rubeola, scarlatina,
and variola.
If we incline to seek for examples of the several
forms of pathological redness which we have enume-
rated, we shall find as illustrations of hyperasmia
subsiding without secondary changes, erythema,
urticaria, and roseola ; suspended nutrition of epi-
dermis resulting in exfoliation is seen in the
exanthematic fevers; and suspended nutrition of
the epidermis with hypernutrition of the cell-tissue
or exudation, in ekzema ; ekzema may also be taken
as indicating besides, a hyperaamia of a chronic
character and belonging to the group of secondary
rather than of primary lesions.
Eedness, therefore, is an important sign of cuta-
neous disease, and betokeus either an excess of
blood in the skin or an escape of blood from its
vessels. The excess of blood may be' physiological
or pathological, and in the latter case it may be
temporary in consequence of resulting from undue
action, or it may be permanent, from an alteration
of structure in the i)art. Again, redness will ex-
cite in our minds a varying degree of interest,
according as it may be general or partial, of larger
or smaller extent, of irregular or circumscribed
figure, or as standing alone, or associated with
other pathological signs or lesions, whether primary
in their nature or secondary.
PATHOLOGY OP PAPULA. 3 1
The PAPULA or pimple is an elevation of the cutis,
for the most part conical, but sometimes semi-
globular or flattened, minute in size, of a variable
tint of redaess, generally accompanied with itching,
and commonly succeeded by a thin scale. We will
ask you to bear in mind the definition of papula
given by Willan, — " a very small acuminated eleva-
tion, with an inflamed base, very seldom containing
a fluid or suppurating, and commonly terminating in
Bcurf." If we seek further into the nature of a
papula, we shall find that it has its seat at the aper-
ture of one of the folhcles, of the so-called pores, and
that it is produced by hyperaemia of the vascular
plexus of the foUicle and exudation into the inter-
vascular parenchyma. The degree of redness of the
papula will bear relation to the extent of the hyper-
emia, and its bulk to the amount of exudation.
You must satisfy yourselves, at the first opportunity,
of the exact seat of the papula, and the knowledge
you will thereby acquire will help you very mate-
rially in comprehending the pathology of the skin.
With careful scrutiny you will discover the aperture
of the follicle at the extreme summit of the papula,
and you will find the summit to be transparent, from
the presence within it of a conical plug of epidermis
which normally occupies the dermal entrance of
the follicle. Eayer and others pricked the summit
of the papula under the expectation of finding
an explanation of this transparency in the
presence of fluid; but they were naturally dis-
appointed, having mistaken the cause of the ap-
pearance.
Besides its conical or semiglobular or flattened
figure, we have to note, in connection with papula,
the disturbance of innervation to which it gives rise
and the consequent pruritus. The papula is remark-
able for its pruritic tendencies, but we are unable to
say vrith any certainty whether the itching is due to
pressure on the filaments of the terminal nervous
32 PATHOLOGY OP THE SKIN.
plexus by the hypertrophied cells of the parenchyma,
or to absorption by the nerves themselves, of the
exuded fluid of the vessels, or of the excreted fluid ol
the cells. In a few instances the papula subsides to
the normal level of the skin without desquamation ;
more frequently the morbid action of the tissues
determines an arrest of nutrition and the consequent
exfoliation of the cuticle covering the summit of the
cone, while, in not a few instances, the itching pro-
vokes scratching, by which the summit of the papula
is torn off, and a scab is produced, either through
the discharge resulting from excretion by the over-
distended cells, or from the escape of a minute drop
of blood, the exudation in both instances desiccating
by evaporation on the summit of the papule. The
duration of an individual papule ranges from a few
hours to one or two or more days.
As redness is the type of the exanthemata and the
erythemata, so prominence is the type of the papulw
or papular affections, and especially of leichen. We
need not stop here to inquire by what perversion of
signification the term leichen, meaning hterally a
tree-moss, has become symbolized by a papula of the
cortex of man ; but we shall do well to accept it as
a fact. By leichen we understand a papular erup-
tion, and we have other examples of a papular erup-
tion in strophulus and prurigo. If we go back to,
the illustration of cutaneous disease which we se-
lected as a standard of comparison — namely ekzema,
we shall find papulae to be a constant element of
that eruption, and sometimes a most conspicuous
symptom, as in the variety which we term ekzema
papulosum and also ekzema leichenodes ; and the
papule of ekzema is true to the characteristics of its
family stock ; the papules are minute, they are coni-
cal, hard to the touch, and extremely pruritic. Stro-
phulus is a papulous eruption occurring in infants,
and the pimples are larger than the typical papula ;
they are frequently rounded at the summit instead
PATHOLOGY OF PAPULA. 33
of being conical, and they have an amount of redness
and exudation around their base greater than is met
with in the typical leichen. The papulae of leichen
planus are remarkable for their flattened and de-
pressed summit, while those of prurigo are remark-
able for the extreme degree of pruritus by which
they are accompanied, they are often not perceptible
until the pruritus has excited scratching, and the
scratching has, as it were, called them into being ;
and they are especially distinguished by the small
black scab resulting from exuded blood that crowns
their summit after they have been violently torn with
the nails. There is another papule which is remark-
able for a tingling itching, which is larger than the
papule of simple leichen, which has the pale hue of
the tubercles of urticaria after it has been scratched,
and which, like the papule of prurigo, is succeeded
by a small black scab : this is an eruption of chil-
dren, and is termed leichen urticatus. Then we find
in our catalogue of papulae, the minute papules of
rubeola and scarlatina ; the papules of variola, hard
and gritty at first, and afterwards undergoing de-
velopment into vesicles and pustules ; the papules
of syphilis, distinguished by their dull-red colour
and the absence of pruritus ; the papules of gutta
rosea ; and the large follicular papules of akne and
sykosis, together with other forms of papulae de-
pendent on follicular accumulations of epithelial
exuviae or sebaceous substance, on hypertrophy
of connective tissue, as in the instance of akro-
chordon, or on hypertrophy of papillae, as in
verruca.
If, therefore, we proceed to sum up the special
chai*acters of a papule, we shall find them compre-
hended in a consideration of its size, figure, colour,
seat, symptoms, and decline. Its size ranges between
a line and two lines, or, may be, three — that is, a
quarter of an inch : the latter would be esteemed a
very large papule, verging on a tubercle. Our
D
34 PATHOLOGY OF THE SKIN.
measurements of the papulas of cutis anserina give
a diameter of half to three-quarters of a line ; while
in height it averages about a line. The figure of the
papule is, for the most part, conical, sometimes
globose, and sometimes flattened or depressed in the
centre, as in leichen planus. Its colour varies from
white to red, and from red to its deeper tints, reach-
ing even to the confines of purple and livid ; the
white colour is seen in leichen urticatus, the bright-
red in leichen simplex, and its purple and livid hues
in leichen li^ddus. The seat of the papule is very
obviously the aperture of a follicle, and from the
follicular plexus it derives its red colour and its
prominence. Its most characteristic symptom is
pruritus, and its decline is accompanied with the
separation of the circle of cuticle which originally
formed the covering of its summit.
The papule, which we have just been describing,
might be called the papula of Willan, or the hyper-
• a3mic papule ; for we need not remind you that the
term pimple is commonly employed in a more uni-
versal sense. According to Hebra, a papula is " a
solid projection above the surface " consequent on
" any morbid change in the skin," and presenting a
size varying between that of a " millet-seed and a
lentil, and containing no fluid." In reference to
sizej he names the papulae miliareSj miliformesy and
lenticulares ; and in point oifigure^ he treats of them
as being acutas, plana3, conicae, and globosaB. These
words of Hebra remind us of the use which we
sometimes make of seeds and coins as a comparison
of size. Thus, there are, the millet-seed ; the mus-
tard-seed, black and white ; the hemp-seed ; the
lentil ; the pea ; the bean ; and several kinds of nuts,
of eggs, and of fruit ; besides the coins in common
use, the smaller and the larger silver pieces, and the
copper pieces. But who amongst us can form any-
thing more than an approximate guess of the size of
an object from the use of such terms ? who has de-
PATHOLOGY OP PAPULA. 35
termined by experiment that the size of the black
mustard-seed is about half a line in diameter ; the
millet-seed, one line ; the white mustard-seed, a line
and a half; the hemp-seed, two lines ; the split pea,
about three lines, that is, a quarter of an inch ; the
fourpenny piece, more than half an inch; the- six-
penny piece, three quarters of an inch ; the shilling
piece, one inch ; and so on ? We know how easily
we can be deceived as to the size of objects ; and,
therefore, we advise you, very seriously, in your
essay to distinguish size, to have recourse to frac-
tions of an inch, be they lines or eighths, in pre-
ference to the before-mentioned objects. When
Hebra speaks of papulae miliares, we may understand
papules having the diameter of a line ; but when he
mentions papulae lenticulares, we hesitate to accept
the comparison, because the lentil measures more
than a quarter of an inch in breadth, and promi-
nences having such a bulk we should at once desig-
nate as tubercles.
Hebra also reminds us that the range of significa-
tion of the word papule, or pimple, is much more
extensive than our definition is calculated to admit.
For example, besides the common papula produced
by exudation, whether in the walls of the follicles or
in the papillae, there are the prominences resulting
from muscular spasm, constituting cutis anserina ;
accumulations of epithelial exuviae in the follicles ;
accumulations of sebaceous matter in the follicles ;
abnormal structure of the sebaceous gland, by Hebra
termed " degeneration," while we should call it
arrest of development ; hypertrophy of papillae ; and
hyperplasia, or new formation of papillae ; to which
he further adds, haemorrhage into the rote mucosum,
and illustrates this state hj reference to Willan's
leichen lividus, — an evident mistake, since the leichen
lividus of Willan is nothing more than purple and
livid papulae. It is well, however, that we should
remember that the word pimple has a general mean-
p 2
36 PATHOLOGY OF THE SKIN.
ing in addition to its specific and technical signifi-
cation.
The VESicuLA is a prominence of the epidermis
containing an aqueous fluid, of minute size, and
variable shape, being sometimes conical in figure,
more frequently semiglobular, and sometimes flat-
tened or depressed. Willan defines it as " a small
orbicular elevation of the cuticle, containing lymph,
which is sometimes clear and colourless, but often
opaque, and whitish or pearl-coloured; and suc-
ceeded either by scurf or by a laminated scab."
The average range of size of a vesicle is half a line
to two lines, and its height is somewhat less than
the breadth of its base. A vesicle three lines in
diameter, — that is, of the bulk of a small pea, — must
be regarded as of large size ; and if it be larger,
we should term it phlyktcena and phlyktisj or, fol-
lowing the Latin phraseology, bullula and bulla.
The vesicles of the smallest kind are those of
ekzema ; namely, about half a line in diameter ;
those of miliaria are as large, and generally larger
than a millet-seed, the diameter of the latter being
one line ; then, above these, we have the large
vesicles, the almost phlyktasnas of herpes, as large
as moderately-sized peas, measuring two and three
lines in diameter, and leading upwards to the
phlyktsB or bullae of pemphigus.
The pathological seat of the vesicle is the same
as that of the punctum of hyperaBmia or of the
prominence of papula, — ^namely, the aperture of
a follicle ; and, when a vesicle increases in bulk, it
takes in one or more neighbouring pores. Its
shape is governed by the degree of resistance
afforded by the cuticle, and in some measure by
the force of exudation; in the neighbourhood of
the hair-follicles, the vesicle is semiglobular, some-
times irregular in outline or angular, in accordance
with the figure of the areas of the lines of motion ;
sometimes solitary, and sometimes clustered around
the opening of the follicle like a row of beads. On
PATHOLOGY OF VE8ICULA. 37
the finer skin between the fingers, where there are
no hairs and only perspiratory pores, and where
the cuticle is thin and moist, the vesicles are conical
in figure ; and, under the same conditions, on
the trunk of the body and where the hyperasmio
base is greater than between the fingers, the
vesicles are semiglobular, as in miliaria. These
same conditions, and especially the thinness of the
cuticle, are the occasion of the brilliant transpa-
rency of the conical vesicles developed between the
fingers in scabies, and, par excellence, of the hemi-
spherical vesicles of miliaria. On the other hand,
wherever the cuticle is thick and dense, as on the palm
of the hands and the palmar surface of the fingers,
the minute effusions of lymph fail in the power of
lifting the epidermis into vesicles, but may be seen
through the cuticle in the form of transparent
globular cavities, and where they are very numerous,
they are apt to lift up the entire epidermis of the
part ; for example, the whole of the palmar surface
of an intemodial portion of a finger, or a con-
siderable extent of the palm of the hand. At other
times, in consequence of the development of vesicles
in great numbers, and often in clusters, they blend
with each other, and form beneath the cuticle mul-
tilocular spaces, sometimes of considerable extent.
Vesicles, therefore, may be dispersed or scattered
over the skin, when they are termed discrete; or,
they may be aggregated in numbers, so as to touch
each other by their bases, when they are said to be
coherent ; or, they may be still more closely packed
and communicate by their cavities, when they are
termed confluent. An eruption of ekzema vesi-
culosum generally presents all these forms at the
same time ; in miliaria the vesicles are nearly always
discrete ; while in herpes, when the clusters are full,
there is always some confluence of the matured
vesicles.
A vesicle always makes its first appearance in the
38 PATHOLOGr OF THE SKIN.
immediate circumference of a pore ; it may be on
one or other side of the pore, or it may form part
of a row which surrounds the pore ; or if, on the one
hand, the pore be small — for example, that of a
sudoriferous duct,— or the vesicle itself be mode-
rately large, the vesicle may cover the entire cir-
cumference of the pore. In the latter case the
aperture of the pore may be seen on the summit of
the vesicle ; or it may be tilted to one or the other
side ; and sometimes, by its connection with the
sheath of the follicle, it is held down in such a
manner as to flatten the summit of the vesicle, or
to give the summit an indented, or, as it is com-
monly termed, an umbilicated appearance.
It must be mentioned, also, that vesicles present
some differences in their contents, having reference
to their age ; at their first appearance the fluid
which they contain is limpid and transparent ; in
the course of a day it is lactescent and opaque, and
at a later period it becomes yellowish. Pathologi-
cally it is an albuminous lymph, more or less tena-
cious and viscous, and its opalescence is due to the
occurrence of changes iti its composition which
lead on to the production of pus, and convert the
vesicle into a pustule. We have examples of these
changes in ekzema, which convert an ekzema vesi-
culosum into an ekzema pustulosum; we see it
also in herpes, and still more strikingly in vaccinia
and variola. In both the latter affections the
first developed of the primary cutaneous lesions is
redness ; then follows a papula, hard and gritty
to the touch ;- then a vesicula ; and finally a
pustule. In miliaria, on the other hand, the change
is limited to opalescence, and scarcely ever runs on
to the purulent stage. It must also not be for-
gotten that a vesicular eruption may be subjected
to pressure or finction, and that such violence may
result in rupture of the vessels of the derma, and
the effusion of blood into the vesicles : in such a
PATHOLOGY OF VESICULA. 39
case the contained fluid may be pinkish or reddish,
or even purplish or black in colour ; but the nature
of the yesicle remains the same, and this occurrence
is only to be regarded in the light of an accident.
Older pathologists were wont to look upon the
production of a vesicle as the consequence of a
passive transudation of the fluid part of the blood
through its vessels ; but the distinguished Virchow
and his school treat of it as a physiological opera-
tion of the cells. According to the former, the serous
fluid was poured out upon the surface of the corium,
and so lifted the epidermis in totahty from off its basi-
mentary bed ; but, at the present day, and in con-
formity with the the cell-theory, we look upon the
transuded fluid as a product of the rete mucosum,
absorbed from the tissues of the corium by the cells of
the rete, and exuded from the latter at its surface,
so as to break up the connection of the mucous
and homy layer of the epidermis, and lift up the
latter in the form of a dome. It is also to the
functional operations of the rete mucosum that we
must look for the explanation of the opalescence
of the transparent lymph that first makes its ap-
pearance, and of the development of pus-globules
and the transition of the lymph into pus, as in some
instances occurs.
In speaking of redness as a lesion of the skin, we
had occasion to remark that hypersemia was some-
times followed by exfoliation of the cuticle; the
termination of papula is, in general, a thin scale
corresponding in size with its inflamed base; but
vesicula, as it combines with the hyperaemia of
papula the production, besides, of a morbid secre-
tion, gives rise to a more decided and thicker scale,
and, in general, to a crust. When a sudden out-
break of ekzema vesiculosum, such as the ekzema
solare of WiUan, quickly subsides, the contents of
the vesicles are dispersed, partly by absorption and
partly by evaporation, and the separated cuticle
40' PATHOLOGY OF THE SKIN".
dries up into a thin scale, and is cast off in due
season, of a size and thickness scarcely greater than
that of papula, excepting in the instance of a co-
herent or confluent eruption, when the desquamation
would be more extensive. Miliaria terminates in
this way by a thin and almost inappreciable scale.
But when the vesicle lasts longer, and runs through
its opalescent to its pustular stage, it is apt, by the
desiccation of itself and of its contents, to form a
covering of considerable thickness, which is no
longer a scale, but a scab or crust. Such are the
thick and hard scabs of herpes, firmly and deeply
embedded in the skin, at first amber-coloured, then
brown, and sometimes black; remaining adherent
for a considerable time, and leaving cicatrized pits
when they fall off. Of another kind is the crust
formed by ekzema, when it assumes a chronic cha-
racter, and pours out a morbid secretion. In this
instance it is not the vesicle which forms the crust,
but the secretion exuded fi*om the denuded surface.
This secretion is partly serous aad partly purulent,
and, not unfrequently, it is discoloured with san-
guineous effusion : hence the crust varies in consist-
ence, in thickness, and in colour ; it may be dense
or friable ; it may be thick and porous, or lami-
nated ; and it may be greyish, or brownish, or
greenish, or yellow, reddish, or almost black.
Crusts of this kind are met with on the face and
scalp in cases of ichorous and pustular ekzema,
and especially in ekzema infantile, in that frightful-
looking affection termed crusta lactea. But crustce
will form a theme for future consideration, as being
one of the secondary lesions, and we allude to them
here, partly in consequence of being a mode of termi-
nation of vesiculae, and partly because we desire thus
early to call your attention to the three words, scale,
scab, and crust. Scale is the thinnest of the three,
and may be the separated cuticle alone, or the cu-
ticle in conjunction with a thin varnish of desiccated
PATHOLOGY OP PUSTDLA. 4 1
albuminous secretion ; scab is the desiccated vesicle,
together with its contents, and sometimes includes
a portion of the deeper tissues involved in destruc-
tion, as in herpes ; while crusty however thick and
hard, is superficial, and the consequence of the
desiccation of morbid secretions. If you look to
your dictionary, you will find that a scale is a thin
lamina, anything that is exfoliated or desquamated ;
a scab is an incrustation formed over a sore by dried
matter ; and a crust is a collection of matter into a
hard body.
The pathological lesions of the skin are the alpha-
bet of dermopathology, out of which we construct
words which represent its different diseases. Like
the characters of the alphabet of language, they
are simple and definite, and may be acquired with
the most moderate attention. Nevertheless, though
simple, a perfect knowledge of them is essential and
important ; and we can hope to make as little pro-
gress in dermatology without a familiarity with
them, as we could in the study of language without
an acquaintance with its letters. We have already
examined the A, B, and C of dermopathology, and
we proceed, in the next place, to the study of D. A
is represented by redness ; B, by piinple ; and C by
vesicle ; each, as we have seen, offering to our ob-
servation a greater or less variety of type. The
fourth on our list of primary pathological lesions is
pustule; and we have now to inquire upon what
features its special peculiarities are founded.
The PusTULA is a prominence of the epidermis,
containing pus ; in other words, it is a vesicle cori'
taining pus. From the nature of its contents it is
yellow, or yellowish ; it is round, generally hemi-
spheroidal, and ranges in size from one to several
lines in diameter ; its average breadth being two or
three lines. The presence of pus in or on the skin
indicates the existence of a new pathological pro-
42 PATHOLOGY OF THE SKIN.
cess, one of a graver kind than that which gives
rise to a papule or a vesicle, — of a higher form of
morbid activity, and therefore one which we must
regard, if possible, more seriously than the pre-
ceding lesions. In hyperaemia there may be present
a diffused exudation, giving rise to general swelling ;
in papula the exudation is limited and concentrated
and more intense ; in vesicula, the exudation is the
watery part of the blood, very little, if at all,
altered in its nature, poured out upon the rete
mucosum ; whereas in pustula a new product ia
developed, the pus-globule, by a formative opera-
tion, namely by the proliferation of the cell-substance
of the cutaneous tissues.
Two things, therefore, must be present to our
remembrance in pustule^ namely, a more or less
yellow colour ; and the dependence of that colour
on a new formation, the pus-globule, which con-
sumes and destroys the normal structure of the
tissues in which it is produced. The colour may
range from the lightest primrose to the deepest
yellow, with every degree of intervening tint ; and
the pustule itself may be superficial and minute ;
or, on the other hand, it may be deep and of con-
siderable size, suggesting the comparison with a
small abscess. The characteristic primary lesion ot
ekzema, as you well know, is a minute vesicle ; but
ekzema sometimes assumes a pustular form, and is
then denominated impetigo. If you observe the
pustules of impetigo in the course of their develop-
ment, you will find them to be, in the first instance,
vesicles containing a transparent fluid; and this
transparent fluid passes more or less quickly into
the state of pus. A similar change takes place in
the pustule of variola : the primary lesion of variola
begins as a punctum or stigma; then becomes a
papule ; thirdly, a vesicle ; and, in the fourth stage
only, a pustule : hence, observes Hebra, — *' Pus-
tules are among the forms of eflBorescence, which
PATHOLOGY OF PUSTULA. 43
for the most part arise from pre-existing eruptions
of a diflferent character, and they therefore do not
strictly deserve the name of primary symptoms, of
which the distinguishing mark is, that they are
caused directly by the original morbid products.
As, however, the exudation which precedes the oc-
currence of suppuration beneath the epidermis fre-
quently escapes notice till it becomes converted into
pus, and thus betrays its presence by its yellow
colour, it often happens that pustules are the first
perceptible morbid appearance; and hence one
cannot help admitting them among the primary
affections." But we must remember that pus is in
reality a primary formation, produced in a totally
different manner from lymph ; indeed, it is not a
mere exudation, but a hyperplastic development
occurring in the solid tissues themselves. It does
not follow lymph as a modification of that fluid,
and therefore as a secondary change; but it is
substantially a new and primary formation in a part
previously altered by morbid action. It may be a
secondary process ; but it is a primary lesion ; and
overlooking these nice distinctions, which are prac-
tically of little importance, we may accept pustule
without demur, as one of the most striking of the
lesions accompanying disease of the cutaneous tissues.
The special characteristics of a pustule result from
the varying depth of the tissue implicated in its
development : when produced amidst the cells of the
rete mucosum, its situation is wholly superficial;
the tissue out of which it is formed is easily repro-
duced, and hence no trace of its presence is left
when the skin is restored to health. This is the
case in ekzema pustulosum or ekzema impetigi-
nodes, also in impetigo, and in the pustule sometimes
accompanying scabies in children. But when the
substance of the skin is involved, and the pus is
generated at the expense of the connective tissue of
the corium, there results a destruction of substance
44 PATHOLOGY OP THE SKIN.
which is not susceptible of restoration in perfect
integrity ; and therefore a permanent mark in the
form of a pit or cicatrix is left behind. In one of
the severest forms of ekzema pustulosum that may
be presented to you, such as occurs on the face in
ekzema infantile, and gives rise to the hideous-
looking mask of crusta lactea or ekzema larvale, you
may without hesitation predict a perfect immunity
from cicatrix ; whereas, in some other forms of pus-
tule, and especially in variola, you know that the
cicatrix is indelible, and must remain for ever as a
permanent deformity.
A superficial pustule, or vesico-pustule, is very
generally unaccompanied with any special hyperaemia
or alteration of the derma ; but a deep pustule is
always produced upon a hard and more or less con-
gested base ; the pustule of impetigo is an example
of the superficial kind ; that of ekthyma, of the
deeper sort. This distinction was appreciated by
the ancient Greeks, who styled the pustule without
the inflamed base, psydralcion, meaning thereby a cold
or non-inflammatory blister or pustule ; and that
with the inflamed base, phlyzahion^ firom phluzeirif
to be hot, a hot or inflammatory blister or pustule.
Willan*s definition of " pustule " is, — " An elevation
of the cuticle, sometimes globate, sometimes conoidal
in its form, and containing pus, or a lymph which is
in general discoloured. Pustules are various in their
size, but the diameter of the largest seldom exceeds
two lines." He indicates four kinds of pustules,
which he terms — phlyzakium, psydrakium, achor,
and phlyktis. Phlyzakium is, as we have just in-
formed you, the pustule with the inflammatory base
represented by ekthyma; psydrakium, the pustule
without inflammatory base, namely, impetigo ; and
achor, a pustule pecuUar to the follicles of the scalp.
Phlyktis we no longer regard as a pustule, but as a
large vesicle or small bulla.
The classification of pustules regarded as a pri-
PATHOLOGY OF PUSTULA. 45
mary lesion of the skin, is very restricted ; limited,
in fact, to impetigo, ekthyma, and achor ; but be-
sides these we have numerous instances of pustule
presenting the character of a secondary lesion ; for
example, akne and sykosis, wherein the follicles are
principally concerned ; herpes, variola, gutta rosea,
furunculus, hordeolum, lupus, and pustular derma-
tosyphilis, the pustules in all these cases having the
ekthymatous type, that is to say, being developed
on a hard and inflamed base.
We have said that the typical colour of pustule is
yellow, but a yellow varying in tiut in accordance
with the degree of concentration of the pus. When
the preponderance is in favour of lymph and mucous
cells, the colour is pale, milky, or primrose; while in
the case of excess of pus-globules, the depth of yellow
increases to a golden and sometimes to a greenish
tint, the greenish hue being referrible to an admix-
ture with the pigment-matter of the blood. When
pustules are bruised, or when their dermal base is
highly congested and weak, blood is apt to be
mingled with the pus in various quantity, and thereby
to communicate a purplish and sometimes a livid
hue to their contents. These remarks are applicable
also to the scab or crust which results from the de-
siccation of the pustule ; it may be amber-coloured,
or reddish-brown, or a deep black.
A pustule left to its normal course terminates by
desiccation of its contents, accompanied with a
shrinking and corrugation of its vesicle, and the
formation of a dense and hard scah, which, accord-
ing to the depth of tissue involved in its production,
either rests lightly on the surface, or is more or less
deeply embedded in the skin. The scab produced
by the pustule of impetigo is quite superficial, and
leaves no mark or cicatrix when it is shed ; but the
pustule of ekthyma, as it sinks more deeply into the
substance of the skin, and destroys the papillary
layer of the derma, which cannot be restored, is fol-
46 rATHOLOGY OP THE SKIN.
lowed by a pit and by a cicatrix of life-long dura-
tion. But the pustule not unfrequently bursts, or is
broken accidentally, and then, the pus being set
free, dries upon the denuded surface and forms a
crust of variable extent ; and the crust may be mo-
dified in colour, in thickness, and density, by a
variety of conditions. The yellow crust of impetigo
suggested to the Greeks the term melitagra, from
melif honey, in consequence of its resemblance to
dried honey; while the mask-like crust of ekzema
impetiginodes or ekzema pustulosum of the face and
head, called also crusta lactea, and porrigo larvalis
or ekzema larvale, is very commonly greyish or
greenish, and generally, from admixture with blood,
in parts brown and even black. When, however,
the pustule is broken, the exposed surface sets up a
secreting process, which results in the production of
a quantity of discharge, which may be principally
purulent, or only partially purulent, and the density
of the secretion will be the occasion of a difference
of density of the crust, the pure pus producing the
most dense form of crust, and that which is diluted
with serum, producing one which is spongy and
light, and probably of considerable thickness.
Therefore, in the consideration of pustule we have
not only to bear in mind its manner of development,
its colour, and its contents, but also its mode of dis-
appearance. It will very probably leave behind it
indelible signs, by which the disease to which it
belonged may be recognized to the end of life ; such,
for example, is the cicatrix of the vaccine pock, the
cicatrix of variola, the cicatrix of lupus, and also
that of dermatosyphilis.
The pustule also brings before us another pheno-
menon which deserves our attention. We have said
that pretty constantly, it is preceded by an exuda-
tion of lymph : hence we have to consider, as be-
longing to the process of pustule-formation, a
lympho-genesis as well as a pyo-genesis : but there
PATHOLOGY OF BULLA. 47
is present besides, another operation, namely that by
•which the pus is circumscribed and limited to the
spot in which it is produced : this is eflFected by a
kind of hypertrophy, or hyperplasia, of the con-
nective tissue, which gives rise to a wall or cyst by
which the pus is surrounded. There are conse-
quently three different forms of manifestation of the
morbid process, which may very possibly represent
degrees of force, or stages of diseased action,
present in the. development of a simple pustule.
There is the force which occasions the primary
lymph-exudation ; the pus-globule-generating force ;
and the circumambient wall-producing and limitary
force. In noting these phenomena we have an
explanation of the plus or mimis of the three
elements of the pustule-forming process ; of the pre-
ponderance of lymph in one case, of pus-globules in
the other ; of the production of pus or pustules at
one point, of lymph or vesicles at a neighbouring
point ; and we have also an explanation of the nature
of a phlyktaBnoid or vesicular pustule that not un-
frequently shows itself in children possessing a weak
and delicate skin, namely, impetigo phlyktcenodes.
This form of eruption begins as a pustule ; but, the
limitary process being weak, the morbid action
creeps for a small space into the surrounding tissue,
and wanting the pus-generating force, throws out an
exudation of lymph and produces a vesicle. Hence,
we find developed a kind of compound lesion, a
plyktaena possessing the compound character of a
pustule at the centre and a vesicle at the circum-
ference ; the vesicular elevation being sometimes a
circle of coherent vesicles, and sometimes a^ single
circular or annulate vesicle.
Bulla, or bleb, or blister, the pemplnxy pomphos,
and pomphohcx of the Greeks, is a large vesicle,
identical in structure and contents with a vesicle,
developed in a similar manner, and running a similar
course. Its chief characteristic is size ; hence, in
48 PATUOLOGY OF THE SKIN.
the language of Willan, it is " a large portion ot
cuticle detached from the skin by the interposition
of a transparent watery fluid." Or we may regard
it as the superlative degree of vesicle, the positive
degree being vesicula, and the comparative, phly-
ktaBna or phlyktis. The size of the bulla may range
from that of a large pea to that of an egg or an
orange ; in figure it may be hemispherical or
globular, sometimes oblong, sometimes crescentic,
sometimes tense, shining, and transparent, and some-
times wrinkled and opaque. While its contents^ which
are usually clear, transparent, and colourless, like
water, may be amber-coloured or purplish, with-
out loss of transparency ; or they may be opaline or
lactescent, or yellowish, or purplish, and opaque.
The development of a bulla is sometimes a sjiecific
action of the skin, accompanied with a specific
hyperaemia, as in the instance of pemphigus ; and
sometimes, as in erysipelas, a secondary process
resulting from a previous state of oedematous infil-
tration of the cutaneous tissues, and acting the
part of a drain to the accumulated fluid. In both
instances the contents of the bulla are the same, —
a serous fluid, albuminous and moderately alkaline,
and sometimes holding in solution bile-pigment, and
occasionally urea and uric acid ; while its seat is the
epidermis between the corneous layer and the rete
mucosum. When of large size, it begins by several
small vesicles, which quickly unite ; and having in-
creased to a considerable bulk, the circumference
creeps along the surface, taking in more and more of
the surrounding skin. It is this creeping quaUty
that constitutes the chief distinction between ve-
sicula and bulla ; the former being fixed and rarely
increasing by its base; the latter running along
the surface to a more or less considerable extent.
The bulla likewise is sometimes deficient in areola
and sometimes surrounded by a narrow streak of
redness.
PATHOLOGY OF SQUAMA. 49
The period of duration of a bulla is several days ;
very frequently it rises up in the course of a few
hours, or it may increase gradually during several
days ; and having completed its development, it is
either broken, or its fluid evaporates, and the con-
taining sac of cuticle becomes wrinkled and col-
lapsed, and subsides by degrees upon the excoriated
base. In this way it forms a thin crust, which
remains adherent for a while, and exfoliates in the
form of a scale ; at other times the excoriated base
is converted into a secreting surface, and a thicker
crust is produced, sometimes greyish or brownish,
and sometimes almost black from admixture with
blood.
As an idiopathic affection, bullaB are met with in
pemphigus and pompholyx ; and symptomatically in
erysipelas, in dermatosyphilis constituting rupia,
in pernio or chilblain, and in elephantiasis anaas-
thetica. They are also produced artificially in
burns and scalds, and by the appHcation of
epispastics.
Squama or scale, in a general sense, is a lamina of
cuticle separated from the surface of the skin ; but
in its special character of a primary cutaneous
lesion, the term is intended to signify, in the
language of Willan, " a lamina of morbid cuticle."
A desquamation of cuticle or exfoHation of cuticular
scales, taking place after a previous state of hyper-
SBmia of the skin, as in scarlatina or measles, is
necessarily a secondary lesion : but our business at
present is to fix your attention upon a primary
squam/i^ such, in fact, as accompanies lepra; the
secondary squamas shall be considered hereafter.
If we have the good fortune to see a case of lepra
at its earliest appearance, we shall probably dis-
cover papulad in no respect differing from the
papules of leichen. It may be imoertain whether the
lesion will remain a papule, or whether it may
become a vesicle or a pustule ; but in a short time^
£
50 PATHOLOGY OF THE BKIN.
sometimes in a few hours, a white glistening cap of
altered cuticle appears on the summit of the papule ;
and we are enabled to recognize the first develop-
ment of a squama.*
The primary squama is therefore a lamina of
morbid cuticle, and the chief example of the lesion
is met with in the lepra alphos of the Greeks, the
lepra vulgaris of Willan, the misnamed " psoriasis"
of the foreign schools. The squama of lepra is a
portion of cuticle developed upon a base of morbid
derma, and as a consequence, is itself a morbid
product. Its abnormal characters are, its white-
ness, — ^hence the term alphos (albus), its porosity or
sponginess, its opacity, its laminated structure, its
dryness, its friability and brittleness, and its tend-
ency to be cast off or shed ; the whole of these
qualities being referrible to imperfect elaboration of
the cell-elements of the epidermis. The cells retain
more of the albuminoid than of the corneous
character ; they are turgid with serous fluid ; and
when subsequently they are desiccated by evapora-
tion, the spaces previously occupied by fluid become
filled with globules of air : hence arise the light-
ness, the sponginess, and the silvery brilliancy of the
scales.
The squama of lepra ranges in size from a line to
an inch or more ; it is generally circular in figure^
and from half a line to a line in thickness. The
circular disk is depressed in the centre, which is
more dense and homy than the rest ; farther from
the middle point it is thick, spongy, and laminated,
and at the extreme periphery presents the thinness
of a single lamina. The first-produced scale is
always the most complete, and when removed, its
place is usually taken by several smaller and less
perfectly constructed laminae. Like all morbid
tissues, it presents varieties bearing relation to its
* Vide Alpbos punctatus and Alphos papulosus, Jouri^al of
Cutaneous Medicine, vol. i pp. 209 and 114.
PATHOLOGY OF SQUAMA. 5 1
greater or less divergence from the normal standard ;
sometimes it is as thin as the scales of bran, sug-
gesting the term pityriasic ; sometimes it is almost
homy; and sometimes it is irregular in figure,
from the unsymmetrical blending of the several
papules or tubercles on which it is produced.
But besides the scale of lepra there is another
form of scaliness which deserves to be considered as
a primary lesion ; namely, the flaky and pulverulent
desquamation which accompanies phytosis versicolor,
the pityriasis versicolor of Willan. In this disease,
as in lepra, there is a degeneration of structure of
the epidermic cells ; they possess a granular charac*
ter ; and thence the cuticle which they form is loose
and porous, easily separable from the layers beneath,
and, upon scratching or friction, breaking up into
small flakes and powdery fragments. This breaking
up of the cuticle is supposed to be due to the
destructive operation of a vegetable parasite, the
microsporon fiirfur ; certainly it is the consequence
of a phytiform growth, or a phytifonn degeneration
of the cell-structure of the epidermis, but we are
unwilling to regard the granular elements of which
the desquamation is composed, as an independent
vegetable organism.
The scale of lepra, beginning at a central point,
increases by the circumference, creeping slowly over
the surrounding skin; hence it happens that the
centre of the disk is much older than the circum-
ference ; hence, also, the greater density and thick-
ness of the central portion than of the border ; and
hence also the imbricated appearance of the siu'face
of the scale. Its adhesion to the surface beneath,
although occasionally firm, is generally very slight ;
hence it is easily rubbed oflF by the friction of body-
clothes or bedclothes, and when it is removed, it
exposes to view the red and prominent surface on
which it was produced, the latter being invested
with a thin layer of transparent cuticle.
s 2
52 PATHOLOay OP THE 8KIN.
TuBEBCULUM, literally a little tuber or tumour, or
tubercle, is a solid prominence of the skin, larger
than a papula and smaller than that greater or more
extensive prominence which is denominated tumour.
The difference between papula and tuberculum is
simply one of bulk ; and the same between tuber-
culum and tuber : hence a point exists, when we
may be in doubt whether to term an eruption, one
of large papulas or small tubercles ; and, on the
other hand, whether large tubercle or small tumour.
In determining the size of an ordinary papule, we
stated its breadth to be one or two lines ; and of a
large papule which might under certain circum-
stances be considered as a tubercle, to be three lines,
that is, a quarter of an inch. So, in fixing a limit
to the size of a tubercle, we may start with a
quarter of an inch, and allow of a progression of
another quarter of an inch ; thus estimating its size
at a quarter to half an inch in diameter. Hebra's
estimate of the size of a tubercle corresponds with
this. It is, he says, " as large as a lentil, bean, or
hazel nut."
The resemblance of papula and tuberculum is not
altogether one of similitude only : a'papula by growth
may reach such a size that it would be more correct
to term it tubercle than papule. As a papule, its
seat might be limited to a single cutaneous follicle,
whereas the implication of two or more follicles
would constitute a tubercle. This we see illustrated
in lepra, which begins as a small pimple, and spreads
out to a breadth which entitles it to the denomi-
nation of tubercle. In lupus we often perceive a
similar phenomenon, but the transition of papula
into tubercle is most remarkably shown in dermato-
syphilis ; a first eruption of constitutional syphilis is
generally one of erythema and stigmata ; the second
will be one of papulae, and receive the name of
leichen; while a third or fourth, or a subsequent
evolution of the disease at the stage termed tertiary
PATHOLOGY OP TUBBECULUM. 53
syphilis, will be a tubercle : this latter is the form of
eruption which is so commonly confounded with
that other tubercular affection, lepra, and which we
see described, but very incorrectly, by the name of
lepra syphilitica and psoriasis syphilitica.
Willan's definition of tubercle leaves little room
for improvement : — " A small, hard, superficial
tumour, circumscribed and permanent, or suppura-
ting partially " ; and if we turn to his examples of
the lesion, we find phyma, verruca, molluscum, akne,
sykosis, lupus, elephantiasis, and fi^amboesia; we omit
vitiligo as having crept into the group in error.*
Phyma includes the femily of boils or fiirunculi, and
also anthrax ; but it will at once occur to you that
certain furunculi deserve to be termed tumour,
rather than tubercle, while anthrax or carbuncle is
a decided tumour. MoUuscum, again, not unfre-
quently reaches the bulk which is correctly expressed
by the term " tumour." On the other hand, as far
as mere size is concerned, akne and sykosis are
instances of pimples rather than of tubercles. But
Willan, in the latter part of his definition, namely
" suppurating partially," points out a special cha-
racter by which he endeavours to distinguish papulaa
firom tubercula ; the papulas of Willan, namely,
leichen, strophulus, and prurigo, have no disposition
to suppurate — their habit is to subside and disap-
pear ; but the papulad included under the head of
tubercula have a suppurative propensity, — for ex-
ample, akne and sykosis.
Tubercles present some variety of seat, of eleva*
tion, of colour, figure, and density. They may be
situated on the skin, or in the substance of the
skin ; they may be very slightly or very considerably
elevated ; they may evince no departure from the
normal tint of colour of the integument, or they
may be red or white, yellow or purple, or livid or
* Vide Journal of Cutaneous Msdiqnb, toL i p. 108.
54 PATHOLOGY OF THE SKIN.
black ; they may be round or oblong, annulate or
crescentic ; and they may be dense or soft, solid or
hollow, homogeneous or filled with fluid contents.
The family of vemicaB and tegumentary nasvi occupy
the surface of the skin ; lepra and some of the der-
matosyphilitio eruptions, its papillary layer ; while
tubercles formed by enlargement of the sebiparous
glands are situated for the most part in the substance
of the corium, as are the various forms of hyper-
trophy, for example, lupus, cheloma, and the tuber-
cles of elephantiasis. The tubercles of urticaria,
of dermatosyphilis, and lepra, are sometimes scarcely
raised above the level of the skin, and their jwomi-
nence is discoverable by the touch rather than by the
eye ; the tubercles of alme, sykosis, cheloma, verrucaBy
and tegumentary nsBvus^ sometimes reach one or
two lines in elevation ; and those of elephantiasis,
molluscum, and furunculi, are often still more pro-
minent. The colour of tubercular prominence caused
by tegumentary naevus, by the enlargement of sebi-
parous glands, and sometimes by cheloma, in nowise
differs from that of the healthy integument ; the
tubercles of molluscum adenosum, of sebaceous ac-
cumulations, of epithelioma, and cheloma, are some-
times white ; the tubercles or wheals of urticaria are
generally white or yellowish ; other tubercles, such
as those of dermatosyphilis, of lepra, of akne, of
sykosis, of furunculus, and of elephantiasis, are more
or less deeply red ; while in a torpid or congested
state of the circulation the red deepens into purple,
and even into livid ; and in pigmentary n89vus, and
where melanosis infects the skin, the tubercles are
black. The figure of tubercles is commonly round,
but the wheals of urticaria very frequently present
elongated ridges or stripes, and sometimes segments
of a circle. The tubercles of declining lepra are
often annulate, as are those of tubercular derma-
tosyphilis, and occasionally they appear in the form
of segments of a circle and semilunar curves. The
PATHOLOGY OF TUBEE. 55
density of tubercles is influenced by their solid or
hollow texture, by the nature of the tissue involved,
and by the contents of their internal cavities when
such exist. The tubercles and wheals of urticaria
are sometimes soft and sometimes hard to the
touch ; the tubercles of cheloma are firm and re-
sisting, sometimes as rigid as cartilage ; the tuber-
cles with contents are sometimes hard and some-
times soft ; the tubercles of common verrucse are
firm and harsh, while those of akrochordon and mol-
luscum areolo-fibrosum are loose and compressible.
The proximate cause of tubercles presents the
same kind of variety that we have already seen
manifested by papulad ; sometimes the prominence
is dependent on muscular spasm, as is the case
with the wheals of urticaria; sometimes the en-
largement proceeds from interstitial infiltration and
hypertrophy, as in lepra, dermatosyphilis, and ele-
phantiasis; sometimes from accumulation within
the cavities of glands, especially the sebiparous
glands, as in molluscum adenosum, and sebaceous
tubercles ; sometimes from a combination of both
the latter processes, as in akne ; sometimes fi^om
hypertrophy of tissue, as in cheloma, naevus hyper-
trophicus, akrochordon, molluscum areolo-fibrosum,
and verruca ; and sometimes from degeneration of
tissue, as in some forms of dermatosyphilis, in
lupus, and carcinoma.
TuBBB, or tumour, the phyma of the Greeks, is a
swelling of the skin, larger than a tubercle, and
embracing every degree of dimension, fi'om half an
inch to many inches in diameter. Hebra compares
the maximum size of a tubercle with a hazel nut,
and the minimum size of a tuber with a walnut. In
tuber, tuberculum, and papula, we have presented
to us a comparative series of enlargements, as we
have before seen to be the case in the instance of
vesicula, phlyktsBna, and bulla ; and in both in-
stances the determination of the class to which a
56 PATHOLOGY OP THE SKIN.
given enlargement may belong must be left to the
judgment of the observer.
The most familiar example of a tuber that we can
present to you, is the tumor cysticus, the encysted
tumour or wen, which may be so small as to fall
within the category of tubercle, or, on the other
hand, may be as large, or larger, than a man's fist,
a common average size being one inch in diameter.
The observation of encysted tumours shows us that
tumours may be only slightly or very boldly promi-
nent, hemispherical, and sometimes spherical with a
pedunculated base. The seat of an encysted tumour
is a sebiparous gland and excretory follicle, and its
contents the epithelial and secreted product of that
gland ; hence the tumour may be hard or soft, in
proportion to the solidity or fluidity of its compo-
sition, and the skin covering it may be unchanged
in appearance ; it may be attenuated until it assume
the appearance of parchment, or it may be reddened
or purplish, from hyperaemia or congestion.
Other examples of phymata are, the common boil,
the carbuncle or anthrax, hypertrophic conditions
of the cutaneous and subcutaneous areolo-fibrous
tissue, as in molluscum simplex and some local
forms of spargosis, and degenerations of tissue,
such as the tumor gummatus of syphilis or syphi-
loma and the tubera of lupus and carcinoma. A
glance at these examples will show you that as
some take their origin in inflammation, some in
accumulation of secreted products, some in hyper-
trophy of tissue, and some in neoplasma or new
formation, the physical characters of the tumours
must be as varied as their pathological structure.
Hence the tuber may ofier as great a range of
variety in physical signs as the other lesions of
its class, namely, the papulse and tubercula; it
may be prominent in a greater or less degree, and
it may present every degree of colour and density.
Maoula, a spot, a stain, a mark, is the simple
PATHOLOGY OF MACULA. 57
signification of this term when applied to the
diagnosis of a lesion of the skin. It is the ninth of
the lesions to which we have drawn your attention,
and it is unlike all the rest in being independent
of inflammation or of inflammatory processes.
Willan defines macula as " a permanent discolora-
tion of some portion of the skin," and Hebra in-
cludes under it ** every change in the normal colour
of the skin arising fi-om disease." We have a
homely illustration of maculae in the yellow spots
of lentigo or fireckles ; and we find fiirther illustra-
tions in the purple spots and marks of purpura ; in
the red, the blue, and the black spots of nasvus ;
and in pigmentary discoloration in general ; for
example, in the melasmata, the chloasmata, and
also in leukasmus. The majority of these maculae
are in reality "permanent," as intimated by the
definition of Willan ; but the maculae of purpura
are only temporary : hence possibly the word
"stationary" would be better than "permanent,"
as expressive of a more fixed character than that
which belongs to the transient hyperaemiae and in-
flammations, and yet falling short of the idea which
is conveyed by the word " permanent."
Colour is one of the first of the features that
attract our attention when entering upon the con-
sideration of maculae ; then follow, figure, extent,
and pathological nature. Their colour is sometimes
due to the blood, which gives us varied tints of red,
of purple, of livid, or black ; sometimes to the
accumulation of pigment in the rete mucosum,
which contributes various hues of yellow, brown,
grey, and black ; and sometimes to the absence of
pigment, as in the various examples of achroma.
In vascular naevi, the blood is contained in a plexus
of minute vessels, and the colour of naevi may be
scarlet or crimson, as in arterial naevi ; or purple or
livid, as in venous naevi. Whereas in purpura the
blood is effused firom the vessels into the tissues, is
58 PATHOLOGY OP THE SKIN.
crimson at first, then purple, and afterwards black,
before it undergoes its retrogressive or fading
changes ; and finally the spot loses all claim to per-
manence by disappearing completely. The distinc-
tion between naevus and purpura afibrds us an addi-
tional lesson ; the one being due to blood contained
in pervious vessels, is dispersed by pressure, but the
colour returns as soon as the pressure is with-
drawn ; the other, depending on extravasated blood,
remains imaltered however much pressure be ex-
erted, and becomes even more conspicuous from
the contrast of the coloured mass with the white-
ness of the compressed skin. In macular due to
abnormal pigmentation, the colour is seated in
the rete mucosum, and the tints may range from the
yellow of xanthochroia, xanthelasma, and lentigo,
through the yellowish-green and yellowish-brown of
chloasma, to the deep brown, the grey, and the
black of spilus and melasma. While the absence of
pigment from the rete mucosum may give rise to
achroma or leukasmus, and the same may occur
from destruction of the rete mucosum, as in maculas
atrophic89. The pigmentary maculae are truly per-
manent, and undergo no change of colour under
pressure.
The figv/re of maculas, for the most part circular
or oval, as in lentigo and the petechiae of purpura,
may present itself in the form of stripes, as in
vibices, and lineas atrophicas; they are sometimes
circular or annulate in elephantiasis; and islet-
shaped or irregular in chloasma and melasma.
And in point of size they are apt to exhibit
infinite variety, ranging from a mere point in
lentigo, to a patch of considerable extent in me-
lasma.
The pathological nature of maculas we have
already anticipated in grouping them, primarily,
into such as are due to the blood, and such as are
due to the presence or absence of pigment ; in the
PEAOnCAL USE OF THE LESIONS. 59
former section distinguishing between the blood in
the vessels and the blood out of its vessels. In the
latter section, we may further note the diflFerence
between a normal and abnormal state of the rete
mucosum, and a positive absence of the true seat
of colour of the skin, the rete mucosum, as in
maculad atrophicsB.
And now, in concluding the subject of prima/ry
lesions of the skin, let us devote a few minutes
to a recapitulation of the chief points of prac-
tical interest which their investigation suggests.
These lesions have sometimes been termed anato-
micdLj but we believe that you will agree with us in
opinion, that they are no more anatomical than is
tubercle of the lung, but, on the contrary, that they
are essentially pathological. The chief value of the
pathological lesions is their direct bearing on dia^
gnosis, and their adaptability to the determination
of the nature of a disease. And therefore we wish
you to put yourselves ia the position of an inquirer
seeking to distinguish a disease of the skin which
may be purposely brought before him. What is the
most prominent lesion that meets your eye ? Is it
rubor f then the case must be one of hyperaemia,
maybe an erythema, a roseola, the first stage of a
zymotic exanthem, or an erysipelas. Is it papula ?
then you have before you a leichen, a prurigo, an
ekzema papulosum, or what may be termed an acci-
dental papula, such as akne, sykosis, a sebiparous
hypertrophy, or a sebaceous accumulation. No;
the prominence is too large for a papula ; it must
therefore be a tubercle^ a tubercle of urticaria, of
lepra, possibly a strumous, or carcinomatous, or
elephantous, or syphilitic tubercle ; a tubercle from
accumulation of secretion, like molluscum adenosum,
or a tubercle from hypertrophy of tissue, such as
molluscum areolo-fibrosum or cheloma. Are you
still doubtful in reference to magnitude ? Then the
enlargement is a tumour, perchance a furunculus.
6o PATHOLOGt OF THE SKIN.
an anttrax, an encysted tumour, a moUuscum
areolo-fibrosum, a spargosis, a cteloma, or a syplii-
loma. How many diseases we have already passed
in review, — indeed, we bave omitted some, — and as
yet we have taken under our consideration only /our
lesions, or if you please, merely two ; for as we have
already shown, a tubercle and a tuber are nothing
more than magnified papulae.
Or perhaps the pathological lesion is a minute
drop of transparent serum enclosed in a thin case
of cuticle, — in other words, a vegule. Then you
have before you an instance of ekzema, of militia,
or maybe of herpes. Or, the vesicle, stretohing
beyond its accustomed limits, is a bleb or bladder
rather than a vesicula, in truth is a bulla ; and then
the case is one of pemphigus. Instead of serum,
the vesicle possibly contains pus, and so constitutes
a pustula; the pustule is minute, a mere vesicle
filled with pus ; in that case it is impetigo ; no, it is
large, with a hardened base and involves deeper
structures, then it must be ekthyma ; perchance it
is a pustule of lupus or syphilis, and may result in
an ulcer ; or it is seated on the scalp, occupying the
hair-follicles, which seem for the nonce converted
into fountains of slimy pus, in which case it is a
kerion ; on the face or back it may be a pustular
akne ; on the face alone, a pustular gutta rosea, or
on the hair-bearing parts of the face, a sykosis or
mentagra.
But that which attracts your attention is neither
rubor, papula, vesicula, nor pustula, neither is it
tuberculum, tuber, nor bulla; it is a white scale
that looks like a fi-agment of wafer stuck upon
the bkic, — it is, in fact, sguavui., and the disease is
lepra ; and you must guard yourselves at this point,
against confounding a laminated scale of morbid
itick' like that of lepra, with a mere exfoliation or
scjuamation of normal cuticle. It is possible that
tb desquamation, there may be a yellowish and
i
PEAOTICAL USE OF THE LESIONS. 6 1
reddish-brown or greenish discoloration of the
epidermis, and the patches may be distributed map-
like on the trunk of the body and bends of the
neighbouring joints, in which case the disorder will
be the pityriasis versicolor of Willan, or, named
more in accordance with modem knowledge, phytosis
versicolor. Finally, Gentlemen, we need not again
remind you of the distinguishing characters of
macula, of its spots and stains, of its varied colours
and varied forms, and especially of the absence of
inflammation, which directly or indirectly is present
in all the other lesions. But we will ask you to
transcribe and commit to memory the table which
we have here set before you.
Rubor ... ... ... ... Pustula.
Ti 1 CTuberculum a
Papula < Tuber "• " ^Q^ama.
Vesicula, Bulla... ... ... Macula.
The diagnosis of cutaneous disease diflfers in no re-
spect whatever from that of other diseases ; just as
we determine the presence and nature of disease in
general by its symptoms, so symptoms or signs, or as
we term them lesions^ are the characters by which we
distinguish the presence and nature of diseases of the
skin. And it must be remembered that symptoms
or signs are not the properties of disease alone, but
that they belong equally to health. By the bedside
or in the consulting-room, it is as necessary to be
able to appreciate the signs of the skin of health as
those of disease ; and this kind of knowledge is
applicable, not to the skin only, but to the state of
health of every part of the economy.
We have shown that the principal signs of disease
of the skin may be embraced under six, or, if you
prefer it, under nine heads ; and to these heads we
assign the term lesions : thus there is redness ; then
there is prominence in the thr^e degrees oi papula,
62 PATHOLOGY OP THE SKIN.
tuber culunif and tuber; then there is the uplifting of
the epidermis by the effusion of serous fluid, con-
stituting vesicula and bulla; next, the uplifting of
the epidermis caused by the accumulation of pus,
namely, pustula; then a state of abnormal formation
of the epidermis, or squama; and sixthly, an altera-
tion of colour of a persistent character, or macula.
Let this, Gentlemen, be your first lesson in diagno-
sis, and we will ask you to study it well, for in it
you have a key to the knowledge of every disease of
the skin and many of those of the general system.
The expert will tell you off a disease at a glance,
but it is only through this process of examination,
developed by experience into an instinct, that he has
arrived at the extraordinary faciUty which he seems
to possess. We not only call the signs which we
have just been describing, lesions ; but we also dis-
tinguish them as primury lesions^ that is to say, as
the first and earliest appearances of disease ; and not
only the first and earliest appearances, but also as
the complete signs by which, without other help, we
can determine the diseases to which they belong.
But the primary lesions are very rarely permanent,
and in most instances they are little more than the
primary stage of a secondary change ; or they are
the exciting cause of certain secondary phenomena ;
hence, it becomes our duty, in the next place, to
study these secondary signs, or as they are com-
monly denominated, secondary lesions. To illustrate
briefly the nature of secondary lesions, let us run
again over the primary lesions, and consider in what
way they may be capable of operating secondary
changes. Bubor or redness, is a hyperaBmia ; the
causes which sustain hypera3mia will very probably
arrest the nutrition of the epidermis, the homy
layer of the epidermis will separate from the rete
mucosum, desiccate and exfoliate ; this constitutes
the secondary lesion, desquamation. Papula is re-
markable for its itching propensities, so much so
PATHOLOGY OF DESQUAMATION. 63
that one instance of the lesion is termed prurigo ;
itching leads to rubbing and scratching, the heads
j of the pimples are torn off, and then we have an
example of the secondary lesion, excoriation. Ve-
sicula, besides the surface-effusion or exudation,
which gives it its specific character, is accompanied
with a tissue-exudation or oedema, and a persistence
of tissue-exudation leads on to the secondary lesion,
induration. Pustula consists essentially in the
development of a new pathological product ; that
product by drying upon the surface constitutes a
scab or crust : hence the secondary process, incrusta-
tion. Tuberculum and tuber are apt to run on to
solution of continuity, and so to give rise to the
secondary phenomena, fission and ulceration ; and,
consequent upon ulceration, to cicatrization. Squama,
and sometimes macula, results, like rubor, in de-
squamation ; and rubor, or hyperaemia, is very com-
monly succeeded as a secondary change by discolor-
ation. The secondary lesions, therefore, that we
have now to consider, we have arranged in the
tabular scheme to which we direct your attention,
and we shall pursue their further consideration in
the order in which they are here set down,
namely : —
Desquamation, Fission,
Induration, Ulceration,
Incrustation, Cicatrization,
E xcoriation, Discoloration .
Desquamation, that is, the spontaneous separation
of the epidermis from the derma, is a very common
and usual consequence of hyperaemia of the skin,
and presents some variety of manifestation having
reference to the acute or chronic nature of the hyper-
aemia, its depth, and its extent ; and also in respect
of the cuticle itself, which may be normal and
healthy, or may be abnormal and morbid. The
general hyperaemia of the zymotic exanthemata,
64 PATHOLOGY OP THE SKIN.
namely, scarlatina, rubeola, and variola, is followed
by an universal state of desquamation : the corym-
bous exanthem of dermatosyphilis erythematosum
is general without being universal ; while desquama-
tion of a limited aflFection, such as erysipelas or
ekzema erythematosum, is necessarily partial In
general and acute hyperemia, the arrest of nutrition
of the epidermis which determines its fall is sudden
and extensive ; hence the cuticle is thrown off or
exfoliates in broad or membranous sheets, and of a
thickness corresponding with the region of the body
in which the exfoliation occurs ; these sheets will be
thin and pellucid on the trunk of the body and limbs,
and thick on the palm of the hands and sole of the
feet ; and the size of the sheets will be influenced by
the thinness or thickness of the exfoUated layer,
and, in some measure, by the conditions of the part
and the treatment it may have undergone. It is no
uncommon thing to find the cuticular sheath of a
finger or of a toe, or indeed of the entire hand or
foot, cast off after scarlatina, and, ceteris paribus, the
size of the sheets will be proportioned to the degree
of repose, and probably to the neglect experienced
by the patient. In chronic hyperaemia, the arrest
of nutrition is irregular and intermittent, and the
desquamation partakes of a similar character ; the
epidermis is no longer cast off as a single and con-
tinuous sheath like the slough of a serpent, but is
broken and subdivided, and takes a shape corre-
sponding with the figure of the part on which it
occurs, or assumes the shape of the inequalities of
the morbid skin on which it is produced. Hence,
time out of mind, dermatologists have distinguished,
besides the merribranous desquamation or exfoliation
already referred to, u, furfuraceous and a farinaceous
desquamation, to which Hebra has added a modifi-
cation of the membranous desquamation, namely, a
siliquous desquamation.
Purfuraceous desquamation, derived from furfur
PATHOLOGY OP DESQUAMATION. 65
and furfures bran, in other words, branny desquama-
tion, is composed of particles which are compared to
scales of bran, and the particles may be said to range
in size from that of the finger-nail down to a minute,
spangle-like, and micaceous film. Farinaceous de-
squamation, from farina^ meal, or mealy desquama-
tion, on the other hand, includes every form of
pulverulent or powdery and amorphous disintegra-
tion of the cuticle, and may exist independently or
may be associated with furfuraceous desquamation ;
in certain parts of the body where the skin is coarse
you may expect to find the former ; in other parts,
as in the flexures of the joints, the latter form of
desquamation. And siliquous desquamation, from
siliqua^ a pease-cod, is especially applicable to the
desiccated oblong or crescentic domes of the bulto
of pemphigus.
Scales, in their nature, being portions of cuticle
separated fi*om its natural bed, may present some
variety having relation to the degree of healthiness
of the epidermis ; if we produce an artificial bulla
upon the healthy skin, the scale which will result
from the separation of the bulla after its desiccation
will necessarily consist of a fi-agment of healthy
epidermis ; the same may be said of the desquama-
tion consequent upon the irritation of a blister, of
the desquamation following the exanthematic fevers,
erysipelas, pemphigus, and ekzema. It is possible
that the scale may have been more or less com-
pletely saturated with the discharges which have
exuded fi'om the inflamed skin ; but the cuticle itself
is normal in structure, and none the less so because
it is capable of becoming the medium of transmitting
infection from one person to the other, as in the
case of scarlatina. But the scale of lepra is not a
lamina of healthy cuticle, it is composed of unhealthy
and morbid cuticle ; and so also is the exfoliation
which is cast off from the mottled surface of phytosis
versicolor. Hence, even a scale may afford material
P
66 PATHOLOGY OF THE SKIN.
of observation that will aid us in the diagnosis of
cutaneous disease. Place before yourselves the
transparent crumpled film of a fragment of exfoliated
cuticle ; by the side of it the furfuraceous, glistening
lamina produced by a chronically inflamed derma ;
and again, the morbidly composed and opaque shred
of phytosis versicolor, or the elaborate, laminated
and imbricated scale of lepra, brilliant in its snowy
whiteness, and you will have under your eye struc-
tures that can hardly be regarded as the same, ex-
cept through a knowledge of their source.
There are few things more striking in their con-
trast than the scales of lepra and those of chronic
ekzema ; the same may be said of the minute, shin-
ing, micaceous, bran-like scales that have given a
name to pityriasis capitis, as compared with the
ragged, spongy, dull, and uneven films of phytosis
versicolor. So that even the form of desquamation
may help us in our diagnosis. If we apply this test
to the so-called lepra syphilitica, we shall discover at
once that the specific scale of lepra is wanting, and
that the ragged exfoliation from the surface is in
nowise dissimilar from the one which accompanies
ordinary hypersemia. We are led by these observa-
tions to the conclusion, that that which we call a
scale is, one while, nothing more than a separated
or partially separated lamina of normal cuticle con-
tinuous by its border with the rest of the cuticle ; and,
another while, like the scale of chronic ekzema or
pityriasis, a lamina produced as a scale from its ear-
liest formation, and separated by its circumference
before it is set free from its central attachment.
The thickness of a scale is sometimes governed
by the situation in which it is produced ; sometimes
by the formative energy of the inflamed part. The
scales of pityriasis capitis are extremely thin and
small, and are produced and thrown off^ with remark-
able celerity. In some forms of pityriasis, such as that
which occurs upon the face of children, the desquama-
PATHOLOGY OP EXCORIATION. 67
tion is farinaceous rather than furfuraceous; in xero-
derma it is amorphous, and in some parts farinaceous;
on the palm of the hands and sole of the feet it con-
sists of thick yellow lamina3 of desiccated cuticle ;
and on the heel we have seen it assume the character
of a rugged homy mass, three-quarters of an inch
in thickness. The most remarkable example of de-
squamation is that which is met with in the pityriasis
rubra of Devergie and Hebra. The exfoliation is
produced from every part of the body, the skin looks
feathered with shreds, and in the course of a week,
as much as half a pound of cuticular squamaa have
been collected from the patient.
Excoriation of the skin is marked by the exposure
of the derma or of the deep layer of the rete
mucosum, by the removal of the epidermis ; such
removal being the consequence of abrasion, or
effusion beneath its surface. The example which we
have selected as the type of excoriation is leichen
and prurigo, a papular eruption which produces so
much itching that the nails are almost involuntarily
brought into requisition, and the surface is more or
less torn ; but we might also have instanced the dry
forms of ekzema,and especially ekzema papulosumand
squamosum ; the tubercles of lepra ; the hyperaemia
of knidosis or urticaria ; the irritation of the acarus
in scabies, or the neurotic irritation of pruritus.
Next to the excoriation produced by the nails we
may instance the abrasions of surface which result
from friction and some chemical substances, such as
strong alkalies ; and the excoriations which are
brought into view by the rupture of vesicles or the
accidental wiping away of loosened cuticle softened
by secretions ; and the excoriated network of Hues
occasioned by the swelling of a portion of skin
affected with ekzema. Where the excoriation is
accomplished by the nails on an otherwise normal
tissue, the tears of the surface are indicated by
streaks or scratches, which are sometimes red and
F 2
68 PATHOLOGY OF THE SKIN.
bleeding, sometimes black from the desiccation of
effused blood, and sometimes brownish red from the
formation of a linear scab or from the removal of
such a covering. The excoriation in streaks, the
lingual excoriation, is a sign of a pruritic state of
the skin, and may lead us to the diagnosis of a
prurigo, a pruriginous leichen, a leichen urticatus, a
scabies, or a papular ekzema ; we also look for the
marks of the nails in lepra ; while the small black
scabs of prurigo and leichen urticatus covering the
summit of abraded papulaa are a pathognomonic
character.
In the abrasions formed upon the summits of the
papulaa of ekzema there occurs an oozing of a
transparent colourless fluid ; not unfrequently these
circular abrasions have the appearance of holes in
the skin, through which a watery secretion exudes ;
and, where a portion of cuticle of greater extent is
removed from an ekzematous skin, the denuded sur-
face is found to be coated over by a transparent,
jelly-like blastema, the material of reproduction of a
new epidermis or of a muco-purulent secretion.
When dressings drv upon an ekzematous patch, their
removal is very frequently accompanied with the
production of these circular abrasions, and if the
cuticle be already loosened, by excoriations of greater
extent and irregular figure ; and from both kinds of
excoriation, blood is poured out, or the viscous and
transparent exudation already spoken of takes place.
As, in excoriation, there is no important lesion of
the derma, and frequently none whatever, this
form of iniury heals up and disappears without
istence.
Indueation of the skin, with or without thicken-
ing, and with or without implication of the sub-
cutaneous tissues, is sometimes present on the sur-
face of the body to a greater or less extent, and to
a more or less limited degree. The pathological
PATHOLOGY OF INOBUSTATION. 69
change in the dermal tissues is infiltration and con-
densation ; and its active cause is defective nutrition.
This kind of induration is very characteristically
seen in xeroderma, in which the skin of the hands
and feet, and sometimes other parts, resembles
leather or parchment rather than skin. It is met
with also in morphcea alba lardacea, wherein the
infiltrated matter would seem to be a solid white
substance rather than a fluid, but comes before us
most commonly in chronic ekzema. To such a form
of ekzema we have given the names sUerosum and
verrucosum ; and we have seen it most frequently
on the back of the hands, on the shin, and on the
forearm just below the elbow.
To a more inveterate form of induration of the
skin the term skleriasis or dermato-sklerosis has
been applied ; and another form of induration
associated with infiltration is met with in spargosis,
and especially in bouknemia.
Incrustation is a consequence of the formation of
-Becretions on or in the skin, and the desiccation of
those secretions, so as to create a temporary cover-
ing ; and the crusts present a certain variety in
accordance with their deep or superficial origin, the
nature of the secretion of which they are composed,
and the rapidity of production of the secretion.
Thus, they may be as thin as scales of epidermis,
when they result from the desiccation of the tran-
sparent blastema which is the first effort of restora-
tion of an abrasion ; or they will present consider-
able thickness when their formation is protected by
treatment or situation ; when, for example, the
secreting surface is left undisturbed ; when the secre-
tion dries upon the exterior and so favours an
accumulation beneath the desiccated film ; when the
effused fluid is covered by the epidermis, or when it
is retained in situ by the hair. We may remind you
of the thin and almost transparent crusts which are
produced on the excoriated surface of a ruptured
70 PATHOLOGY OP THE BKIN.
bulla or phlyktis, and compare witli this tlie thick
mask of ekzema larvale or crusta lactea, the rugged
crust of impetigo scabida, or the conical or oyster-
shell crusts of rhypia or rupia.
Crusts will be thinner or thicker, according to the
degree of fluidity or inspissation of the fluids of
which they are composed, and in some measure in
proportion to their rapidity of production. Limpid
fluids, besides containing less solid matter capable
of concretion, will evaporate or dribble away from
the exuding surface ; denser and more viscous fluids
will remain, will leave behind more soUd matter when
evaporation has taken place ; and, having a longer
time to desiccate, will fashion themselves into a pro-
tecting crust. Moreover, when the secretions are
produced rapidly, they are carried away by their own
impetus, whereas, when they are poured out slowly,
desiccation and secretion go on simultaneously.
We have next to call to mind the material of
crusts ; in general it is blood, or lymph, or cyto-
blastema, or pus ; sometimes the secretion of the
sebiparous glands and sometimes disorganized or
altered tissue. Sometimes these products exist in a
separate form ; at other times they are commingled,
and occasionally may be produced alternately. The
diverse composition of the crust will naturally
occasion a difference in its colour ; the sanguineous
crust will be black, the lymph crust will present a
shade of light-brown, the blastema crust will be
brownish and yellowish, the purulent crust yellow
and greenish, the secretion crust grey or dusky-
green, the tissue crust or scab, or eschar, amber-
coloured or deep-brown, or even black, and the crust
of abnormal tissue, for example, that of the phyti-
form tissue, greyish or yellow. You will remember
the little black, speck-fike crusts, surmounting the
papulae of prurigo and leichen urticatus ; the thin
and thick, dense and spongy lamellas of ekzema
ichorosum ; the yellow crusts of ekzema pustulosum.
PATHOLOGY OF FISSION. 71 ,
which suggested to the Greeks the term melitagra ;
the greenish crust of ekzema larvale or crusta lactea ;
the grey and rugged and often fissured crusts of im-
petigo scabida ; the grey and greenish or brownish
crusts of rupia ; the grey and brown and greenish
concretions of sauro-derma or sauriodes ; the amber-
coloured and black scabs of herpes zoster and
variola ; the black and enchased scabs of ekthyma
and furunculus ; and the greyish-white and sulphur-
yellow crusts of phytosis tonsurans and phytosis
favosa.
Fission is a breach of continuity of the skin, and
is a consequence of a previously existing infiltration
and induration ; hence, we might, if we chose to be
hypercritical, treat of it as a tertiary lesion, as an
accident consequent on a secondary condition. It is
certainly one of the remarkable phenomena of the
economy of the skin, that under the influence of
hyperaemia, followed by infiltration and thickening,
the skin is apt to become so brittle that it breaks or
cracks, or chaps with the greatest facility — that, in
fact, the motions of a joint are sufficient to produce
a rent or fissure extending through the upper strata
of the derma, and sometimes more deeply. The
most familiar example of fission of the skin that we
can bring before you, is that of the chapped hands
or wrists so common in the winter season. But a
similar occurrence of chaps, the rhagades of the
Greeks — from ragasy a rent or chink, and the nmop
of the Latins — ^is met with under other circum-
stances, as in chapped nipples, in fissures of the
nostrils, the eyehds, the ears, the mouth, and the
anus. Chaps are also seen in association with the
tubercles of lepra and dermato-syphiUs, in chronic
ekzema of the hands and feet, the so-called ekzema
fissum or rimosumy psoriasis palmaris, and plantaris,
and in dermato-syphilis palmaris et plantaris. In
the palm of the hands and in the flexures of the
fingers, the fissures are apt to assume the character
. 72 PATHOLOGY OP THE SKIN.
of deep gashes; we have seen them in children,
extending completely around the finder as though
threatening amputation of the part ; whUe upon the
tips of the fingers they assume a longitudinal direc-
tion, like rents produced by the over-distension of
the tissues. In the case of the nipple, the skin is
often very deeply divided, and the nipple appears to
retain its attachment only through its bundle of
excretory ducts.
XTloeration is another example of a late secondary
lesion ; it is a loss of continuity of the skin conse-
quent upon the removal of a portion of its tissues.
It is circular or oblong in its form, with a well-
defined and abrupt margin; and sinks more or less
deeply into the integument. Besides the common
forms of ulcer of the skin, the acute, the chronic,
the irritable, and the indolent ulcer, which belong
to general surgery, we find ulcers sometimes deve-
loped in ekzema in association with varicose veins ;
we have the ulcers of chilblains, of furunculi, of
anthrax, and, in addition to these, the specific
ulcerations — ^namely, the strumous, carcinomatous,
leprous, and syphilitic ulcers. We must impress
upon you the necessity of distinguishing between an
excoriation, which is always superficial; a chap,
which is a mere fissure of limited depth ; and ah
ulcer, which presents an actual loss of substance,
although to a variable depth, sometimes as in
serpiginous dermato- syphilis, merely sweeping away
the surface of the papillary layer, and at other
times, as in strumous, elephantous, and carcino-
matous ulceration, penetrating through the entire
thickness of the integument, and reaching the sub-
cutaneous tissues.
The features of interest in an ulcer are, its depth
and extent, the condition of its edges, and the
appearance of its base, with the kind of secretion
wluch is poured out. Deep and extensive ulcers are
often troublesome to heal ; the edges in a healing
PATHOLOGY OF GICATBISATION. 73
ulcer slope evenly down to its base ; they are neither
too sharply defined, nor undermined, nor everted,
nor swollen. The base of a healthy ulcer is rough-
ened by growing buds or granulations, — in which
the processes of restoration are proceeding with
active energy, — rising evenly to the level of the
surrounding surface, and Unking, as it were, hand
in hand, one border of the ulcer with the other.
But the smooth, the red, the pale, the weeping, the
dry, and the sloughing ulcer are all unpromising.
The ulcer which creeps gradually outwards by its
circumference, whether uniformly or on one side
more than another, must be looked upon with
suspicion, and will probably turn out to be a specific
ulcer, may be strumous, or carcinomatous, or
syphilitic. An ulcer which runs along rapidily by
the circumference is commonly termed serpiginous,
fi:om serpere, to creep, the equivalent of the Greek
erpeirii or objectively, herpes ; sometimes it heals on
one side as rapidly as it progresses on the other,
and then we have before us a horse-shoe ulcer;
sometimes its rapid destruction of tissue suggests
the term esthiomenon, an eating sore Uke that of
lupus exedens or lupus vorax ; and sometimes the
sudden disappearance of substance admits of being
expressed by the word phagedcena, from phagein, to
devour.
CiOATEiSATiON is a reparative process, and results
in the production of a scar or cicatrix, the oule of
the Greeks. A cicatrix, therefore, is not a lesion,
but the sign of a pre-existing lesion, and may be
the index of a foregone wound or ulceration.
Looked at a little more closely we have not only the
evidence of a reparative process but also of a
reparative material, for the cicatrix is always
distinguishable fi:*om the normal integument and
can never attain the height of organization of the
true skin; it is white and smooth, and often
imeven ; sometimes sunk below the level of the
74 ' PATHOLOGY OF THE SKIN.
surrounding skin, sometimes raised unequally above
it ; sometimes thin and partially transparent, some-
times thick and opaque ; sometimes soft and flaccid,
but more frequently hard and tough.
The material of composition of a cicatrix is
Nature's most abundant and simplest constructive
element, namely, connective tissue, and connective
tissue is massed together to supply the place of the
lost skin ; sometimes it is spread out evenly on the
denuded bed and forms an imiform layer ; but
sometimes the regulating power is lost, and then it
is accumulated in excessive quantity and in varied
shapes, sometimes in the form of a ridge, some-
times in that of a tumour-like prominence, some-
times in cord-like bands, and sometimes in that of
a reticulated web. Excess of connective material
constitutes hypertrophy, that is, excessive growth ;
or hyperplasia, that is, excessive production; and
has further received the name of false cheloma,
cheloides spuria.
The healthy formation of a cicatrix will therefore
be determined in great measure by the nutritive
health of the individual, and in part by the local
injury sustained. Where, from the existence of ill-
regulated or unbalanced trophic power, there is
present in the constitution a tendency to hyper-
trophy or atrophy, the cicatrix will exhibit a corre-
sponding relation. Thus in struma, which is
essentiaUy a disease of defective and ill-regulated,
and consequently, perverted nutritive power, the
false cheloma is a common occurrence ; and another
phenomenon connected with the same diathesis is
the tendency to the breaking down and dissolution
of the cicatrix after it has been completely pro-
duced.
If now, we look into the anatomy of a cicatrix
we shall find it to be a layer of connective tissue,
sparingly supplied with blood-vessels and nerves,
and coated over with an epithelial layer correspond-
PATHOLOaT OP CICATRISATION. 75
ing with the corneous stratum of the epidermis.
There is no proper corium with its pars reticularis
and pars papillaris ; there are no sudoriparous and
sebiparous glands; no hair follicles; and there is
no rete mucosum. While the process of connective-
tissue formation is active, the cicatrix is more or less
reddened in colour from the presence of an abundant
capillary rete, but when the formative process is com-
pleted, the capillaries are reduced in number, and the
cicatrix is remarkable for its dull- whiteness, and at a
still later period for a bluish tint. On close inspec-
tion, a few red streaks, representing small venules,
and sometimes minute arteries, may be found
scattered from point to point, the venules taking
their origin in a coarse network, and sinking here
and there through the bands of connective sub-
stance into the subcutaneous tissue. This coarse
vascular supply very probably represents the track
of the few nervous filaments distributed to the
structure, for of the presence of nerves we have
frequent evidence in the sensibility of a cicatrix ;
generally it possesses but little feeling, but some-
times it is exquisitely sensitive.
One of the most remarkable of the properties of
a cicatrix is its quality of contraction. Attached all
around and continuous at its borders with the
sound skin, and at the same time adherent by the
rest of its extent to the surface on which it is
formed, its contractile action draws from the circum-
ference towards the centre, and the tendency of
this contraction is to produce a puckering of the
surrounding integument ; and where the contraction
is resisted, to draw the unresisting towards the
fixed point. In extensive bums and scalds this
property of the cicatrix sometimes gives rise to
great inconvenience, and produces a contraction of
flexible parts and of joints that ends in serious
deformity ; while, on the other hand, in surgery, we
make use of this known property of the cicatrix
76 PATHOLOGY OP THE SKIX.
whenever we wist to tighten and contract the skin
of a part — as, for example, in that form of derma-
tolysis of the upper eyelids which is commonly
denominated ptosis.
The absence of rete mucosum is the cause of the
want of pigment of the cicatrix ; and a certain im-
perfection of formation of the epidermis, together
with the absence of the papillary layer of the
derma, is the occasion of its abnormal smoothness
and of the tendency to laminated exfoliation and
desquamation, which always exists on the surface
of any cicatrix of considerable extent. And to
the latter cause is likewise to be ascribed the
yellowish and homy tint which the cuticle is apt to
assume.
And, now, gentlemen, we have to call your atten-
tion to a form of cicatrix, in which there has been
no open sore, no ulcer, and no lesion of continuity,
and yet the cicatrix is as complete as that which is
dependent on those conditions. We believe that we
were the first to describe this form of internal cica-
trix, and we propose to distinguish it from the
common external cicatrix by the Greek term,
ouloides, signifying cicatrix-like. The ouloid cicatrix
is met with in lupus, in syphilis, and in elephantiasis,
and is the consequence of a disorganization and
destruction of the skin, effected beneath the epi-
dermis, and without interference with the epidermal
membrane.
The pathological process in operation in the
destruction of tissue now referred to must be
termed degeneration ; the tissues in consequence of
defective nutrition, recede from their complete and
perfect standard, and decline through the stages of
a retrograde metamorphosis which reduces them to
the condition of a gelatinous substance, a substance
similar to that of the cellular tissue of the embryo.
All the tissues participate in this retrograde meta-
morphosis, the vascular tissue, the nerve tissue, the
PATHOLOGY OF CIOATBISATION. ']^
muscular tissue, the gland tissue, and the various
forms of fibrous tissue ; and all are reduced to one
common gelatiniform substance. But the gelatini-
form tissue is a substance of low vitality, endowed
with incomplete life, and possessing an imperfect
form : hence it becomes subject to those laws which
direct the removal of useless and intrusive material ;
and, incapable of resistance, it- is gradually absorbed
and removed, leaving behind it the traces of
destroyed substance which are met with in a
common cicatrix.
The first time a case of lupus non exedens
presents itself before you, examine with care those
tubercles that seem to be composed of a drop of
yellowish or salmon-coloured jelly effused beneath
the epidermis, that tempt you to puncture them,
but being punctured yield no fluid matter ; that are
not imorganized, for one or two minute blood-
vessels may be seen straggling through their mass.
But look around them, or rather behind them, and
observe the devastation which they, or rather a
similar manifestation, have committed : the papillary
layer of the derma gone, the reticular structure of
the corium brought into view, the reticular spaces
filled with the same gelatinous substance, the glands
and follicles destroyed, the rete-mucosum lost, and
only a thin and smooth, desquamating, unhealthy-
looking, and horny epidermis left to cover the scene
of destruction. The pathological process is some-
what similar to that of the operation of potassa fusa
OD the skin ; the surface is gelatinized, then re-
moved by absorption; we look, and behold the
papillary layer of the derma is gone, and the upper
stratum of the reticular layer is brought fully into
view as though by a process of dissection ; or, may
be, the dissolving action has sunk deeper, and a
coarse reticular network exhibits the deeper portion
of the corium.
Take another example of the ouloid cicatrix as it
78 PATHOLOGY OF THE SKIN. *
affects the nose in lupus erythematosus, or the scalp
in the same disease. On the nose, when the ab-
sorption has been superficial, every sebiparous
gland surrounding the hair-folhcle like a chaplet, is
brought into view as clearly as if the surrounding
tissue had been dissolved away and rendered trans-
parent by a chemical process ; while on the scalp
the disorganization has sunk to the fundus of the
follicles, and they, together with the hair-bulbs, are
whoUy destroyed. A similar pathological change
is seen in one of the varieties of sykosis.
The pathological identity of lupus non exedens
and lupus erythematosus is proved by this similarity
of organic change, and a pathological relationship
is, by the same observation, set up between lupus
and syphilis, and both these diseases with elephan-
tiasis Graecorum. In tertiary dermato-syphilis it
is no uncommon thing to find transparent-looking
tubercles which disappear imder the influence of
treatment, and never having broken or ulce-
rated, leave behind them deep pits of the ouloid
cicatrix. The material composition of dermato-
syphilis gummata or syphiloma is similar to these,
and so also are the semi-transparent, oedematous-
looking tubercles and blotches of elephantiasis.
We must also direct your attention to those
remarkable ouloid markings of the skin which have
received the name of linese and maculae atrophicas, or
false cicatrices. In these the appearance and structure
of the cicatrix are identical with common traumatic
cicatrix, but there has been no external solution of
continuity. Some, as the lineae atrophicae matrum
et hydropicorum, are referrible to distension with-
out corresponding growth, but others are met with
in which this explanation is untenable. You will
find some interesting cases of this affection narrated
in the Journal of Cutaneous Medicine, ' vol. i., pages
140, 209; and we may add to those Cases the
remark, that the best example of maculas atrophicae
PATHOLOGY OP DISCOLOBATION. 79
that has come before ub occurred in a man suffering
under elephantiasis Graecorum.
Discoloration, or abnormal pigmentation of the
skin, follows as a sequela several forms of hyper-
semia, and consequently possesses the characters
which properly belong to a secondary lesion. We
may instance the black stain or melasma which is apt
to succeed to a scorch, whether produced by the action
of the sun or by fire ; the melasma left upon the skin
by a bUster ; by the irritant action of an eruption
of lepra; or by the similar action of dermato-
syphiHs. When these discolorations are greenish
in hue they become entitled to the term chloasma ;
and when their tint is yellow they constitute phakia
or lentigines, or xanthochroia. In the series of
secondary lesions, however, we must confine our-
selves to the consideration of discolorations, that
is, abnormal pigmentation, produced directly by
hyperaemia, whether such hyperaemia result from an
external or an internal cause. In some few in-
stances, as in ephelis, the excessive pigmentation
follows the exciting cause so directly that we cannot
doubt the relation of the discoloration to the
hyperaemia : this is the case in the instance of true
sun-bum, the epheUs Solaris; in the fire-bum,
ephehs ignealis, that we meet with so commonly
in France, on the thighs of women, from the use of
the brazier ; and in those curious examples of xan-
thochroia which are sometimes seen on the legs,
just above the ankle, from a hyperasmia due to
varicose veins. In other cases, for example in
epheUs gravidarum and dysmenorrhoeaUs, the
h3rperaBmia is so little defined or so transient that
we are induced to refer the abnormal pigmentation
to the group of primary lesions. In melasma
arsenicale we perceive few signs of hyperaemia, but
nevertheless we have good analogical grounds for
the belief that the morbid pigmentation is preceded
by capillary congestion ; and in this respect melasma
8o PATHOLOGY OF THE SKIN.
arsenicale differs from melasma argenteum or
argyria, in which the morbid coloration is due
to an attempted elimination of the remedy and
the oxidation of the metal in the tissues of the
skin.
Having determined anatomically the structure of
the skin ; physiologically its properties in health ;
and pathologically the appearances which indicate
its morbid conditions, its lesions or signs of disease,
we will take a step further, and analyze any pecu-
liarities of manifestation or local phenomena which
the diseases of the skin may have to offer, whether
in distribution, in figui'e, or in manner of develop-
ment and growth.
And first, as to distribution. The lesions consti-
tuting an eruption may be general, or they may
be partial. A general eruption is indicative of a
general disturbance of the system, such as is met
with in the exanthematic fevers and blood diseases ;
6. g.y rubeola, scarlatina, variola, varicella, roseola,
dermato- syphilis, and elephantiasis Graecorum. The
causa morbi is present in the blood, and the eruption
consequently may be encountered wherever the blood
can reach — wherever capillary vessels are to be
found. The existence, therefore of an eruption
distributed over the entire surface of the integument
awakens our attention to the possibility of the
disease being one of those just enumerated ; and
prepares us for the necessity of a general or con-
stitutional method of treatment. There are a few
other diseases that are in there nature general — not
blood diseases, such an one is the disease xeroderma,
a disease of development and growth, and in an
advanced form termed ichthyodes.
A partial eruption is naturally subject to great
variation in point of extent ; it may be simply
regional, or it may occupy the greater part of the
surface of the body, and in rare instances the whole
DISTRIBUTION OF EBUMIONS. 8 1
of the integxiinent. You may possibly suggest that
if an eruption cover the whole surface of the skin
it must necessarily be general ; to which we must
reply, that its universal distribution is merely an
occasional occurrence— an exception, in fact, to the
general rule. Thus ekzema may be limited to a
spot of very small size ; it may occupy a region ;
or it may pervade nearly the whole of the cutaneous
surface : a perfectly general ekzema is very rarely
seen, and when an approach to such a state occurs
the eruption is not uniform in development on every
part, as it is in the examples of general eruption
already mentioned. The most completely general
of the partial eruptions that has fallen under our
notice was an instance of a form of ekzema first
described by Devergie under the name of pityriasis
rubra. A report of this case you will find in the
sixth edition of our work "On Diseases of the
Skin," page 177. There, indeed, the hyperaemia of
the skin was more universal even than occurs in
many of the general eruptions. We may make
another distinction between general and partial that
wiU serve as a further illustration of the differences
of nature implied by the terms. A general eruption
makes its attack at once, and has the effect of a
single morbid impulse ; but the partial eruption is
the manifestation of repeated impulses, and is es-
sentially successive. It begins in one or more spots,
as an accidental phenomenon, then it may appear in
a similar manner on other spots, and thus by
degrees spread over the entire surface, and prove
to our observation that a partial eruption may also
be universal.
A modification of the partial form of eruption is
met with in the presence or absence of a tendency
to symmetry. A general eruption is necessarily
symmetrical, because no part of the surface escapes ;
symmetry is also seen, but in an uncertain degree,
in the ekzematous eruptions, comprising ekzema«
a
82 PATHOLOGY OF THE SKIN.
leichen and impetigo, but is more decidedly marked
in lepra. This character of symmetry, there-
fore, is one of some interest, and must be dis-
cussed hereafter. At present it is suflBcient to
say that if you find ekzema on one hand you will
generally find it on the other ; if on one ear it
will be likewise found on the other ; if in one axilla
or groin, it pretty certainly exists in the other ; if
on one side of the body, whether limb or trunk, it
is equally present on the similar part of the opposite
side. But there the correspondence ceases ; there
is no uniformity of extent of the eruption; there
may be much on one side and little on the other
side. It is evident that the symmetry obeys an
accidental law — a law independent of the causa
morbi ; in other words, there are two laws in opera-
tion — a law of the system which originates the dis-
ease, and a law of the part which determines its local
distribution and its extent; and these two laws
operate with a certain degree of independence.
But in the instance of lepra the two laws are more
or less intimately united into one, and they operate
together. When the tendency to the disease or the
diathesis exists, the disease will manifest itself not
only with exact symmetry but also on certain special
parts of the body, and independently of Jocal pheno-
mena of any kind. A similar double law would
seem to govern another symmetrical affection,
namely, phytosis versicolor. Thus, if we take a
case of ekzema, we find the eruption selecting a seat,
but without much preference ; it may be the flexures
of joints and the hollows of folds, or it may be the
internodial portion of limbs ; sometimes it is the
sensitive skin of the pudendum, the groins, or the
axillaB, and sometimes the less sensitive scalp or the
atmosphere-hardened hands or fingers. All cer-
tainty is set at defiance by ekzema ; and this, in
fact, constitutes one of its most distinguishing cha-
racters. How different is lepra 1 symmetrical not
I
DISTEIBUTION OF EBITPTIONS. 83
only in situation but also in figure and in size, and
governed by a law which is at the same time a causa
morbi and an ordo figurce et loc% there is a constitu-
tional and a local impetus both synchronous. If
there be spots on the Umbs they will usually be
found symmetrical, and at the same time we discover
the disease on both elbows and on both knees. The
same may be said of phytosis versicolor, always oc-
cupying the chest, the groins, the back, and the
joints, and always with the most exact symmetry.
If we are shown a spot of lepra we can predicate
with certainty that it will exist at the same time on
the convexities of the elbows and knees. If it be a
spot of phytosis versicolor we should, after looking
at the upper and lower part of the trunk, and the
joinings of the trunk with the limbs, just cast a
glance of recognition, not at the convexities of the
joints, as in lepra, but into the flexures of the elbows.
You see, gentlemen, you have now before you three
common diseases of the skin well characterized,
easily distinguishable, utterly incongruous as com-
pared with one another. Let us instance their pre-
sence on the integument of the elbow-joint, and let
us see how we should deal with them. It is the
convexity of the elbow ; then the disease must be
lepra. We look; we find a dry, thick patch of
white desquamating epidermis; no other disease
presents similar characteristics; our diagnosis is
confirmed. But the situation, instead of being the
convexity is the concavity of the joint ; the lesion is
a yellow-brown stain, without hyperaemia, or rather
an assemblage of small islet-like patches more or
less scattered ; the case is inevitably a phytosis ver-
sicolor. Or, still the concavity of the joint, the sur-
face is red and itchy ; we need go no further, the case
is one of ekzema. But for your sake we will make
one observation more : the skin is thickened in
consequence of infiltration ; there are cracks in the
lines of motion, and there is a moist exudation ; no
a2
84 PATHOLOGY OF THE SKIN.
further inquiry is necessary ; it can be none other
than an ekzema.
Gentlemen, we want you to distinguish between
that which is general, because it proceeds from a
general cause ; and that which is partial, because it
depends upon some special although perhaps un-
known [condition of the part. To go back to a
previous illustration, we may regard a state of con-
tamination of the entire mass of the blood as the
cause of the general aflfection, and if we remain con-
tent with that explanation, there our inquiry may
end. But then the question arises — ^is the general
affection, elimination of the poison ; or is it simply
a state of morbid innervation of the skin induced by
the presence of a poison in the blood ? If the latter
supposition be admitted, the cause of the partial
manifestation of eruption may only differ from the
general cause in the nature and quantity of the
poison, whatever that may be. For although we
may say that the partial distribution of an eruption
implies the presence of a local cause as well as a
general cause, the same may also be said of a general
eruption, say of measles, wherein, besides the general
cause, we have undoubtedly a certain condition of
the skin, which favours the development of the ex-
anthem in the papillary layer of the derma in pre-
ference to any other part of the body.
One of the most important and at the same time
a very interesting manifestation of partial distribu-
tion of the eruption is that which has reference to
the selection of a region of the body, and the limita-
tion of the disorder to a prescribed boundary ; in
other words, a regmuil distribution. An early clas-
sification of affections of the skin adopted by the
ancients, consisted in dividing them into diseases of
the head and diseases of the rest of the skin. The
old Italian dermatologist, Mercurialis, observes : —
"The skin of the head, on accoimt of the brain,
which is the most humid and the greatest of the
DISTRIBUTION OF ERUPTIONS. 85
members, is subject to certain peculiar affections.
These affections are, diseases of the hair and dis-
eases of the scalp. The diseases of the hair are : —
ophiasis, defluvium, alopekia, calvitium, and canities;
those of the scalp are ulcers, both discharging (ma-
nantia) and dry. The diseases of the slnn of the
rest of the body are divisible into three groups,
namely, those of colour; those of roughness and
smoothness ; and those of magnitude."
But it is with a very different object to that en-
tertamed by the ancients that we caU your attention
to the special manifestation of cutaneous disease on
certain regions of the body, and also to the special
diseases of those regions. We want simply to fix
in your mind the fact that cutaneous diseases, like
plants, have their regional habitations, and that the
same disease on different parts of the body may be
most diversely manifested. Let us select a few
instances for illustration, for example : 1, the hairy
parts of the head and face ; 2, the non-hairy parts
of the head and face ; 3, the trunk of the body ;
4, the pudendum and perineum ; 5, the arms ; 6,
the legs ; and 7, the hands and feet.
In the hairy parts of the head and face, the com-
monest eruption is, ekzema, in its three forms —
ichorosum, pustulosum, and squamosum; ekzema
squamosum being the porrigo of Willan, and the pity-
riasis capitis of ourselves. Next to ekzema, we nave
lepra; then phytosis tonsurans, or ringworm ; kerion;
and phytosis favosa, or simply, favus ; encysted tu-
mours ; sykosis ; erysipelas, and, lastly, loss of hair
and special affections of the hair. Of this list, ekzema,
lepra, encystis, and erysipelas are common to the
whole body as well as to the head, but on the hairy
scalp ekzema presents peculiar characters, especially
its dry form, namely, pityriasis ; lepra also has a
special character on the scalp, namely, a diffused
form ; encystis is more frequent on the scalp than in
ftny other regiop of the body ; apd erysipelas of th^
86 PATHOLOGY OP THE SKIN,
scalp is remarkable for its dangerous consequences.
Phytosis, kerion, favus, sykosis, and affections of the
hair are special disorders of the hairy portion of
the head and face, although they may occasionally
be met with in other parts of the body ; one of
them, namely, sykosis, being essentially a disease of
the face, and in rare instances only intruding upon
the region of the scalp.
The most prominent diseases of the non-hairy
parts of the head, namely, the face, the ears, and
the nape of the neck, are : — ekzema in all its forms,
including pityriasis, impetigo, gutta rosea, akne,
sebaceous miliary tubercles, herpes, melasma, xan-
thelasma, nsBvus araneus, lupus in its three forms,
exedens, non-exedens, and erythematosus, and epi-
thelioma. Already, you will perceive, a regional
difference manifesting itself in the absence on the
face of lepra, and in the presence of akne, gutta
rosea, lupus, and epithelioma. Akne and gutta
rosea are never met with on the scalp ; lupus exe-
dens is almost exclusively limited to the nose ;
lupus non-exedens encroaches on the scalp very
rarely; lupus erythematosus is not imfrequently
present at the same time on the face and on the
head, giving rise to a form of incurable alopekia
areata ; and epithelioma is also an unusual affection
of the scalp. K we return to the diseases before us,
we shall fiirther discover that each has its own
special tests of manifestation ; ekzema even, which
occasionally occupies the whole face, most commonly
prefers to confine itself to a part, for example, to
the ears; sometimes the entire pinna, sometimes
its creases of junction with the head ; to the fore-
head ; to the grooves at the base of the nose ; to the
hps, or to one or other cheek ; impetigo, an affection
of children, cropping up around the nose, the
mouth, and the chin ; gutta rosea, a disorder of
adults, showing itself on the nose, the adjoining
part of the cheeks, iji the hollow between the lower
DISTBIBUnON OP EEUPTIONS. 87
lip and the chin, and in the centre of the forehead
at the root of the nose ; akne, an eruption of adol-
escence and approaching manhood, scattering its
conical pimples over the forehead, the cheeks, and
the sub-maxillary, sub-auricular, and sub-occipital
regions of the neck ; herpes occurring on the fore-
head or temple of one side only, or at the apertures
of the nose ' and mouth ; melasma, a disorder of
females, fixing upon the forehead ; xanthelasma, an
aflfection of the eyelids ; sebaceous miliary tubercles
dispersed around the eyelids and along the temples ;
lupus exedens attacking the nose; lupus non
exedens the cheek, and thence spreading to the
nose ; and lupus erythematosus, the nose and
cheeks, in scattered spots of small extent ; and,
lastly, epithehoma, making its appearance as a small
transparent tubercle, slowly ulcerating, on the nose
or on the cheek ; possibly in the near vicinity of the
lower eyelid.
The more common eruptions of the trunk of the
body are, in addition to ekzema, lepra, phytosis
versicolor, herpes zoster, prurigo, leichen planus,
and molluscum areolo-fibrosum. Ekzema on the
general surface of the body commonly appears in
its papular form, while in the hollow of folds, as of
the axiUsB, the groins, the mammas, and around the
mamillae, it is ichorous, mucous, and encrusted.
Lepra is most abundantly accumulated around the
waist in women and about the lower half of the
trunk in both women and men. Phytosis versicolor,
which is almost special to the trunk, is found on
the sides of the chest converging to the middle line,
and on the flanks, the groins, and upper part of the
thighs, in front ; and in the vertebral groove, and
thence spreading outwards on the ribs and upon
the flanks behind. Herpes zoster, an imilateral
eruption, may occupy the lower border of the pec-
toralis major and scapula ; the loin, the flank, and
the inguinal region ; or the lower ribs ; but is moat
88 PATHOLOGY OF THE SKIN.
commonly met with in the latter situation ; in both
the former it is apt to spread to the adjoining limb,
to the shoulder and arm above, and to the thigh
below, always following the course and ramifications
of one or two neighbouring nerves. The papulas of
prurigo with their black encrusted heads are
scattered more or less sparmgly over the en-
tire surface, and are intermingled with scratches
inflicted by the nails for the relief of the pruritus.
Leichen planus may be found on any part ot
the trunk, but is most abundant around the
waist, upon the loins, and upon the hips. And
molluscum areolo-fibrosum, a disorder of elderly
persons or of a neglected skin, is more frequent on
the coarse integument of the back, and upon the
sides of the trunk than elsewhere. The regional
distribution of eruptions on the trunk is influenced
by a variety of conditions, to which we may now
briefly advert, as being more easily studied on a
large scale on the body than on the limbs. One
condition relates to ventilation ; the weU- ventilated
parts are less susceptible of disorder than those
which are ill ventilated, such as the hollows of the
axillae, the groins, and the folds of flexion generally.
In the latter category must be placed the waist m
women, which is unnaturally heated and unduly
pressed by the bands and ligatures of their clothing.
Another condition is the presence or absence of a
wholesome friction and ablution ; on the back of
the trunk, which is beyond the reach of the hand,
diseases of abnormal growth are apt to make their
appearance which are not so commonly seen else-
where, and especially in elderly people. While a
third condition, has reference to the distribution
of the cutaneous nerves as we see exemplified
in phytosis versicolor, and particularly in herpes
zoster.
The chief diseases of the region of the pudendum
and perineum are-^ekz^ma, pruritus, herpes, and
DISTRIBUTION OF ERUPTIONS. 89
thymic warts. The ekzema appears in its ichorous
and squamous forms; and, occasionally, in one
/ which is peculiar to the region, namely, ekzema
marginatum or leichen marginatus. Pruritus is
another annoying affection which attains the highest
point of aggravation in this region, whether as
pruritus scroti, perinei, pudendi, or ani ; sometimes
existing alone, but more frequently in association
with or on the skirts of ekzema. Herpes pra3pu-
tiahs, or more correctly progenitalis, because it is
by no means limited to the prepuce and may occur
in the female as well as in the male, is another
troublesome affection ; and not less so are the tegu-
mentary growths and vegetations comprehended
under the name of thymic warts, moUusca and con-
dylomata.
On the arms we have to consider the joints and
the intemodial portions ; on every pa^ ekzema
may make its inrSads, for ekzema is^ cosmopolitan,
or rather cosmodermatical, and to it no modification
of the cutaneous tissue comes amiss ; sometimes we
find it on the thicker integument of the outside of
the Umb ; sometimes on the thinner skin of the in-
side ; and anon, in a favourite haunt, the flexure of
the elbow. There, also, in the bend of the elbow,
if it exist at the same time on the trunk of the
body, we may find phytosis versicolor ; while the
convexity of the elbow belongs especially to lepra.
So with regard to leichen planus ; in its discrete
form it is pretty sure to be found on the front of
the forearm just above the wrist ; and if it be
coherent, it may occupy the inner side of the fore-
arm as high as the elbow.
The peculiarities of the region of the lower limb
are principally due to the dynamical impediments of
the circulation ; ekzema and lepra are distributed
as on the arms ; being pretty certainly present on
the concavity and convexity of the knee respectively,
when absent or only soantily developed elsewhere,
90 PATHOLOGY OP THE SKIN.
Ekzema is more frequently dispersed in nummular
and circumscribed blotches on the lower limbs than
in other situations ; and is apt, from the existence
of hyperasmic congestion, due to the torpid circu-
lation through varicose venous channels, to spread,
often from a small spot, over the whole leg from
the ankle to the knee.
The nervous relations of pruritus are manifested
on the lower extremities by regional itching ; such
as in the course of the internal cutaneous nerves
of the thigh ; the cutaneous branches of the great
saphenous nerve below the knee; and the cuta-
neous nerves of the ankle. Another consequence of
the paresis of circulation in the lower limbs and
the consequent hypersemia, is the occurrence of a
.change in the blood that results in pigmentation.
A mottled pigmentation, sometimes black, sometimes
brown, but more frequently yellow, a xanthochroia
or chloasma, is a common phenomenon on the shin
and on the small part of the leg just above the
ankle.
The hands and the feet are common seats of
ekzema, but the protective influence of clothing is
strikingly manifested in the less frequent affection
of the latter than of the former. On the hands,
ekzema is chiefly met with on the fingers and on
the dorsum. Lepra, in inveterate cases, is apt to
encroach on the dorsum maniis, but mostly attacks
the nails. Other affections of the hands are, im-
petigo, scabies, syphilis, lupus erythematosus, per-
niones or chilblains, and disorders of the nails,
including whitlow. That disorder of the back of
the wrists that is almost peculiar to the region,
namely chaps, the effect of cold weather, is an
ekzema. A chronic inflammation with exfoliation
taking place on the palm of the hands, is termed
psoriasis palmaris, but psoriasis palmaris may be
the representative of four different diseases. It
may be ekzematous, or syphilitic, or lepra, or a
FIGUEE OP ERUPTIONS. 9 1
leichen planus; for all these affections manifest
their existence by attacking the palm of the hand,
and present appearances not very dissimilar. Im-
petigo phlyktaBnodes, a pustulo-vesicular eruption
of children is met with on the front of the wrists
and the back of the hands. Scabies bears upon the
hands, the acari, and the consequences of their
irritation ; the animalcules are met with in tortuous
burrows on the sides of the fingers, the ulnar side
of the hand, in the grooves of the wrist, and in
infants in the grooves of the palm ; the eruption
is found on the thinner integument between the
fingers, on the dorsum of the hands, and on the
wrists. Chilblains and chilblain-like congestions
are met with on the fingers of children and young
persons ; and on the toes and heels of the feet and
on the borders of the feet. While whitlow is found
on the ends of the fingers and near the margins of
the nails.
Regional distribution is also influenced sometimes
by the age of the patient : an eruption, such as mol-
luscum adenosum sen sebaceum, appearing in a
child, will show itself chiefly on the face ; in an adult
it must be looked for on the front of the trunk of the
body or on the neck ; and some affections are
especially diseases of a certain age. Ekzema may
be developed within a month after birth in the form
of ekzema infantile ; while three or four years, and
generally later, is the age at which lepra is first
manifested. The age of evolution of akne is
puberty; while that of the appearance of gutta
rosea is thirty or forty.
Next to distribution, the figure of eruptions of the
skin claims our attention : an eruption may be
diffusedy that is, it may be spread out more or less
extensively ; or it may be less extensive and circtmi^
scribed^ that is, limited by a well-marked boundary.
Thus you may find an erythema or an ekzema, which
shall be diffusum ; and another, which is distinctly
92 PATHOLOGY OP THE SKIN.
circumscriptum. Then an eruption may be circinatuSi
that is, circular ; or armulatus^ shaped like a ring ;
or marginatus, distinguished by a prominent margin ;
or qyratus, an irre&rular and confused assembla&ce of
inte^zpted or broken rings. ^
Or, the elements of an eruption may be scattered
separately over the surface, that is, disseminated ; or
they may be accumulated in a mass, aggregated.
When they are perfectly separate and distinct, we
distinguish them by the term discrete ; when thev
are assembled in small separate clusters like a bunch
of currants or grapes, we style them corymbous ; then
they may be aggregated so closely as to touch each
other by their base, when they would be termed
coherent; and lastly, they might become fused or
blended in one continuous mass, or confluent. It
must not, however, be supposed that these figures
and shapes are simply accidental ; they all obey a
physiological, or rather a biological law, and it would
not be difficult, were it not for the amount of
detail required, to give a very satisfactory explana-
tion of them all.
So, in the instance of development and growth of
eruptions, there is no accident ; there is an ever-
present biological law, which, by mere perversion,
lays the foundation of a pathological state. In its
development, an eruption may attack the most
superficial part of the skin, or it may affect its tissues
more deeply ; it may give rise to an uniform hyper-
aemia, or it may influence chiefly the follicular
element of the derma, and give origin to a punctated
rash ; it may be stationary, or it may have a tendency
to spread ; and it may spread with rapidity or very
slowly ; and again, the spreading may be a mere
expansion of a causa morbi, or it may be a symptom
of exhaustion of the disease. Our fathers have left
us a poetical illustration of the outburst of an erup-
tion, as also of its expansive evolution, in the term
exapthema, ^ blossoming forth, This term was
DIAGNOSIS OP CUTANEOUS DISEASE. 93
common among them as the expression of the ery-
themata and the knidosis or urticaria of the present
day, and before the so-called exanthematic fevers,
rubeola, scarlatina, and variola, had made their
appearance in Europe.
In point of growth^ cutaneous eruptions have a
centrifugal activity, spreading from a centre, or from
the border of a matured patch, into the neighbour-
ing tissue, by a law .of contiguity. Sometimes the
centrifugal growth only tends to increase the size of
the patch or the dimensions of the eruption ; at other
times, the centre of the patch recovers its healthy
condition, and the eruption is converted into a
ring, of which the growing belt possesses a greater
or lesser degree of breadth. In the annular forms
of erythema this character is very conspicuous ; as
also in erythema or herpes iris ; in herpes circinatus;
m phytosis annulata ; in lepra ; in ekzema margina-
tum or leichen marginatus ; in leichen planus ; and
in some forms of ulcerative disease, such as lupus,
cancer, and dermato-syphilis. Ordinarily the ring is
single, at other times, as in erythema or herpes iris,
and sometimes in ekzema marginatum or leichen
marginatus and phytosis annulata it is successive.
In the more superficial affections, the energy of
growth is uniform throughout the whole extent of
the circle ; but occasionally, and pretty constantly
in the ulcerative diseases, it is more active at one
part of the ring than elsewhere. This method of
growth is suggestive of various terms, for example,
9p^g from ipTTSiif to creep, among the Greets ;
serpigo and serpiginous among the Romans; and
spreading or creeping amongst ourselves : added to
which, where ulceration is concerned, we have
ta-dtofjLtvoy among the Greeks, and rodens and ex«
edens derived from the Romans.
Diagnosis. — ^And now, gentlemen, you will be
anxious to put in practice the knowledge which you
have attained ; you will be desirous of applying your
94 PATHOLOGY OF THE SKIN,
observations to the purpose for which it was
intended, — namely, the diagnosis of disease. We
have said enough to prove to you the importance,
nay, the necessity of careful observation ; you have
to determine the differences between health and
disease, and therefore you must be acquainted with
the appearance and quaUties of the skin in both
those states. The aberration from the standard of
health is one in which, perchance, the epidermis may
be principally concerned ; it may be too dry or too
moist ; too rough or too smooth ; too thick or too
thin ; or it may be in a state of exfoliation or de-
squamation. Or it may be that the rete-mucosum is
chiefly in fault, as indicated by variation of com-
plexion or colour. Or, the follicles and glands of
the skin are the seat of disorder, the sweat glands,
the sebaceous glands, or the hairs.
In the next place, you may discover those signs
that prove the affection to be not simply epidermic,
but also sub-epidermic; there may be swelling
denoting infiltration of tissue, and with infiltration
you may find vascular congestion, prominence of
follicles constituting papulaa, effusion of serum in
the form of vesicles and bullae, or of purulent fluid
producing pustules, excoriation of the cuticle, and
crusts resulting from the desiccation of morbid
discharges.
Then there may be symptoms of nervous irritation
in the occurrence of abnormal sensations of various
kinds, and especially of itching. There is the tick-
ling itch of lepra and scabies, the tingling of
urticaria, accompanied with spasm of the skin pro-
ducing wheals ; there is the burning and piercing
itch of herpes ; the creeping and prickling itch of
ekzema ; and the fierce and lancinating itch of
prurigo. And in addition to these symptoms there
are the traces of scratching upon the skin, in various
degrees of freshness, and the pigmentary marks which
continued scratching is certain to leave in its train.
ETIOLOGY OP CUTANEOUS DISEASE. 95
Besides all this, the material of diagnosis, we have
to take into consideration the locality of the erup-
tion, the age, the sex, the rank, the occupation, the
habits of the patient, and every circumstance in his
surroundings which may bear upon his health. All
these appearances and circumstances taken together
constitute the physiognomy of the disease ; and the
physiognomy, in its totality, leads us to the correct
discrimination of the nature and of the name of the
disease.
Etiology. — The caitse of disease of the skin either
originates from within, or proceeds from the exterior
of the organism, in the former instance constituting
an internal^ and in the latter an exteiiml cause. The
internal cause operates through the agency of other
portions of the economy, such as the nerves and the
blood, and is therefore indirect, while the external
cause is without intervening agency, and conse-
quently direct. Moreover, the affection of the skin
in the instance of the internal cause is an indication
or symptom of an internal state, and is therefore said
to be symptomatic ; while the disease, originating in
direct agency, belongs essentially to the part, and
is therefore, idiopathic^ or simply heal. An internal
cause is, consequently, symptomatic of some disorder
of the economy, while the external cause is local and
idiopathic.
The agents of the internal cause are, the blood,
the nerves, and the internal system of organs, such
as the digestive, the assimilative, the emunctory, and
the reproductive ; and the disease of the skin may
be said to be symptomatic of a condition of the
blood, of the nerves, or of the different organs.
We sometimes make use of the term sympathetic,
and speak of an eruption as sympathetic of or in
sympathy with a morbid state of the stomach or
digestion; or of the reproductive system or its
fimctions.
We find illustrations of the morbid influence of
96 PATHOLOGY OP THE SKIN.
the blood, in the so-called blood-diseases ; the ex-
anthematic and continued fevers, in secondary-
syphilis and elephantiasis, and also in the altered
constitution of the blood which we term dyskrasia.
The operation of the nerves is shown in some forms
of erythema, in prurigo, and herpes ; while morbid
sympathies with the various organic systems of the
body are evinced in knidosis or urticaria, in ekzema,
and in chloasma and melasmata.
Local cause will comprehend all those conditions,
either existing in the tissues of the part, or operat-
ing from the exterior, which are capable of setting
up a morbid action in the skin. Akne, cheloma, and
ichthyodes we must regard as an aberration of
function of the part. While the external agencies
capable of influencing the skin injuriously are very
numerous ; for example, extremes of cold and heat,
of dryness and moisture, friction, contusion, and
mechanical and chemical irritants of every kind.
Among mechanical irritants are comprised the
epizoa, namely, the acarus scabiei, the pediculus, the
pulex, the cimex, and other insects which attack the
skin. Some dermatologists comprehend in this
series the epiphyta, as well as the epizoa ; but, we
believe, without suflficient proof; the phytiform
degeneration of the cells of the rete-mucosum has
been regarded as a parasitic plant ; and the number
of these supposed plants is very considerable. At
one time there was a striving of the microscopists
for the appropriation of a parasitic plant, each to
himself; at present the efibrt is to show that the
diversity in the supposed plants has reference to a
difference of locaUty of the skin. Soon, we doubt
not, it will be admitted by all, that the plant-like
structure in question is a degeneration of an animal
tissue to a lower form. In the mean time the
doctrine that you will hear from our lips — a doctrine
to which we have held imshaken for nearly twenty
years, and seen no reason to alter — is, that the so-
ETIOLOGY OF CUTANEOCS DISEASE. 97
called dermatophyta are an eflfect, and by no means
a cause of disease.
But while, gentlemen, we are discussing internal
and external causes, we must not fail to bear in
mind the phenomena of causes in general. A lesion
represents a cause in action, and is therefore
denominated a proximate cause ; now the lesion has
been excited by another kind of cause, and that we
distinguish as an exciting cause ; but the excitement
in a multitude of instances would fail, unless there
were a disposition or predisposition to be so excited ;
this, therefore, is a predisposing cause; and, very
commonly, there exists a still more distant cause,
which we term a remote predisposing cause. Let us
take an example : bad and improper food occasion
mal-assimilation ; mal-assimilation induces a dys-
krasis of the blood ; and, as a consequence, a debility
of the skin ; cold or heat or friction, insuflBcient to
irritate a healthy skin, operates as an exciting cause
on a skin weakened by nutritive debility, and an
ekzema results. In this case, we should regard the
improper food, the error of diet, as a remote predis-
posing cause ; the resulting general and cutaneous
debility, as a predisposing cause ; a trivial accidental
stimulus becomes the exciting cause, and so the
ekzema is the consequence ; or, if you please, we
will take an illustration that you will meet with
over and over again in practice : a child is attacked
with ekzema inmntile ; the cause of the lesion is a
weak cutaneous tissue ; the cause of the weak
cutaneous tissue is mal-assimilation. What, in this
case, would we ask, is the cause of the ekzema ?
We should not hesitate to answer, — the error of
diet ; because, without the error of diet acting as a
remote predisposing cause, the other links in the
chain would never have occurred.
There is another reason why the error of diet
should be recognized as a causa causanim. Your
business is to cure the ekzema ; for this reason you
u
98 PATHOLOGY OP THB SKIN.
must find the cause, for without a knowledge of the
cause of a disease, you have nothing whereon to
found your therapeutical treatment ; you may treat
the stomach in vain unless you recognize the fault
in diet as the ruling cause ; and then, a more whole-
some diet, perhaps a wet nurse, is your means of cure.
Knidosis or urticaria ofiers us a variety of examples
in which an error of diet, a peccant matter intro-
duced into the stomach as food, is the cause of the
peculiar indtation of the skin ; we may instance
shell-fish ; although, as you are well aware, a variety
of harmless edible substances may be equally hurt-
ful. Other causes of afiections of the skin, some-
times exciting and sometimes predisposing, are chills,
mental emotion, nervous irritation, and also epidemic
and endemic conditions. We are not now using
language to which you are unaccustomed and for
which you are unprepared, and we could adduce a
multitude of examples if we thought it necessary, to
confirm what we hold to be an obvious and indis-
putable truth.
If you have followed our instructions with atten-
tion up to this point, you will be in a position to
distinguish between a healthy and an unhealthy
skin ; and you will also be able to determine the
differences of character presented by the symptoms
of cutaneous disease ; in other words, by the different
pathological lesions. Thus you will recognize the dis-
tinctions between hyperaBmiation, papulation, tuber-
culation, vesiculation, phlyktaanation, pustulation,
squamaformation, and maculation ; together with
desquamation, excoriation, induration, incrustation,
fission, ulceration, cicatrisation, and discoloration.
You will also be familiar with the phenomena of dis-
tribution, of figure, of development, and growth of
those diseases ; and moreover with the principles of
diagnosis and of causation. And we may further
point out to you, that by the method of induction
NATUEE OF CONTAGION. 99
which we have heretofore followed we shall have
brought you to a new and very important subject of
study, namely, that of the treatment of cutaneous
disease.
Before, however, we take leave of the etiology of
cutaneous aflfections, we may glance for a moment at
two causes which we have not heretofore men-
tioned; namely, contagion and hereditity. The
views of contagion propounded by Lionel Beale, and
so ably advocated by Morris, namely, the transfer-
ence of an atom of one individual into the blood or
tissues of another, are now very generally received.
The atom is the means of conveyance of the con-
dition of one body into another body, just as a
particle of yeast, of extreme minuteness, is capable
of communicating zymosis or fermentation to the
whole mass of fluid which receives it. The atom of
matter which thus becomes the bearer of contagion
is living substance, capable of germination and
growth when it meets with a favouring soil : hence
its name " germinal matter ; '* and, although of ex-
treme minuteness as to size, has its type in the ovum
of a bird or in the seed of a plant ; for what more
is an egg or a seed than germinal matter inclosed
in a shell, and the atom which we are now considering
has also its shell, produced through the desiccation of
its surface by the atmosphere. The germinal atom
may therefore be dry on the exterior and moist
within ;• but what if it bo dry throughout, it is only
then in the condition of a seed, or of those rotifera
which, although dried up to a powder, waken into
life when moistened by a drop of water. The ger-
minal atom explains all the known phenomena of
contagion, which is not the case with other theories
of the communication of disease from man to man.
You must remember also that there are kinds and
degrees of contagion, and that when we speak of
the contagion of measles, scarlatina, variola, or
typhus fever, we signify a kind of contagion that is
H 2
lOO PATHOLOGY OF THE SKIN.
highly active and extremely dangerous, that the po-
pulation can barely escape if brought within its
influence even at a distance. Then if we speak of
the contagion of syphilis or elephantiasis, we per-
ceive an evil that we may avoid, and in which there
is no danger to the community except by personal
contact. Next we have the contagion of ringworm,
which imperils the safety of children, but is nowise
comparable to that of rubeola, scarlatina, or smallpox;
and then we have besides the impetigo phlyktae-
nodes, which has received the name of " contagiosa "
from Tilbury Fox ; and the molluscum adenosum,
which has likewise been termed " contagiosum " by
observant authorities. We might carry our illustra-
tion a little further and show that hereditity is itself
a kind of contagion, since it was the parent that
communicated to the embryo by means of germinal
matter those conditions of tissue which in after-
years become manifested as a lepra, an ichthyodes,
or even an ekzema.
You may possibly remind us, that in this our
brief sketch of contagious diseases, we have omitted
to mention scabies, a disease which, with the so-
called epiphyta, has very unreasonably given the
odour of contagion to all cutaneous diseases. But
we have made the omission on purpose, in order to
impress upon you more forcibly the true nature of
scabies. K a patient be brought to you covered
with an eruption which has been obviously occa-
sioned by the bites of a parasite, say of one of
those domestic tyrants, the pediculus, the pulex,
or the cimex, you do not treat the case as con-
tagious, because you know the cause to be an ex-
ternal one, and easily removable. The efiects are
little more than would be occasioned by the powder
of cantharides sprinkled on the skin. We must
ask you to apply the same reasoning to scabies.
Scabies is a simple and varied irritation without
specific type, being neither vesicular, nor papular,
NATURE OP CONTAGION. lOI
nor pustular, nor anything fixed and certain, although
all these forms of lesion may be present, occasioned
by the presence of an animalcule on the skin ; an
animalcule of such delicate organization that the
mere vapour of sulphm* is sufficient to destroy it in
a few hours. We have here no question of germinal
matter and germinal atoms, and therefore the dis-
ease cannot be included in the same category of dis-
eases with those that are truly contagious.
The contagion of rubeola, scarlatina, variola, and
typhus is at present believed to consist in atoms or
particles of ^nninal matter, imbued with the prin-
ciple of disease, and thrown off by the sick, to
become dispersed through the atmosphere. It is
also believed that by the mere act of respiration
these germinal atoms are conveyed into the air-cells
of the lungs ; that, permeating the waUs of the air-
cells and of the capillaries, they reach the blood ; and
that there their germinal and reproductive powers
are developed. If this be the fact — and wo are dis-
posed to believe it, — the same explanation should bo
carried through the whole series of contagious affec-
tions. Thus, in the case of a sick child introduced
into association with those that are sound, the
germinal atoms given off from that child, and re-
ceived by respiration into the circulating fluids of
the rest, would set up all the phenomena of the con-
tagion of ringworm, of impetigo, or of moUuscum,
with which we are acquainted. And we think it not
improbable that the phytiform matter of the epiphyta,
the so-called spores, may, by way of respiration,
reach the blood of many children, and pursuing its
destiny, become developed in the rete-mucosum of
the 8^, and so establish the contagion of the phy-
tiform diseases, and especially of ringworm.
But you will hear a different doctrine than this in
the outside world. You will be told that the phy-
tiform matter is an independent organism of vege*
table nature ; that it lives like a parasite on the skin ;
I02 PATHOLOGY OF THE SKIN,
that it produces sporules or seeds ; that these seeds
are conveyed from head to head by means of the
atmosphere, by brushes and combs ; and that, reach-
ing the scalp, they there take root and grow. This
is the explanation which we have called the "gardener
theory," and which we totally disbelieve ; and this
theory, amongst others, presents the great drawback
of limiting the view of its followers solely to the
outer surface of the skin. The disease is not a dis-
ease of the system, but of the part, and only a dis-
ease of the part so far as that it is occasioned by a
foreign body^ acting as an irritant— that, like the
acarus scabiei, simply penetrates the epidermis, and
draws upon the rete-mucosum for its nourishment.
The epiphyton is regarded in fact as a vegetable
acarus, or a vegetable louse ; and all that is needed
to cure the disease is to kill the vegetable miscreant ;
and the remedies which are employed for this
necine purpose are termed parasiticides ; and first
amongst them stands the ancient " sublimate " of
the popular world, the perchloride of mercury. Now
if we object to the term contagion as applied to the
operations of an insect on the skin, we might equally
object to it when the irritation is caused by a plant ;
and we think ourselves warranted in protesting
against the application of the same term to the
transmission of the itch or the ringworm that we
should to the conveyance from one person to another
of rubeola, or scarlatina, or small-pox. In fact, in
whatever way we may choose to regard the matter,
it is clear that the term contagion is at present used
very loosely, and it behoves us to draw some line
of distinction between a contagion which is certain
and inevitable, and another which is uncertain, or
may be avoided.
There is no question which you will be asked
more frequently in practical life than — Is it con-
tagious ? and as trustees of the public health, it is a
question which you must be ready to answer. If the
NATURE OF CONTAGION. IO3
case be one of rubeola, scarlatina, or variola, you
can have no hesitation ; the disease is not only con-
tagious, but highly contagious. With regard to all
other diseases of the skin, you must speak in the
most qualified terms. It may be necessary to put
the public on their guard ; but it is not necessary,
nor is it honest, to create unnecessary alarm. Ring-
worm is one of the diseases the very mention of
which is suflBcient to create a panic ; boys are robbed
of their education by the most vulgar prejudices on
the score of contagion, and medical men are too
prone to adopt any fashionable theory of the day
rather than rely upon their own practical experience,
and make there a sturdy stand. For nearly twenty
years we have maintained the parasitic theory of
contagion to be false ; for almost as many years we
have felt the diflficulty of explaining the occasional
transmission of ringworm from one child to another,
and the more rare occurrence of the conveyance of
ringworm from a child to an adult. This diflSculty
is now removed by Lionel Beale's discoveries in
relation to germinal matter, and we are thereby
enabled to comprehend how a party of children,
huddled together, may reciprocrate the disorders of
each other, and how such disorders may even be
communicated to an adult placed in similar circum-
stances. But, as you well know, ringworm is an
affection of childhood, and adults suffer very rarely ;
and when they do receive the disease, it assumes a
trivial and exceptional character, namely, that of
tinea or phytosis annulata. Moreover, gentlemen,
we call your attention to the fact that children, to
engender ringworm, must be packed together too
closely, to the deprivation of proper ventilation;
there must be errors of diet, air, and exercise in
order to bring about the state of body in which ring-
worm is prone to contagion. Experience has con-
vinced us that ringworm is periodic and epidemic,
p,nd that contagion occupies a very secondary place
I04 rATHOLOGY OP THE SKIX.
in the history of its phenomena. We remember
being consulted, on one occasion, in the case of a
little boy and girl, brother and sister, who were both
attacked with ringworm in the same week, and yet
there had been no communication between them for
more than a year, for one was in Essex, the other in
Cornwall. Mr. Hutchinson* has directed the atten-
tion of the Profession to the fact of the infrequency
of ringworm amongst the very poor, in comparison
with the children of boarding-schools, and of the more
comfortable classes ; and he sees in this circumstance
an argument against the supposed influence of dirt,
and in favour of the theory of the conveyance of the
disease by brushes and combs. We, however, see
in it only an argument in favour of fresh air, a hardy
life, and a varied and not insuflBcient diet. How-
ever, gentlemen, these difierences of opinion should
have the efiect, on your mind, not of creating doubt,
and of weakening your trust in authority, but of in-
ducing you to take a broad view of any obscure and
difficult questions that may come before you, and of
inducing you to think for yourselves.
While on this point, and in connection with the
present question, we will make another observation
to you which is deserving of your attention, and
which, although on previous occasions often pre-
sented to our mind, has been more particularly
impressed upon it by a suggestive remark from the
len of Mr. Hutchinson, t In a recent visit to the
It. Louis Hospital in Paris, he saw a case of tinea
or phytosis tonsurans in an adult ; and he also re-
marks on the frequency of favus or phytosis favosa.
Now, such cases as these are entirely exceptional
in England, and, therefore, you must learn to bo
cautious in accepting the observations and expe-
rience of a foreign country as a standard for regu-
• JovKSAL OP Cutaneous Medicine, vol. L p. 174.
t Idem, vol. ii. p. 88.
HEEEDITITY OP ERUPTIONS. IO5
lating the practice of your own. There is, undoubt-
edly, a great difference in the manifestation of
cutaneous diseases in different countries under dif-
ferent conditions of climate and diet ; and there are
also undoubtedly, differences of manifestation of
disease amongst the different classes at home. A
scabies in the out-patient room of an hospital, or at
the door of a workhouse, is a different thing alto-
gether from a scabies in the middle rank of life, and
similar differences run through the whole catalogue
of cutaneous diseases.*
And now a few words as to hereditity. Here-
ditity is sometimes a vice and sometimes a habit : it
is a vice in the instance of struma, syphilis, elephan-
tiasis, and lepra ; it is a habit in the instance of the
most universal of diseases of the skin, namely,
ekzema. In the four first-named affections, the
disease is a repetition of a dyskrasia or disorganiza-
tion ; in the last, it is a consequence of disorder of
function : we call both by the name of diathesis,
implying tendency ; but there is the difference be-
tween the two that there is between organic and
functional. We cannot suppose that the actual
* Lepra " is remarkable for its rarity among the manufacturiDg
population ; one in 41, as compared, in tlie better fed and better
housed members of the wealthier class, with one in 16. It will
be in the knowledge of our readers that we have pointed out the
substitutive character of lepra in relation to tuberoulosis ; and the
disproportion of lepra in the strumous and the non-strumous class
gives an unexpected support to our opinions. In phytosis or
tinea, again, we have an illustration of the more frequent occur-
rence of ringworm among the wealthier than among the poorer
classes, that cannot be attributed to better feeding, but must be
explained by reference to the hardier constitution of the latter.
Among the Belfast hospital patients, the proportion of ringworm
cases is one in 59 ; whereas in the wealthier classes it is one in 40.
Another curious &ct is, that in the hospital cases the figures re-
presenting phytosis annulata and tonsurans are respectively 43
and 10 ; while, among the wealthier classes, the relation which
the two forms of affection bear to each other is nearly reversed,
being represented by the figures 64 and 188." — Joubkal of
CvTAKEOus Medicine, vol. iiL p. 277.
I06 THERAPEUTICS OP CUTANEOUS DISEASE.
poison of syphilis is conveyed from parent to off-
spring, but only the dyskrasia to which the poison
gives rise: this is more manifest in struma or
scroftda, where there is no virus, but only a dyskra-
sis ; and the same in elephantiasis and lepra.
Amongst the commoner forms of disease, the here-%
ditity of lepra is very remarkable, and it occurs the
most frequently without any other disorder of the
health. Bkzema is also very commonly hereditary,
but it is so indirectly, and secondary to some
general disorder of the economy, more especially of
the digestive or of the nutritive system.
Therapeutics. — ^And, now, gentlemen, we will
direct your attention to the Therapeutics of cuta-
neous disease. In these diseases there is a cutane-
ous lesion and very commonly a state of constitu-
tional disorder ; hence our remedies must be of two
kinds, namely, external or cutaneous or local ; and
internal or constitutional. To classify the external
or local remedies, we must divide them into allevia-
tives and stimulants and caustics. While the con-
stitutional remedies are, aperients, alteratives, and
tonics. Thus if we have a cutaneous disease before
us, we soothe it to remove irritation ; we stimulate
when the indication is to restore the tone and func-
tion of the skin ; and we apply our caustics if the
intention be to destroy exuberant or morbid growth.
Then in the case of constitutional disturbance,
whether primary or secondary, we regulate the se-
cretions, we modify nutrition, and we restore the
vital power. You may interpose the remark, that
the method which we are now propounding is the
method in common use for the treatment of every
disease of the body. Our answer is, that it is so ;
and that it is an error to suppose that disease of the
skin has a special pathology of its own, and a special
principle of treatment ; the treatment of a cut finger
and of an ekzema is in reality identical. You will
observe that we make no mention of specifics, an4
THERAPEUTICS OF CUTANEOUS DISEASE. I07
simply because there are no such things ; arsenic is
a neuro-tonic applicable to every disease wherein
there is loss of power of the peripheral nervous
plexuses and a consequent disorder of capillary cir-
culation and of cell-nutrition. Sulphur, in its special
usage, is a simple fumigatory, destructive of the life
of the humble animalcule which represents the cause
of scabies, but effecting no more than a variety of
other substances could accomplish; for example,
common olive-oil, or the seeds of the stavesacre.
Tar, again, is simply a stimulant; while the per-
chloride of mercury is both a stimulant and a
caustic. There cannot be a question that there is a
manner of handling our remedies that is worth your
study, and is, in fact, the matter that most demands
your attention. The master is known not by the
mere excellence of his tools, but by his method of
using them ; and this, in fact, creates the need for
clinical instruction.
The theory of medicine— and the word medicine
includes surgery and every ramification of the heal-
ing art, just as the word physician is the general
denomination of the practitioner of the healing art,
for nature knows none of the pigmy distinctions of
men — the theory of medicine at the present day is,
happily, a very rational one ; we no longer talk of
humours and humoralism, things of the imagination,
mere ideas, and incapable of demonstration, but we
refer disease in its aggregate to a plus or a mvrms of
vital power ; our local diseases are dependent upon
diminished vitality of tissues, our general diseases
upon a depreciation of the vigour of life. And
bringing this method of reasoning down to the dis-
eases which we are now investigating, it may be
shown that all our processes have for their object to
remove the causes of depression of vital power
on the one hand, and to restore vital power upon
the other. The alleviators remove irritants which
\>j their operation upon the peripheral nervous
I08 THERAPEUTICS OF CUTANEOUS DISEASE.
•
structures depress and exhaust, while the stimulants
are direct tonics. And the same may be said of the
internal remedies when judiciously employed ; ape-
rients and emunctories remove elements which by
their excess weigh down the beam of life ; they
create a waste which instantly becomes the most
active impulse of supply ; in a word, they are active
agont. of^renovatioiTand then, ^i a/the proper
moment, we step in with our tonics, our digestive
tonics, our blood tonics, and our nerve and tissue
tonics.
We sa^ again, and we can hardly repeat the say-
ing too frequently, that cutaneous disease is a low-
ered state of vitality, in fact, a debiUty ; a debility
of tissue or of the part ; and a debiUty of the entire
constitution; and that the aim of our treatment
should be to restore the power of the part, and to
restore the tone of the constitution. We express an
apparent truth when we say, in a particular case,
that the constitution is sound, although a local dis-
ease be present; but such a statement is neither
philosophical nor is it rigorously true ; and it is not
true for this reason, that you may add increased
vigour even to that which is assumed to be sound on
the average ; and by the addition of new vigour the
local disease will disappear. Therefore, gentlemen,
while you should always keep in view, as a para-
mount duty, the cure of a local disease, you must
also endeavour, as a still higher duty, to improve
the constitution. There are cases in which you can
make no progress with the local disease until the
constitution is improved ; and we can hardly realize
a case which will not get well spontaneously, if we
can succeed in elevating the vital power.
The LOCAL BEMEDiES appHcablc to cutaneous dis-
ease are: water, in a great variety of forms; aJkohol,
powders, soaps, glycerine, oils and fats, acids and
alkalies, vesicants, caustics, cantharides, and certain
vegetable and mineral substances ; for example :
THERAPEUTICS OF CUTANEOUS DISEASE. IO9
wheaten flour, oatmeal, starch, linseed, poppy, bitter
almond, stavesacre, camphor, resin, iodine, tar,
carbolic acid, lead, zinc, silver, mercury, and sul-
phur.
Water, in its several states of cold, tepid, and
hot, simple and medicated, possesses a variety of
properties and an equally varied range of utility.
As an abluent it serves to cleanse and soften the
epidermis ; as a lotion it cools ; as a fomentation or
poultice it warms ; it relaxes when hot, and braces
and invigorates when cold ; and may be made the
medium of applying medical substances to the skin
to modify the tissues or facilitate their absorption by
the organism, and this . either to a part, or to the
entire surface of the body. When used to the whole
surface of the skin, it constitutes a bath, and the
bath may be charged with a variety of substances,
and so become a medicated bath ; thus we have
baths of starch, of oatmeal, of bran, of milk, of gela-
tine, of iodine, of mercury, of sulphur, &c. Hebra
invented a permanent warm bath, in which he kept
a patient, afflicted with variola, during the whole
course of the disease, amounting to several weeks.
One of the commonest, and, at the same time, one
of the most popular uses of water, is, the water-
dressing and the poultice. These remedies are
essentially relaxing in their operation on the skin ;
they quiet nervous irritability and muscular con-
tractility, and in this way tend to alleviate the pain
and heat of local inflammation. But you will per-
ceive that this state of relaxation may be carried to
the extent of producing weakness and debility of
tissue, and then the remedy which a few days before
was of the greatest utiUty has gradually merged into
a cause of disease. Herein you will see the explana-
tion of a cluster of ekthymatous pustules or small
boils rising up around a furuncle or a carbuncle that
has been long poulticed ; and you will also compre-
hend an occurrence of frequent experience, namely.
no THEBAPEUTICS OF CUTANEOUS DISEASE.
a kind of permanent ekzema, maintained by water-
dressing and oiled silk.
Alkohol we employ as a refiigerant for subduing
the heat and burning of local inflammation, and
especially in the diluted form to which we give the
name of evaporating and cooling lotion ; it is also
a stimulant, and by that property controls and
diminishes the relaxing effects of lotions in general.
As a solvent of certain substances, such as camphor,
soap, and perchloride of mercury, it is of much
practical usefulness in enabling us to employ
remedies which are insoluble in water alone, and
would otherwise be inefficient. We sometimes rub
down a drachm of alkohol with an ounce of the
benzoated ointment of oxide of zinc for the sake of
the cooling effect produced by evaporation ; a thin
fold of linen dipped in a lotion containing alkohol,
will reduce the heat and soothe the pruritus of an
ekzema capitis, a result of no mean consequence in
an unreasoning and irritable infant ; the combina-
tion of alkohol with soft soap and tar, made known
to us by Hebra, is a remedy of great value ; and
the spirituous solution of the perchloride of mercury,
familiar to all as Gowland's lotion, is also an excel-
lent remedy.
Powders are useful to relieve heat and irritability
of the skin, and also to absorb moisture ; they are
cooling and desiccant, and by combination may be
made antipruritic and mildly stimulant. We recog-
nise their value in erysipelas, in the popular appli-
cation of a layer of wheaten flour by means of the
dredger ; in the starch-powder and fiiller's-earth
employed in the excoriations and erythemata of
children and also of adults ; and in the moderately
stimulant properties of the pulvis cinchonas in
erythematous burns and scalds. The principal
forms of powder suitable to cutaneous purposes
are, starch, the pollen of the lycopodium, zinc,
calamine, silicate of magnesia or French chalk,
THERAPEUTICS OP CUTANEOUS DISEASE. Ill
and silicate of alumina and soda, or talc, &c. ; and
with these may be mixed other remedies, such as
camphor, carbolic acid, and perchloride of mercury.
Powder forms the Ughtest kind of dressing that can
be apphed to the cutaneous surface ; it excludes the
atmosphere, maintains a normally dry state of the
skin, and is easy of removal. But when these
conditions are altered, it may become an irritant ;
as in cases where exudation is copious, and the
powder masses together, or where it cakes and dries
up into hard and rigid clods.
Soap is a detergent and a solvent of the epi-
dermis ; it is therefore the means that we commonly
have recourse to for the sake of removing impurities,
such as discharges, crusts, and epidermic and seba-
ceous concretions and deposits. And it is also a
stimulant ; and we may remind you that moderate
stimulation is equivalent to a corroborant or tonic
action ; a tonic prescribed for internal use is a
stimulant ; externally, also, the stimulant is a tonic
when properly employed, and soap may be regarded
as the natural tonic of the skin. There would be a
great mitigation of cutaneous disorders if this truth
were accepted generally, and as generally acted
upon ; for to prejudice against the use of soap may
by traced a very considerable number of diseases.
Soap is also made available as the vehicle of several
medicinal substances ; for example : glycerine, cam-
phor, tar, carbolic acid, petroleum, and sulphur;
and the soaps, by these additions, may be soothing
and softening to the skin, or stimulant and desic-
cant, or even irritating. Price's glycerine soap is
one of the best of the softening soaps, and the
detergent and stimulant principles of soap ar^ well
illustrated by the tinctura saponis cum pice of
Hebra in its application to the treatment of lepra.
GLyoEEiNE, from the property of retaining its
moisture and resisting evaporation, is very valuable
in a dry and parched state of the skin; for the
112 THEBAPEUTICS OP CUTANEOUS DISEASK.
same reason it is a useful adjunct to lotions : it is
also important from its property of holding other
substances in suspension or solution, and of assum-
ing a semi-solid, or rather gelatinous form, when a
small quantity of starch is added to it, and the
mixture is subjected to a temperature of 240**.
The British Pharmacopoeia gives to these com-
pounds the name of glycerina; a more classical
term is one proposed by Dr. Frederic Farre, namely,
glycyria. We have already mentioned to you the
glycerine soap of Price's Company, which contains
upwards of 45 per cent., or nearly one-half its
weight, of the purest glycerine at present manu-
factured.
Oils and Fats harmonize with the epidermis and
blend with its structure; when smeared on the
skin, they form a dressing, which, like a varnish, is
almost impermeable ; it is to a great degree imper-
meable from within, and therefore it preserves the
natural moisture of the skin; and it is equally
impermeable to the atmosphere from without. We
have been in the habit of comparing a thin stratum
of fat with a water-dressing of the lightest and
least injurious kind, and we may remind you that it
was the chief protection on which the ancients
relied for the preservation of their wines. The
only word of detraction that can be urged against
oil and fat is their tendency to imdergo decompo-
sition by exposure to the air, and so to generate the
fatty acids which are irritating to the skin ; in
popular phrase, the fat becomes rancid. But, the
"vanity of woman,*' as old Oelsus observes, the
demand which the fair sex have made from time
immemorial upon the inventive genius of man to
supplv them with the means of improving and
seeming their beauty, has furnished us with a con-
trivance to prevent the rancidity of our oils and of
our ointments. First used by the French for the
perfection of their pomades, gum benjamin was
THEBAPEUTICS OP CUTANEOUS DISEASE. II3
suggested by Alexander Ure, to the celebrated
house of Jacob Bell for the preservation of their
ointments. It was first applied to the oxide of zinc
ointment for our purposes, and has since been
extended to the lard of which ointments are com-
posed, and equally to oils. The British Pharma-
copoeia has latterly adopted its use, and we may
almost say that no ointment or oil is suitable for
application to the skin that has not been previously
benzoated. As a maintainor and regulator of the
surface temperature of the body, oils and fats
possess remarkable virtues and remarkable power ;
with some of the nations of the world, oil is the
principal article of costume ; and, occasionally, to
an under-garment of oil they superadd a dressing
of desiccant powder.
Acids and Alkalies sometimes enter into the
composition of our local remedies to relieve irrita-
tion and pruritus ; sometimes as stimulants ; some-
times to prevent the formation of crusts, or as
solvents of the surface of the epidermis ; and some-
times to remove scales. Distilled vinegar and
hydrocyanic acid are both antipruriginous ; sulphu-
rous acid and acetic acid are stimulants. A soda-
bath or lotion is sedative and detergent; sapo
mollis or sapo viridis, is, by virtue of its alkaline
composition, an admirable remedy for the removal
of concretions and scales ; and ammonia is often a
valuable stimulant.
Vesicants are represented by cantharides in
various forms — ^in ethereal and acid solution, and
also in solution and suspension in fat. We rarely
have occasion to raise a blister ; but sometimes, as
in chloasmata and melasmata, we are called upon to
induce desquamation. And we further make use of
cantharides as a means of producing stimulation
short of vesication. Vesication may also be pro-
duced by ammonia, by kreoeote, and by the
oleum sinapis ; but these, like the preceding
1
114 THKRAPEUTICS OP CUTANEOUS DISEASE.
remedies, we employ only for their stimulant pro-
perties.
Caustics are acids or alkalies, or their salts ; of
the former we have the three mineral acids, nitric,
muriatic, and sulphuric, chromic acid, and arsenic ;
the principal acid salts being the nitrate of silver
and mercury, and chloride of zinc. Of these the
most important is the nitrate of silver, and next to
the nitrate of silver the potassa fusa, either solid
or in solution. For certain diseases of the skin,
caustics must always be ready to your hand; for
example, for lupus, for epithelioma, for angeioma,
and for morbid growths ; and we will venture to say
that you will find none more useful than the caustic
potash. Arsenic is sometimes employed as a caustic
for cancer ; but we believe it to be inferior to
potassa fusa and chloride of zinc, and dangerous,
from the Habihty of absorption into the system.
Under one head may be included the vegetable
PRODUCTS : wheaten flour, oatmeal, starch, and
linseed. Wheaten flour we have already mentioned
to you as a remedy for erysipelas. Oatmeal in the
form of a thin gruel is a valuable fomentation,
tranquilUzing and emollient. Starch is the principal
constituent, the diluent, in fact, of our cooling and
desiccating powders ; in decoction it is, Uke gruel,
soothing and sedative, whether as a fomentation or
as a bath ; and as a jelly, in its cold state, and
enclosed in a muslin bag, it constitutes a valuable
poultice. Linseed also is an excellent fomentation
when used in decoction, and our best poultice when
prepared with the meal.
Other products of the vegetable kingdom are
poppy capsules, bitter almonds, camphor, seeds of
the stavesacre, iodine, resin, and tar. A decoction
of the capsules of the poppy is a valuable sedative
fomentation. Emulsion of hitter almonds^ by virtue
of the contained prussic acid, is also a sedative in
pruritus. Oamphor^ in powder, soothes the pungent
THEBAPEUTICS OF CUTANKOUS DISEASE. II5
heat of erythema, relieves itching, and is a mild
stimulant to the skin ; and in the form of spirituous
solution, it enters into the composition of our
sedative lotions. The seeds of the stavesacre are an
efficient substitute for sulphur in the treatment of
scabies, and may be used either in tincture or in
ointment ; which are also antipruritic.
Iodine is a discutient, and is employed in the
simple state of spirituous solution or tincture, in
solution in glycerine, or in the form of iodic salts
of potash, sulphur, lead, or mercury. As a tincture
it produces stimulation of the skin and desquama-
tion of the epidermis, and by these properties is
usefiil in the removal of discolorations, such as
chloasmata and melasmata, and thickenings of the
epidermis, for example, callosities and corns. Its
combination with sulphur, the iodide of sulphur, is
the active ingredient in an ointment, which is the
njost effectual remedy we possess for the treatment
of sykosis.
Resin is the constituent of one of our most
valuable ointments, the yellow basiUcon, for the treat-
ment of broken boils, carbuncles, and chronic ulcers.
Tab, in its varied forms of pine tar, juniper tar,
birch tar, beech tar, and coal tar, is antipruritic
and stimulant. As an antipruritic it is combined
with soft soap and alkohol to form a lotion ; it is
also employed for the same purpose as an ointment
in a diluted form; but as a stimulant it may be
used in its pure state or as a more concentrated
ointment, and apphed with more or less friction.
In the same group must be included the so-called
mineral tar or coal tar and the Barbadoes tar ; for
coal tar can only be regarded as the product of
destructive decomposition of wood, and coal tar
has of late been adapted to our purposes by in-
corporation with soap, and also in the compound
which goes by the name of liquor carbonis
mineraUs.
I 2
Il6 THERAPEUTICS OP CUTANEOUS DISEASE.
Also intermediate in origin between the vege-
table and mineral kingdom is carbolic or plienic
acid, a valuable cutaneous sedative and stimulant.
It enters into the composition of a very useful
soap; in conjunction ^th glycerine it forms an
antipruritic lotion; and as a lotion, or in com-
bination with ointment, is antagonistic of pyo-
genesis. Lately it has been used by Dr. Yates,
of Kingston, in Canada, as a constituent of an ektro-
tic ointment in the treatment of variola, and, as he
informs us, with remarkable success ; and it would
seem to be especially valuable wherever a purulent
discharge is in process of formation by the skin.
From the mineral kingdom we derive a store of
valuable remedies ; for example : zinc, lead, silver,
mercury, and sulphur.
ZiNO as an oxide is a constituent of our best
powder and our best ointment; as a carbonate
under the name of calamine, it is also used as a
powder and an ointment ; and as a chloride it
constitutes a useful lotion and caustic. The oxide
is desiccative, protective, and sedative. The oint-
ment, in its benzoated form, is also protective and
sedative ; while the chloride, in various degrees
of dilution, is stimulant, antipyogonic and destruc-
tive of lowly-vitalized cell-structures.
Lead is sedative in its more useful forms, namely,
as an acetate, constituting the saturnine lotion of
various degrees of strength ; in the state of car-
bonate, and used as a desiccant powder ; and also
as a carbonate, and in combination with benzoated
lard constituting an ointment.
Silver, in combination with nitric acid, and pro-
ducing a nitrate, is a remedy of considerable im-
portance ; applicable in solution in water or nitric
ether of every degree of strength, and applicable
also in its solid form. According to the manner of
its use it may be a sedative, a stimulant, an irritant,
or a caustic. In an irritable state of the tissues no
THERAPEUTICS OP CUTANEOUS DISEASE. II7
remedy restores the healthy balance of action, and
quiets refractory nervous excitement so quickly as a
lotion of nitrate of silver. It converts at once the
most perverse irritability into a quiescent normal
process and produces the state of calm which is
necessary for cure. Hence we find it of service in
chronic ekzemata, in chronic ulcers, and in local
pruritus. The name of Higginbottom, of Notting-
ham, is associated with its application to erysipelas,
apparently on a similar principle ; and it is destruc-
tive of lowly-vitalized tissues and thereby assumes
the character of caustic. Hebra advises and uses
it in lupus, wherein it not only destroys the crude
granulations, but promotes a more healthy nutrition
of cell growth. Btit as a caustic for other than
the most trivial purposes it is in nowise reliable ;
and for epithehoma and angeioma should never be
trusted.
MBECUBy supplies us with a host of valuable
remedies, of which we may enumerate the sub-
chloride amd perchloride, the latter commonly em-
ployed in the form of lotion ; and the red oxide,
the nitrate, the ammoniated, and the red and green
iodide in ointment. The lotion of the subchloride
of mercury and lime-wat^r we employ in ulcerating
dermato-syphilis. The perchloride of mercury in
solution in emulsion of bitter almonds is the famous
Gowland's lotion. The ointment of the red oxide
diluted with benzoated lard, in the proportion of
one to three is the best possible remedy for pity-
riasis, and the ointment of the nitrate and am-
moniated mercury excellent discutients of chronic
ekzema. Active inunctions with the mercurial
pomade are useful in some forms of syphiloma ; the
green iodide of mercury ointment is sometimes
appHed with advantage in lepra ; and the acid
nitrate is suitable in lupus.
SuLPHUB is presented to us as the immemorial
cure of scabies, the parasiticide of the acarus
Il8 THEEAPEUTIOS OP CUTANEOUS DISEASE.
scabiei ; and is also of value in the treatment of
akne, of gutta rosea, and sykosis. It exists in
solution in the liquor calcis pentesulphidi, or solutio
sulphuris cum calce, the remedy employed in
Belgium for the ** speedy cure," the two-hour
cure, of itch. As an ointment, we have the simple
unguentum sulphuris of the British Pharmacopoeia,
which is improved in efficacy by the addition of
carbonate of potash, and used for a similar purpose.
For akne and gutta rosea the best-known remedy is
the unguentum sulphuris hypochloridi compositum,
omitted by the British Pharmacopoeia, and for
sykosis, the most efficient local application is the
unguentum sulphuris iodidi.
The constitutional bemedie^ at our command
are : antiphlogistics, aperients, alteratives, and
tonics. First among antiphlogistics are effer-
vescent salines, which facilitate secretion and allay
irritability.
Aperients exist in abundant store among the
neutral salts, and especially sulphate of Diagnesia ;
in vegetable extracts, such as colocynth, scammony,
rhubarb, belladonna, and hyoscyamus ; and in the
oxides and salts of mercury.
Alteratives are found in sarsaparilla, dulcamara,
and tar, in the vegetable kingdom ; and among
metals, iodine and mercury.
Tonics also occur in great variety, and with an
equal variety of uses ; some being assimilative tonics,
such as vegetable bitters and the mineral acids ;
some nutritive tonics, such as cod-liver oil and
phosphoric acid ; some blood tonics, for example
iron and perchloride of mercury ; and some nerve
tonics, such as quinine and arsenic.
Of all these remedies we shall have occasion to
speak in their application to the treatment of the
different diseases, and that occasion will be the
most suitable for their further consideration. They
will then be ranged opposite the symptoms and the
CLASSIFICATION OP CUTANEOUS DISEASES. 11 9
morbid phenomena which they are called upon to
control, and their more attentive investigation and
study will awaken a Kvelier interest than can be
the case in their more general and abstract exami-
nation.
OuB inquiries have led us, up to this time, to the
study of the skin in health and the skin in disease ;
or, more in detail, to the study of the Anatomy, the
Physiology, the Pathology, the Etiology, and the
Therapeutics of cutaneous diseases.
We have next to announce to you that the recog-
nized forms of cutaneous disease are very numerous,
nearly one hundred in number, and that a necessity
thereby arises of arranging them according to some
convenient plan ; such an arrangement would con-
stitute a classification of diseases of the skin. The
individual diseases you are not supposed to be
acquainted with yet, but the basis of their classifi-
cation is comprehended in our previous studies of
the anatomy, physiology, pathology, etiology, and
therapeutics of the skin.
Thus if we take the anatomy of the skin as a basis
of classification, we might arrange a series of groups
under different heads, thus : diseases of
Epidermis Nerves
Rete mucosum Papillae
Papillary layer Hair
Fibrous layer Sebiparous glands
Vessels Sudoriparous glandB.
Again, if we were to select the physiology of the
skin as our basis, we might form other series of
groups, for example : diseases of
Circulation Secretion
Nutrition Innervation .
120 CLASSIFICATION OP CUTANEOUS DISEASES.
How simple it would be to arrange every known
disease of the skin under these separate heads, and
the result could not be otherwise than instructive ;
nevertheless, these are not the framework usually
accepted for the purpose, and therefore we proceed
to another basis, namely, that of pathology. The
pathology of the skin introduces us to those changes
of structure which have been denominated lesions^
and the lesions are so striking in their dissemblances
that they very naturally suggested to earlynosologists
a mode of classification which was accepted many
years since Avith universal approbation and has
remained very popular until a recent period. The
elemental foundation of the classification of lesions
is the appearance of the disease ; for example, its
redness, papulation, vesiculation, pustulation, squam-
ation, tuberculation, or macula tion and discolora-
tion. And upon this basis, the celebrated nosologist
Plenok, in the first edition of his work published in
1776, raised up a scheme of arrangement which
consisted of fourteen classes, for example : —
1. Macular 8. Callositates
2. Pustula9 9. ExcrescentiaD
3. Vesiculae 10. Ulcera
4. BuUaD 11. Vulnera
5. PapulaD 12. Insecta
6. Crusta9 13. Morbi unguium
7. Squamas 14. Morbi pilorum.
Such a classification as this, so far as heads of
groups are concerned, leaves little more to be desired.
With the most critical eye, we can discover scarcely
anything to be wanting ; the glandular apparatus of
the skin alone needs a place — the sudoriparous
apparatus and the sebiparous apparatus having been
unfortunately omitted.
To the classification of Plenck succeeded that of
WiLLAN, £|,nd Willan, it is to be supposed, — ^repre-
CLASSIFICATION OF CUTANEOUS DISEASES. 121
senting a department of medicine which had been
neglected since the days of Daniel Turner, nearly a
century before, — ^with the view of presenting to his
disciples the philosophy of the skin in the most
simple shape, abbreviated the method of Plenck
very considerably. It is to be remembered also that
we are here dealing with a nosologist, side by side
with a practical physician, and that that which might
have been considered of importance by the former,
may have been thought unnecessary by the latter.
But whatever may be the explanation which may
find acceptation in your mind, the fact remains the
same, that several valuable heads existing in the
classification of Plenck, are omitted by our country-
man Willan, for example : — crustaD, callositates, ex-
crescentiaB, ulcera, vulnera, insecta, morbi unguium,
and morbi pilorum ; and we find here a practical
illustration of the fact, that diminution in the
number of heads does not necessarily conduce to
the clearness and plainness of a subject.
Willan's classification, bearing date 1790, is
composed of eight groups, which he names orders of
the class of cutaneous diseases, and these eight
orders contain somewhat more than forty genera.
The eight orders of Willan are : —
1. Papulae 5. Pustulae
2. Squamae 6. Vesiculae
3. Exanthemata 7. Tubercula
4. Bullae 8. Maculae.
You will observe in these orders the absence of
any place for vulnera, insecta, morbi unguium and
morbi pilorum ; the reason for the omission in the
case of vulnera is made obvious by reference to the
members of that group admitted by Plenck, which are,
excoriatio, scissura, pressura, morsus, punctura, and
ictus ab insecto. Willan might have concluded that,
in the first place, these were not cutaneous diseases
122 CLASSIFICATION OP CUTANEOUS DISEASES.
proper ; and secondly, that they were surgical rather
than medical in their nature; nevertheless, scalds
and burns would have been safely located under
this head. The inseota of Plonck includes, phtheir-
iasis, holmintiasis, malis, and crinones ; but Willan
very possibly omitted them for similar reasons to
those wo have just stated. Morbi unguium and
morbi pilorum, however, are serious defalcations,
and the only excuse for their omission must have
boon the want of knowledge of the anatomy and
physiology of the organs concerned, and, as a natural
consequence, of their pathology. The crusta9 of
Plenck, consisting of crusta, eschara, achores, crusta
capitis neunatorum, crusta lactea, tinea, mentagra,
malum mortuum, exanthema labiale, and exanthema
subaxillare, would all meet with a better and more
appropriate resting-place among the orders of Willan
than by themselves, ^vith one exception, namely, the
crusta capitis neunatorum, that is, the concretion of
sebaceous matter termed vemix caseosa occurring
on the scalp of young infants, which would neces-
sarily be referred to the sebiparous system. The
callositates of Plenck, * namely , callus, cicatrix, and
clavus, are transferred by Willan to his very hetero-
geneous order, tubercula. Neither can we be sur-
prised that the ulcera cutanea of Plenck, namely,
excoriatio purulenta, intertrigo, aphthas, fissurae, and
rhagades, should have failed to find favour with
Willan. For we must admit that we should have
been as little disposed ourselves to give them so
distinct and prominent a plaoe. All, therefore, that
remains to be said as to the comparison of the
methods of Plenck and Willan is, that whereas a
knowledge of the pathology of the glandular system
of the skm would have contributed towards the per-
fection of the classification of the former, yet,
that the latter has helped us as little in the same
direction. And while we give expression to our
admiration of the system of Willan as adapted to
CLASSIFICATION OF CUTANEOUS DISEASES. 1 23
the century which is past, we must also declare its
imperfection, as suited to the wants of the present
advancing age.
In 1826 a^great step in the forward direction was
made in the classification of these diseases by the
publication of the work of the distinguished Rayee.
Rayer takes as his basis both the anatomy and the
pathology of the skin, and was the founder of the
first anatomico-pathological classification. Anatomy
supplied him with his primary divisions ; while his
secondary divisions are founded on the pathological
lesions.
PBiMAEy Divisions.
1. Diseases of the skin.
2. Alterations of the appendages of the skin.
3. Foreign bodies observed on the surface or in
the substance of the skin.
4. Diseases primarily foreign to the skin, but
which sometimes produce peculiar alterations
in that membrane.
Sbcondaey Divisions.
a. Inflammations of the skin.
h. Cutaneous and subcutaneous congestions and
haemorrhages.
c. Neuroses of the skin.
d. Alterations in the colour of the skin.
e. Morbid secretions.
/. Defects of conformation and texture, hyper-
trophies and accidental productions.
g. Alterations of the nails, and of the skin which
produces them.
h. Alterations of the hair, and of the follicles
which produce it.
Now, if we compare this ample and admirable
classification with those of Plenck and Willan, and
especially with that of the latter author, we shall
124 CLASSIFICATION OP CUTANEOUS DISEASES,
find nearly the whole of Willan's orders absorbed
by the first of the secondary divisions, namely,
"inflammations of the skin," which includes the
eleven following groups : —
Bxanthematous Papulous
Bullous Tuberculous
Vesiculous Squamous
Pustulous Linear
Furunculous Gangrenous
Multiform.
Two years later, namely in 1828, Biett in his
excellent lectures, edited by Cazenave and Sohedel,
fell back upon the pathological scheme of Willan,
adding to the original eight orders, seven additional
ones, as follows : —
Lupus, Elephantiasis Arabum,
Pellagi'a, Sebaceous follicular
Syphilida, diseases,
Purpura, Cheloides.
GiBEBT, in ] 834, confined himself strictly to the
eight orders of Willan ; limiting the scope of his
book almost entirely to that of its title, namely, a
practical treatise on the special diseases of the
skin.
Deveegie, in 1854, again, revives the anatomico-
pathological scheme so ably planned by his prede-
cessor, Kayer. In the second edition (1857) of his
practical treatise on the diseases of the skin, he
divides them into : —
Diseases of the skin.
Diseases of the hair.
Diseases of the nails,
including under the first head : —
CLASSIFICATION OF CUTANEOUS DISEASES. 1 25
Erythematous diseases,
Vesiculous and bullous diseases,
Pustulous diseases,
Papulous diseases,
Tuberculous diseases,
Epidermic, squamous, and horny diseases.
Sebaceous diseases,
Chromatous diseases,
Haamatous diseases,
Diseases of vegetable production.
Diseases of animal production.
Compound forms.
Thus, gentlemen, you will perceive that the
anatomico-pathological classification is deserving of
our deepest respect; it has been considered and
reconsidered by a succession of our most eminent
dermatologists, namely, by Plenck, Willan, Eayer,
Biett, Gibert, and Devergie ; has existed for nearly
a century ; and has received such modifications at
the hands of its supporters as were likely to con-
duce to its perfection. Nevertheless, it will perhaps
occur to you, that the signs by which the difierent
groups are known, are too superficial, too trivial,
and too artificial. When Plenck made distinct
groups of vesiculas, pustulas, and crusta3, Willan
perceived that as crusta3 might very possibly be
simply a declining stage of vesiculas or pustular, it
became necessary to take the mature condition of the
eruption as the standard of classification ; hence, in
the hands of Willan, exanthemata, vesiculae, pustula),
&c., represented the acme of development of the
disease, and the group of crust® was abandoned as
calculated to lead into error. Again, in reference
to its artificial character, the anatomico-pathological
classification has been compared to the LinnaBan
classification of plants, and, like the latter, has
been accused of being open to the objection of
separating rather than of drawing together, and of
126 CLASSIFICATION OF CtJTANEOUS DISEASES.
afifording little information beyond that which tends
to diagnosis.
A similar train of reasoning possibly induced
Jussieu to dissent from the classification of the
vegetable kingdom by Linnseus, and to raise up in
its place a system which should draw his subjects
together into families possessing mutual depend-
encies and relationships, in a word, into natural
families, and his system was in consequence, termed
the natural system. An arrangement of diseases of
the skin which should prove capable of grouping
together diseases similar in their nature, causes, and
treatment, was an idea worthy the pains of elabora-
tion. Certain diseases pointed naturally to such a
mode of grouping, for example, the diseases origi-
nating in the poison of syphiUs, in the kachexia of
scrofula, and in that of cancer. The question then
arose : Would the great bulk of diseases of the
skin be equally submissive to a similar arrange-
ment ? The honour of making the effort is due to
Alibert who in the year 1810, pubhshed his classi-
fication; in this classification he grouped together
the whole of the diseases of the skin under twelve
heads, which he termed the twelve branches of the
" Arbre des Dermatoses." The basis of his system
derived nothing fi'om anatomy, it was purely patho-
logical, and for the most part dermato-pathological ;
its divisions being as follows : —
Ekzematous Syphilous
Exanthematous Strumous
Tineous Scabious
Dartrous Ha3matous
Cancerous Dyschromatous
Leprous Hetero-morphous.
The term ekzematous, Alibert employs in a sense
peculiar to himself, namely, as synonymous with
"eruptive," and quite independently of the disease
CLASSIFICATION OF CUTANEOUS DISEASES. I27
ekzema ; it represents, in fact, eruptive diseases or
eruptions, suoli as erythema, erysipelas, pemphigus,
herpes zoster, urticaria, anthrax, furunculus, &c.
The exanthematous dermatoses are : — variola, vari-
cella, roseola, rubeola, scarlatina, &c. The tineous
dermatoses are the affections of the tinea family.
Then comes the family of the dartres or tetters^ to
which belong lepra, psoriasis, pityriasis, akne,
sykosis, impetigo, and lupus. The cancerous group
speaks for itself. The leprous group is devoted to
elephantiasis. The syphilous, strumous, and scabi-
ous groups are also self-confessed. The haematous
group is represented by purpura. The dyschromatous
group includes discolorations ; and the heteromor-
phous group, such diseases as fail to fit in nicely
with the preceding groups.
Alibert remained for a long time without a dis-
ciple. " There is a fantastic air about his scheme ;
a tree of dermatoses ; the trunk of the tree repre-
senting the skin, its limbs the genera of diseases ;
its branches, species ; and the twigs, varieties ; he
committed the error, moreover, of changing fa-
miliar names for others that were new, harsh-
sounding, and difficult of pronunciation." Such
is the criticism of his countryman Hardy, who,
nevertheless, recognizes in the system sufficient
points of importance to make it the basis of his
* own classification. It is, he says, philosophical ;
it enables us to class the diseases in accordance
with their affinities and their diversities ; it is, he
thinks, the sole truly practical method of consider-
ing and treating cutaneous diseases ; and he
adopts it as a means of throwing up into strong
relief the cause, the most characteristic phenomena,
and the therapeutical indications, in opposition to
fine-drawn distinctions and variable pathological ap-
pearances. What matters, he observes, whether an
eruption appear in the guise of vesicles or pustules,
the essential matter for the true physician, who
128 CLASSIFICATION OP CUTANEOUS DISEASES.
studies disease for the purpose of discovering its cure,
is to know if it be accidental or constitutional ; if it
will disappear spontaneously at the end of a given
time, or if it be curable only by a well-conceived and
steadily-pursued course of treatment.
After such a commentary, Habdy, in 1856, " pro-
poses a natural classification, which resembles in
several points that of Ahbert; and he groups
diseases of the skin into ten classes," thus : —
1. Maculaa; difformitates 6. Dartres
2. Local inflammations 7. Scrofulides
3. Parasitic afiections 8. Syphilides
4. Eruptive fevers 9. Cancers
5. Symptomatic eruptions 10. Exotic affections.
The term " skin,** as commonly employed, has a
double signification, according as it may be used
in a special or in a general sense ; in the former
case it applies to the derma only ; in the latter it
comprehends, besides the derma, the dermal appen-
dages, namely the glands and the hair. Willan,
Gribert, and Hardy treat of the diseases of the skin
special, in their classification ; Rayer and Biett em-
brace in theirs the consideration of the appendages
also, the former fully, the latter partially ; but the
skin special is only a part of the skin, and the.
classifications founded upon it alone, can only be
regarded in the light of imperfect classifications.
Such, in fact, is the classification of Hardy, who is
under the necessity of supplementing his scheme by
a heteromorphous group, namely, maculae and defor-
mitates, which is composed of corresponding affec-
tions of the —
a. Chromatogenous d. Papillary apparatus,
apparatus, e. Epidermic apparatus,
b. Vascular apparatus, and
c. Follicular apparatus, /. Derma.
CLASSIFICATION OP CUTANEOUS DISEASES, 1 29
And ftirthermore, these six groups of his first class
contain no less than nineteen species.
But our business is not to criticise ; it is simply
to place before you the various schemes of classi-
fication by which dermatology has been compli-
cated ; to point out to you the basis on which they
rest ; and, if possible, to convince you that there
is an unity in the plurality, an unity which is easily
fathomed, and renders their comprehension very
simple, and their investigation an useful exercise.
We propose, in fact, and have undertaken, to
classify the classifications, and we trust to be able
to make clear, that which, at the first glance seems
a heap of confusion. Hardy's classification will
serve to illustrate one of the errors of classification
which is very objectionable, namely, the profession
of dividing a subject with fairness into a small
number of heads ; and then giving to one head a
preponderating share of the whole. It would be
more just, and equally convenient, to adjudicate
more fairly in the beginning, by declaring a larger
number of recipients. Hardy's classification pro-
fessedly consists of ten heads ; but by taking in the
sections, it really presents sixteen heads. Again,
he has to divide under six heads, fifty species ; but
of these fifty, nineteen, or more than one-third of
the whole, fall to the lot of the class of sundries
accumulated under the head of maculsB and difibrmi-
tates. But, we make these remarks not in the
sense of adverse criticism, but simply to show that
classification of diseases of the skin has its difficul-
ties, which are not surmounted by the mere an-
nouncement of a new classification, Devergie offers
another criticism against existing classifications,
which is, that they assign no place to compound
forms of disease.
The simplest idea of the pathology of the skin that
can be presented to the mind, is that which is con-
veyed by the more obvious of the appearances of the
K
130 CLASSIFICATION OF CUTANEOUS DISEASES.
morbid changes in the dermal tissues, the so-called
lesions, for example, the papulae, vesiculsB, pustulae,
squamsa, and so forth ; hence these terms have
become fixedly identified with dermatopathia, and
find admission into the ranks of every classification,
however much it may be sought to exclude them as
the actual basis. We have shown that it is this
conception of the pathology of the skin which was
seized upon by Plenck and adopted by Willan, as
the foundation of their classification ; and we may
observe further, that such a scheme of arrangement
may very justly be termed the
DeEMATO-PATHO LOGICAL CLASSIFICATION.
Then, as we have already explained, Alibert in-
vented an arrangement founded on the mutual
resemblances of these diseases, and distinguished
his scheme by the name of natural classification ;
this we may in like manner, and with like propriety,
term the
HOM(EO-PATHOLOGICAL ClASSIFIOATION.
And in the third place we have to call your
attention to another classification, which is intended
to identify the pathology of the skin with that of
the general system ; this is the arrangement pre-
sented to us by Hebra, and this we may fairly
designate the
Systemato-patholoqical Classification.
Hebra was led to the construction of his classi-
fication by the desire of developing a scheme which
should realize the idea of uniformity of all the diseases
of the body, whether cutaneous or systemic. He
projected this arrangement in 1844, but he scarcely
does himself justice by naming it the pathologico'
anatomical classification ; for we believe that the
term which we have just assigned to it more fairly
expresses its merits. His groups or classes are
CLASSIFICATION OP CUTANEOUS DISEASES. I31
twelve in number, but might, he observes, have
been reduced to eleven or even to ten, for the
separation of malignant from innocent growths is
uncalled for, and possibly incorrect in a histo-
logical point of view, while ulcers might have been
omitted completely. His twelve classes, therefore,
are : —
1. HyperaemisB 6. HypertrophisB
2. Anaemiaa 7. Atrophias
3. Anomaliaa secretionis glan- 8. Neoplasmata
dularum cutanearum 9. Pseudoplasmata
4. Exudationes 10. Ulcerationes
5. HsBmorrhagiaB 11. Neuroses
12. FarasitsB.
It will be seen that the two first classes depend
upon the amount of circulation in the derma;
whether in excess, hypercemiay or deficiency, ancemia.
The third class is devoted to the glandular in-
growths of the skin, the sebiparous and sudori-
parous glands. The fourth and fifth classes com-
prehend exudations from the bloodvessels, whether
of the colourless portion of the blood or of inflam-
matory products, exudationeSy or of the red consti-
tuents of the blood, hcemorrhagice. Then follow
four classes, comprehending nutritive changes in
the skin, namely, hypertrophiaj atrophia, neoplas-
mata (homceoplasia) or new formations of innocent
nature, and pseudo-plasmata (heteroplasia) or new
formations of a malignant character. Next we find
ulceration of the skin ; nerve diseases or neuroses ;
and lastly, cutaneous parasites^ whether belonging
to the animal or to the vegetable kingdom.
It is impossible to reflect upon this scheme of
classification without a feeling of admiration for its
comprehensiveness ; but the thought involuntarily
intrudes itself, that it may be too general and too
comprehensive, that it is fitted for the master and
K 2
132 CLASSIFICATION OF CUTANEOUS DISEASES.
for the professor rather than for the student and
the practitioner. The student demands a simpler
and easier introduction to the study of dermato-
pathia ; the practitioner one which is more practical.
If we were to analyze the scheme critically, we
might find that hypera^mias includes only a part of
the hyperasmic diseases, and that exudation is very
commonly present wherever hyperemia exists;
hence, a further illustration is required than that
which is conveyed by the mere designation of the
class.
In our own early studies of dermatopathia (1842)
we endeavoured to correct the omissions of Willan
by taking the anaiomy of the skin as our basis,
and grafting upon this foundation a pathological
arrangement of its diseases : thus we proposed in
the first inst^mce four primary divisions^ consist-
ing of : —
1. Diseases of the Derma
2. Diseases of the Sudoriparous Grlands
3. Diseases of the Sebiparous Glands
4. Diseases of the hair and hair-follicles.
The diseases of the derma were, inflammation,
hypertrophy of the papillaa, and disorders of the
vessels, nerves, and chromatogenous function. The
diseases of the glandular apparatus included, aber-
rations of secretion, aberrations of elimination, and
inflammation of the glands. And the diseases of
the capillary organs, aberrations of growth, quantity,
colour, and direction, together with derangements of
formation and disorders of the follicles.
But however complete, for scientific purposes, a
classification may be that is founded on a structural
basis, the practitioner cannot fail to experience a
yearning desire to possess himself of an arrangement
that shall lead upwards to a practical purpose ; in
fact, to the treatment of disease. It was this desire
v'>
CLASSIFICATION OF CUTANEOUS DISEASES. 1 33
.that prompted us, in 1851, to publish a scheme
fouuded upon the supposed cause of these diseases,
and which we named " etiological classification."
According to this plan, we divided diseases into such
as arise from —
1. General causes; e.g.^ nutritive, assimilative,
and nervous debility
2. Special external causes
3. Special internal causes
4. Poison of syphilis
5. Poisons of unknown origin.
But a new train of thought was suggested to us by
some researches into the statistics of cutaneous dis-*
ease, with which we were engaged in 1864. In an
analysis of a large number of cases we found one
disease, namely Ekzema, stand forth so prominently
before all the rest, occurring in the ratio of nearly
thirty-four per cent. (33'54), that is, one-third of
the whole number of diseases of the skin, — that we
were led to believe that, both for educational and
practical purposes, ekzema should be made the
standard of cutaneous disease, the first to be studied
by the student, the chief to be comprehended and
mastered in all its details by the practitioner. In
other words, the practitioner who knows ekzema
alone, already knows one-third of all the diseases of
the skin ; for every third case that comes before him
will probably be a case of ekzema. Here, it must be
allowed, there is something practical ; and there
would be something practical in a classification which
should be founded upon this idea ; practical, in me-
dicine, is synonymous with clinical; and the reality
is brought home to us when we have placed before
our minds the idea of a " clinical classification."
Moreover, ekzema is essentially a multiple disease,
and in the subdivisions of Willan its varieties would
find, indeed have found, a place in each and every
134 CLASSIFICATION OP CUTANEOUS DISEASES,
one of the eight orders of that classification ; so that
in the study of ekzema alone, we are enabled to ob-
serve the pathological lesions which form the basis
of the entire classification of Willan ; for ekzema is
constantly papulous^ sometimes squamous^ frequently
exanthematouSf often hdlousy very Qovaxnovly pustxi-
lou8 and vesiculous^ sometimes tuherculovSi* and oc-
casionally maculcms.
Need we tell you, gentlemen, that with these re-
flections forced upon our contemplation, the clinical
CLASSIFICATION became a necessity of our mental
organization; and we now place before you the
results. Indeed, as we have before said, upon this
plan we teach ; upon this we practise ; and upon
this we propose to arrange the subjects of our lec-
tures. Our clinical classification of cutaneous afiec-
tions comprehends the —
A. — 1. Ekzematous D. — 10. Exanthematous
2. Erythematous 11. Syphilitic
3. Phlyktfenous 12. Elephantous
4. Dothienic E. — 13. Chromatopathic
B. — 5. Neurotic 14. Epidermic
C. — 6. Nutritive 15. Onychopathic
7. Leprous F. — 16. Trichopathic
8. Strumous G. — 17. Steatopathic
9. Carcinomatous 18. Idrotopathic
H. — 19. Traumatic.
You will observe that we have divided our nine-
teen groups into seven collective groups or families,
of which A represents simple inflammation of the
skin ; B, afiections of the nerves ; C, disorders of
liutrition; D, blood-poisons; E, affections of the
epidermis ; F, affections of the hair ; 6, affections of
the glands ; and H, injuries of the skin. The groups
are all pathological, and several enjoy the advantage
of being homoeopathological. While, if we were dis-
* Vide Chapter lY, and Index.
' >
CLASSIFICATION OF CUTANEOUS DISEASES. 1 35
posed to attach any importance to a small number of
heads, we might say that the chnical classification is
composed essentially of eight groups only, the same
in number but more comprehensive than those of
Willan himself; for example : —
1. Inflammation 5. Epidermic
2. Neurosis 6. Trichopathic
3. Nutrition 7. Adenopathic
4. Ezanthematic 8. Traumatic.
The CAUSE of cutaneous diseases, actual or pre-
sumed, has in its turn suggested to the mind of
thoughtful men several schemes of classification.
The mother idea of constitutional or local, had already
attracted the attention of the Fathers of Medicine ;
and, at this moment, you will be frequently inter-
rogated by your patients as to the fundamental cause
of the disease, namely, whether existing in the skin,
or in the system. As a knowledge of the cause of
disease is the only rational foundation of treatment,
the subject is not without its interest and import-
ance. Lorry, for example, in 1777, adopted for the
arrangement of the subject of his " Treatise on
Cutaneous Diseases,'' an etiological classification.
He divided those diseases primarily into —
1. Symptomatic affections ; or such as were deter-
mined to the skin by some internal disease ;
2. Idiopathic affections ; or such as originate in
the skin itself;
And in both of these groups he treated separately of
diseases attacking the general surface, and diseases
of parts of the surface only. The sub-groups of his
primary division
Acute affections, not critical ; acute affections,
critical ; and non-acute ehminatory affections.
136 CLASSIFICATION OP CUTANEOUS DISEASES.
While those of his second group are —
Diseases involving the entire organization of the
skin;
Diseases producing deformity ; and
Diseases resulting from poisons ;
The diseases of particular parts of the skin being
those of — the hair and scalp ; the face ; the trunk of
the body ; and the limbs. And to this same cate-
gory of classification may be added our own arrange-
ment of 1857, namely, into general and special causes,
external and internal, syphOitic, and others of poison-
ous origin.
A classification, to be a classification, must pre-
sent a certain homogeneity of character ; its primary
divisions should be capable of comprehending every
possible form of the objects to be classified ; and,
therefore, its groundwork must necessarily be very
general. Simple and general are the terms properly
applicable to a sound classification ; but there exists
a great temptation to nosologists of special subjects
to compress more than enough into their classi-
fications, and thus give them a heterogeneous cha-
racter; and this is especially the case when the
assumed basis of the classification is itself uucertain
in its nature. Hence the diflBculty, and we might
almost say, the unfitness of " cause," as a founda-
tion for a general arrangement. In the word cause,
dififerent men may see dififerent things, and, as you
know well, there really exists a great variety of
causes ; there may be a primary cause with a suc-
cession of secondary causes, a proximate and a re-
mote cause, a precQsposing and an exciting cause,
a positive cause and a theoretical cause. Therefore
you will perceive an obstacle in dealing with such
classifications ; and understand the difficulty which
we feel in our endeavour to present to you a classi-
fication of classifications.
An able, but imaginative, French dermatologist.
<
CLASSIFICATION OP CUTANEOUS DISEASES. 1 37
Baumes, published in ] 842 a work entitled " New
Dermatology," founded on " a new medical classifi-
cation." Baumes begins by assuming a distinction
between dermatology and dermatography ; his der-
matological considerations comprehend his special
views of a new etiological classification ; the der-
matographical part of his work is simply the ordinary
description of cutaneous disease. In disease of
whatever kind he recognizes deranged vital action
concentrated in the suffering part, and this theoret-
ical condition he distinguishes hj the term ^'fliixion.**
In what other way, he observes, can we explain a
phenomenon of hourly occurrence, — a suppression of
haemorrhoids, succeeded by a bilious disorder ; this
by an epistaxis ; epistaxis by pain and swelling of
the joints and muscles, otherwise a rheumatism;
rheumatism by a cutaneous eruption ; then a neu-
ralgia ; afterwards a diarrhoea ; the whole concluding
with a return of the lost haemorrhoids ? The hae-
morrhoids, according to him, are the expression of
a deranged vital action ; and the cure of the substitu-
tive disorders, is the restoration of the haemorrhoids;
in these phenomena he perceives nature's cure, and
he goes no further ; the phenomenon, the fluxion,
he takes to be an unknown quantity, an a?, a given
starting-point ; although he admits, that as the
nervous system is the most hkely repository of vital
force, the phenomenon may, in its origin, be essen-
tially neurotic. So absorbed is Baumfes in his
attractive theory, that he ventures to repudiate
pathological considerations altogether, one may say,
he observes, that pathology is a complete nullity.
Having, therefore, settled his unknown quantity, his
fluxion^ he .proceeds to distinguish seven forms of
fluxion, namely : — from exterior cause, reflex, sub-
stitutive, eccentric, diathetic, idiopathic, and com-
plex ; and these supposed causes he applies to the
different forms of disease accumulated in the several
orders of Willan.
138 CLASSIPICATIOS OF CUTAXEOCS DISEASES.
Our accomplislied contemporary Bazin proposed
in 1855, anew method of viewing cutaneous diseases;
he objects to the methods of Willan, Rajer, and
Alibert, that they confuse together the disease, the
affection, the lesion, and the symptom. It may not
have occurred to jou before that such a distinction
as Bazin refers to, really exists ; but if we take any
one disease, such as ekzema, to test his argument,
we shall perceive that the disease impUes the cause,
the affection the assembled characters which dis-
tinguish the disease, the lesions the objective
phenomena, and the symptoms the subjective pheno-
mena. Hence Bazin entitles his work, published in
1862, " Lectures on the Generic Affections of the
Skin ; " he insists on the necessity of searching out
in every affection its primitive element, its kind, and
its natiu*e. And he proposes as an illustration of
his views, to divide cutaneous diseases into two
primary classes, namely : —
1. Affections in course of evolution; and,
2. Affections arrested in evolution.
The first class embraces two orders, external
cause and internal cause ; and the second, accidental
and idiopathic cause. As may be inferred, the
diseases of internal or constitutional cause greatly
predominate over the rest, and in this order we find
eight sections and numerous subsections. You may
judge of the nature of the sections by their titles,
for example, they are : —
1. Pestilent 6. Haemorrhagio
2. Febrile 7. Symptomatic of con-
8. Exanthematic stitutional disease
4. Pseudo-exanthematio 8. Symptomatic of dia-
5. Phlegmatic thesis.
Here, gentlemen, you will see evinced one of the
faults of the medical classifications ; the accumula^
CLASSIFICATION OP CUTANEOUS DISEASES. 1 39
tion under a single head of a large majority of the
whole of the diseases of the skin ; and how can it
be otherwise, the symptomatic affections are un-
doubtedly more numerous than the idiopathic affec-
tions, and the symptomatic affections necessarily
embrace every variety of pathological change of which
the skin is susceptible. Thus under the seventh
section of the second order of the first class we
find included five important svhsections or genera,
namely : —
a. Herpetides c. Scrofulides
b. Arthritides d. Syphilides
e. Leproides.
And these five genera, or rather the first four,
embody the very essence of Bazin's classification ;
the very essence of the originality which he claims
as especially his own. We may therefore inquire
a little further into the nature of his views.
At the present day it may strike you as self-
evident, that diseases should be divided into de-
pendent and independent entities. You will pos-
sibly also admit, that when the Physician, invoking
the inspiration of knowledge to unravel the signifi-
cance of facts, perceives the substitutive relation
of hsBmorrhoids, gastritis, epistaxis, rheumatism,
ekzema and neuralgia occurring in successive
sequence, he should be led to conclusions similar to
those put forth by Baumfes; conclusions, possibly,
more nearly approaching the truth than many of the
accepted theories of the day. You would also regard
with interest those phenomena by which we were
ourselves led to establish a relation between assimi-
lation, nutrition, and neurotic aberrations, with
certain forms of disease ; and which, in the mind of
Bazin, have suggested the otherwise perplexing
terms, herpetism, arthritism, and scrofulism. By
lierpetism is meant an original tendency to puri
I40 CLASSIFICATION OP CUTANEOUS DISEASES.
cutaneous disease ; by arthritism a tendency to
cutaneous disease originating in the gouty, the
rheumatic, and the lithic mal-assimilation ; and by
(crofulism a tendency to cutaneous disease dependent
on aberrant and defective nutrition. But, alas,
however interesting the association, and by other
terms the facts have been very long and very
generally known, how slight a basis is here on which
to found either a classification or a reputation. We
should esteem any one of you a dunce and unworthy
our teachings, who should treat the ekzema of the
nutritive and scrofulous period of life, as you would
that of the mal- assimilative, the arthritic, and the
rheumatismal period ; neither should we hold you
harmless if you submitted the uncomplicated diathetic
ekzema to a similar treatment with the rest. These,
gentlemen, are considerations which crop out in
abundance in the therapeutical management of our
diseases, and hardly, as we think, belong to classifi-
cation at all, although forced into it by our dis-
tinguished colleague. Of all the classifications which
have come before us, there is scarcely to be found
one which departs more fi-om that simplicity which
we consider essential to a classification, nor deserves
more the accusation of being a heterogeneous classi-
fication, than does the classification of Bazin.
( 141 )
CHAPTER II.
Ekzema.
Having passed in review the general pathology of
the skin, together with the general principles which
should guide us in its treatment, and the various
schemes of classification of its diseases, we propose
to introduce you to a knowledge of the special
cutaneous afifections by the aid of a very simple and
practical arrangement ; one which is suggested, in
fact, by the diseases themselves, such as . they are
presented to us on the integument of the patient,
and such as they occur to the physician by the bed-
side ; and this latter conception of the plan has
suggested the term by which we designate this
arrangement, namely, Clinical Glassification.
The Clinical Classification distinguishes one dis-
ease as infinitely more common than all the rest,
and not less important in reference to its symptoms,
to the amount of sufiering which it occasions, and
also to its treatment ; that disease is the itching^ or
rather the scratch-impelling disease, the psora of the
Greeks, the ekzema of modem medicine. Not that
ekzema is the sole pruritic affection of the skin, for
we meet with itching in urticaria or knidosis, and
also in prurigo, in scabies, and in simple pruritus ;
but ekzema, and particularly the dry and squamous
form of the complaint, realizes, more than any
other, the idea which is conveyed by the word
>|/a>eiy, to rub or scratch, from which is derived,
in the first place psora, and secondly psoriasis.
The essential nature of ekzema is, inflammation
142 PHENOMENA OP EKZEMA.
of the skin ; inflammation with more or less super-
ficial prominence, more or less eflnsion of the colom*-
less part of the blood, more or less displacement and
disruption of the cuticle, more or less suppuration,
and more or less pruritus. It is easy, therefore, to
distinguish ekzema from aU other affections of the
skin when the whole or several of these symptoms
are present, and, with a little care and observation,
it may also be recognized when one or two only of
the symptoms are developed. Thus, if we find
associated, redness and pruritus, we may have a
suspicion of ekzema, but no certainty from those
two symptoms alone, because redness and pruritus
are, in an equal degree, the symptoms of several
forms of erythema and especially of urticaria ; but
if there be added to redness and itching a mpist
exudation, or a desquamation of the epidermis, we
may be sure that the case before us is an ekzema.
Again, if we meet with an example in which we find
combined, redness with itching and vesicles, the
probability is that we have to deal with a case of
ekzema, but not so necessarily, for the affection may
be herpes or even erysipelas, and it becomes need-
ful to know the special distinctions of the two latter
diseases in order to avoid the danger of an incorrect
diagnosis. This, in fact, is a part of our labour and
study, and with moderate attention and observation
the chance of such error will be impossible.
You will, gentlemen, appreciate the necessity of
being able to distinguish ekzema, not only because
it is THE eruption, par excellence, of the skin, in itself
a suflScient motive, fi-om the practical bearings of
the disease ; but also because it is the standard with
which other cutaneous affections are to be compared
and their relative importance to be estimated ; and
moreover is the basis of the clinical classification.
We shall, therefore, at the risk of being thought
tedious, recapitulate the diagnostic characters of the
disease. First, then, there is redness, which is
PHENOMENA OP EKZEMA. 1 43
permanent and not evanescent ; secondly, there is
itching ; thirdly, there is disturbance of the epidermis^
which is either thicker or thinner than natural, or
cracked and broken up into loose fragments and
scales, or lifted up into small vesicles by the effusion
beneath it of a serous or sero-purulent fluid ;
fourthly, the pores of the skin may be raised up
into papules by congestion and infiltration of the
coats of the follicles ; fifthly, the epidermis may
be separated from its bed, and the derma may be con^
verted into an actively secreting surface^ pouring out
a secretion, which is for the most part limpid and
colourless, sometimes viscous and opalescent, and
sometimes purulent; and, sixthly, the derma may
be swollen, or thickened, or indurated, and at the
same time superficially ulcerated, or chapped and
cracked. We say nothing of the crusts produced
by the desiccation of secretions, for the reason, that
they are mere accidental consequences, and simply
cover or conceal the pathologiccd states included in
the last two members of our definition.
Now, it is perfectly possible for all these signs to
be present at the same time, and then the diagnosis
of ekzema is self-evident ; but the art of diagnosis is
to determine the identity of a given disease by the
aid of the smallest number of signs, and to this
object we direct your attention. By-and-by, we shall
have occasion to explain that the diagnosis of
ekzema is very much facilitated and corroborated by
other known phenomena of the disease ; for example,
situation, or, as the botanists term it habit<it ; but
for the present our purpose is simply to point out
the visual or objective signs by which the disease
may be recognized, associated with that almost
universal subjective sign or symptom, namely
pruritus. There is, however, another subjective
condition which is of great importance in the
diagnosis of ekzema, and that condition is time or
duration. At its earliest appearance, ekzema may
144 PHENOMENA OF EKZEMA.
be nothing more than a redness or erythema ; but
an erythema by mere lapse of time and disturbed
formation of the epidermis may become an ekzema ;
for example, a chronic erythema will be attended
with infiltration and thickening, it will itch, the
nails produce an excoriation, the excoriation exudes,
and then we have an ekzema with four out of our six
enumerated signs ; namely, redness, itching, de-
squamation, and exudation. Or, let us take a more
homely example : — in the cold weather the back of
the hands is apt to chill, hyperaemia succeeds, with
infiltration and induration ; then come — itching,
exudation, and chapping. The case which began as
erythema has merged into ekzema ; for erythema is
a mere transitory redness, only occasionally fol-
lowed by exfoliation of cuticle ; but in the instance
which we have taken for illustration there are —
redness, pruritus, desquamation, exudation, and
fission ; or nearly the whole of the characteristic
signs and symptoms of ekzema.
The most striking picture of ekzema that we can
present to your imagination is one which formed the
subject of an essay read before the British Medical
Association in 1856,* namely, ekzema infantile. It
may be premised that ekzema displays the self-same
characters at whatever age, and in whatever region
of the body it may be developed, and that any
variation of those characters it may present must
be ascribed to the greater or less degree of irrita-
bility of constitution or tissue of the individual or
to the duration of the disease. Infancy is a period
of great irritability of constitution and of tissue,
and ekzema infantile may be expected, as, in fact, is
the case, to present the highest degree of develop-
ment, and the utmost range of variation of which
the disease is susceptible. On the other hand,
ekzema infantile comes before us as an idiopathic
* We have so frequently been asked for a copy of this paper,
that we have reprinted it in Chapter IV. of the present volume.
MODIFICATIONS OP EKZBMA. 14-5
affection ; as an affection in which the cause and
effect of the disease are easily demonstrable ; and
with the extremest degree of variety of manifesta-
tion of which the skin is capable. Thus in ekzema
infantile the hyperaemia and consequently the redness
may be intense ; the exfoliation and desquamation
of cuticle may be excessive ; the follicles, as well as
the interfoUiculai' portion of the skin, may be hyper-
semiated and infiltrated so as to produce papules ;
the cuticle may be raised in minute vesicles more or
less discrete or coherent ; some of the vesicles may
contain pus ; the cuticle may be separated so as to
present extensive excoriations ; the excoriated parts
may secrete an abundance of limpid and purulent
fluid ; the fluid secretions may dry up into crusts —
of various colour, density, and thickness ; fissures
and superficial ulcerations may be formed in the
derma ; and, as secondary consequences, lymphatic
glands may become enlarged, superficial abscesses
may be formed, and furuncles may be produced.
Moreover, there may be more or less of swelling,
and less or more of pruritus ; the latter being, in
general, excessive.
It is not, however, because ekzema often presents
its severest form of manifestation in^ infants that we
have selected as our example ekzema infantile ; but,
because we are enabled, in the infant, to study
ekzema as an idiopathic affection, to see it often
covering the whole or the greater part of the integu-
ment ; and to note its changes in degree, and its
variations of form, not merely at different periods of
its existence, but at the same moment in different
regions of the body. In this observation we have
an apt illustration of the varieties due to habitat or
situation ; thus, in one part, say the head and face,
we may find the hyperaemia, the swelling, and the
infiltration, the greatest in amount ; in another, as
the trunk and limbs, the follicular hyperaemia or
papulation may be most strikinir ; in a third, as in
L
146 VARIETIES OF EZKEMA.
the flexures of the joints and in the recesses of folds
and contiguous partSi secretion may most prevail ;
while in other .parts again the tendency may be
greatest towards desiccation and desquamation.
It was the contemplation of these variations of
form of the same identical eruption that, no doubt,
suggested to Hebra the use of subjective terms
which should convey to the mind a notion of the
particular kind of variation. This suggestion is one
of great value, and we approve so highly of our
learned colleague's proposal that we have ourselves
adopted a similar principle of nomenclature. The
terms employed by Hebra are : squamosum^ papu^
losv/m, vesiculare^ madidans^ and impetiginosvm ; but
we have given a preference to the following,
namely : —
Ekzema erythematosum Ekzema ichorosum
papulosum „ pustulosum
vesiculosum „ squamosum.
99
99
It is important to be understood, that these terms
do not refer to kinds of ekzema, but simply to
modes of manifestation or forms of ekzema ; and
very commonly, very usually in fact, the whole of
these forms may be present together upon the same
patient. But, on the other hand, the eruption y^ry
frequently exhibits a predominating tendency to-
wards one or other of the forms in question ; it
may be that the case is chiefly or solely erythe-
matous, or papulous, or vesiculous, or ichorous, or
pustulous, or squamous ; and then these terms are
of value, and indeed necessary to the intelligent
intercommunication of our ideas.
The earliest stage of ekzema, as of other phleg-
masiae, is generally hyperaamic, that is, it is erythe-
matous, and we might be in doubt whether to
consider it an erythema or an ekzema; and for
some days it may retain an uncertain character. If,
EKZEMA ERYTHEMATOSUM. 1 47
however, its permanence, its teasing pruritus, the
condensation of the derma from infiltration, the
exudation of moisture on being scratched, its
locality, its occurrence in a person diathetically
predisposed to ekzema, determine the diagnosis in
favour of the latter complaint, the case will be one
of ekzema erythematosum. Ekzema erythematosum
may occupy the whole surface of the body more or
less extensively, or it may be limited to a spot, and
be simply local. Let us take an example of the
latter kind as another illustration of the phenomena
of ekzema. A person has a boil on the leg and
applies a poultice for its relief; the nerve- force of
the skin is weakened by the prolonged influence of
moisture and heat, hyperaemia follows, accompanied
with desquamation of cuticle and pruritus ; in fact,
ekzema erythematosum is established, and without
proper treatment may become permanent, and
assume other forms.
Sometimes the most striking feature of an
ekzema is the presence of minute papulae, united
into patches of varying extent by means of an
erythematous base. In such a case the hyperaemia
is in the first instance follicular, the congested
follicles swell into papulae, the hyperaemia spreads
from the papulae to surrounding papulae, and in this
way a patch of variable extent is produced. This
is ekzema papulosum. It will be remembered that
papulae produced after the manner described, when
they occur alone and without other signs of ekzema,
are termed leichen ; hence the terms ekzema leich-
enosum and leichenodes are synonymous with
ekzema papulosum ; but they are neither so appro-
priate nor are they so correct as the latter term.
The association of scattered papulae with un-
doubted patches of other forms of ekzema, is
sufficient to establish their identity with ekzema;
and this occurrence is nowhere so striking as in
ekzema infantile ; and it will generally be found that
l2
148 VABIETIES OF EKZEMA.
ekzema erytliematoBum is very rarely present
without a sprinkling of papulao in its immediate
neighbourhood. One of the commonest examples
of ekzema papulosum that can be adduced is an
affection of the back of the hands, which was
termed by Willan — ^leichen agrius. In it we find a
cluster of papulsB, circumscribed, united by an
infiltrated and thickened base, excessively itchy,
exuding a colourless ichor when scratched, and
sometimes coated over with a thin crust, formed of
desiccated secretions. And this illustration brings
to our notice the extreme itchiness of papulao in
general, and the tendency of the papules of ekzema
to pour out an ichorous exudation whenever their
summits are abraded.
It will be seen that, heretofore, our attention has
been engaged by simple hypersemic congestion, for
hypersBmia is, at the same time, the essence of
ekzema erythematosum and of ekzema papulosum.
In the next place we shall have to occupy ourselves
with the phenomena of exudation. We have
already spoken of infiltration as it accompanies
ekzema erythematosum and ekzema papulosum,
which implies a moderate degree of interstitial
exudation ; but we refer especially, at the present
time, to exudation upon the surface of the derma,
which raises the epideimis into minute vesicles,
and constitutes ekzema vesiculosum. The precise
seat of the vesicles is the point of greatest vascu-
larity of the derma, namely, the apertures of the
follicles, and, around these, several minute vesicles
are sometimes congregated, while at other times
one only exists. Occasionally, several minute
vesicles are blended together, constituting a large
vesicle or small bulla ; and in certain situations, as
on the palmar surface of the fingers and hands,
where the cuticle is thick, the vesicles are often
coherent and lift up the epidermis to a considerable
extent, constituting a multilocular vesicle. It will
EEZEMA ICHOBOSUM. 1 49
be remembered that the minute vesicle is the type
of the ekzema of Willan, and the example of the
affection selected by that author is a singular one,
and one to which he gave a name derived from its
cause, namely, ekzema solare. But at the present
day we know fiill well that an ekzema solare may be
an ekzema erythematosum or an ekzema papulosum,
as well as an ekzema vesiculosum; and sJso, that
ekzema vesiculosum, instead of being the most
frequent of the forms of ekzema, and the type of
the disease, is in reality the rarest, and almost
exceptional.
Of a still more exclusive character is the ehzema
ichorosum, which pours out an excessive quantity of
secretion, generally transparent and colourless,
sometimes opalescent, and sometimes purulent.
This secretion is remarkable for its viscosity,
stiffening, when dry, the coverings which absorb it,
and desiccating into crusts, sometimes thin and
dense, sometimes thick and spongy, friable or
tough, and varying in tint of colour from a
yellowish-brown to a honey or amber-yellow, and if
blood be accidentally intermingled, deepening in
hue to a deep black. The secretion often rises in
quantity to a state which may be termed ichorrJuBa^
soaking through dressings and bedclothes, and justi-
fying the designation attached to it by Hebra, of
ekzema madidans. Willan is less happy in his
synonym, for he terms it ekzema rubrum, pointing
to the hyperaBmic condition of the derma rather
than to the profuse secretion. It may be remarked,
in reference to this excessive secretion, that it is
periodic, possibly in obedience to a neurotic law,
that it presents every variety of degree in quantity,
and that, although it generally follows a separation
of the cuticle, it may happen without such inter-
vention; the morbid integument, for the time
being, seeming to take on the attributes of a
mucous membrane.
150 VABIBTIBS OF EKZEMA.
The production of pus, constituting ekzema
pustulosum^ is another form of exudative pathoge-
nesis, exhibiting a lower standard of vitality of the
tissues than the serous and ichorous forms, ekzema
vesiculosum and ekzema ichorosum. In the lan-
guage of a former age of pathology, the deve-
lopment of pus implies a greater impetus of
morbid action than the production of a watery
secretion ; and the formation of vesicles filled with
pus was denominated impetigo ; for the same reason,
the combination of the vesicles and ichorous dis-
charges of ekzema with pustules or purulent
secretion is designated ekzema impetiginosum, or
impetiginodes, and is accepted as a synonym of
ekzema pustulosum. As at present understood,
however, weak resistance and increased force give
rise to similar consequences, and the question of
impetus is one of no importance whatever, and may
as well be forgotten.
Ekzema squamosum is sometimes a primary afibc-
tion, but more fi-equently the evidence of an ekzema
of a more than usually chronic character. As a
primary afiection, we meet with it on the fingers
and hands, where a dry, hardened cuticle is the first
apparent sign of disorder of the skin. In this case
the cuticle cracks and exfoliates in fragments and
shreds, and a desquamation is established with little
or no redness, and no exudation, but usually with
much heat and soreness and considerable itching.
In fact, a new pathological element presents itself
to our observation in the squamous form of ekzema.
It is no longer hyperasmia or exudation that occupies
a first place in our thoughts, but induration and
thickening of the derma, partly due to infiltration of
the tissues with the serous constituents of the blood,
and partly also to hypertrophic growth. In some
instances the hardness and inflexibility of the tissues
are such that the derma cracks with the mere
movements of the part, as in the case of the joints
EEZEMA SQUAMOSUM. 151
and palm of the hands, and sometimes by simple
pressure, as on the pulps of the fingers. This is a
modification of ekzema which has been termed
ekzema fissum and ekzema rimosum ; but a separate
designation is altogether unnecessary, excepting for
descriptive purposes, for cracking and fission of the
derma are an almost necessary associate of the con-
densation and induration of tissues, which consti-
tute a part of chronic and squamous ekzema. The
hypertrophy of the tissues is of a kind that may be
termed passive hvpertrophy, a mere consequence of
the more abundant supply of blood induced by
hyperemia ; in these cases, of which the examples
are chiefly local, there is a degree of hyperplasia of
connective tissue with hypertrophy of the papiUae
cutis and a consequent hypertrophy of epidermis,
with separation of the broken epidermis in the form
of scales. A minor degree of this process, giving
origin to scales remarkable for their fineness and
thinness, constitutes the afiection termed pityriasis ;
while a coarser example of the same pathological
condition is that dependence of psora to which the
term psoriasis is properly applicable.
If, therefore, we cast back a glance of review
upon the forms of ekzema, we shall find that the
governing idea of their division into groups is
threefold ; namely, hypersBmia, exudation, and
desquamation : to hyperaamia belong ekzema erythe-
matosum and papulosum; to exudation, ekzema
vesiculosum, ichorosum, and pustulosum; while
desquamation is represented by ekzema squamosum.
And these distinctions bring to mind the ancient
division of ekzema, as represented by its Greek
synonym psora, and its Latin synonym scabies, into
psora or scabies humida and psora or scabies sicca ;
psora sicca being further distinguished into psora
porrigo, the equivalent of pityriasis; and psora
lepra, the equivalent of psoriasis.
And now, gentlemen, let us ask ourselves the
152 DEFINITION OF EKZEMA.
question : What is ekzema ? And, by the aid of our
foregone examination of the disease, endeavour to
arrive at a satisfactory answer, Ekzema is a
OHEONIO INFLAMMATION OF THE SKIN, ATTENDED WITH
DESQUAMATION, EXUDATION, AND PRURITUS. It WOuld
be difficult to define the disease in fewer words, and
yet these few words embrace all that is reaUy
important and special with regard to it.
Then follows as a second question : What are the
varieties of ekzema ? To which we may answer that
the essential varieties of ekzema are six in number,
namely, —
Ekzema erythematosum Ekzema ichorosum
„ papillosum „ pustulosum
„ vesiculosum „ squamosum;
these varieties being founded on the predominance
in the eruption, of simple hyperasmia, of exudation,
or of desquamation. Therefore, if our diagnosis of
an eruption lead us, in accordance with our defini-
tion, to a diagnosis of ekzema, we must proceed a
stage beyond this point and determine whether we
shaU further distinguish it as belonging to the
hyperaemic or vascular group ; to that of serous
exudation in the form of vesicles, to exudation in
the form of an ichorous or purulent discharge ; or to
that belonging to a state of condensation of the
derma, with exfoliation of the cuticle and desqua-
mation. It will soon become apparent to you that
these forms fi:*equently represent stages of the same
eruption ; that, for example, an eruption originally
erythematous, has, from the operation of certain
causes, such as improper treatment, become icho-
rous, or purulent, or, it may be, squamous. More-
over, these distinctions have another and a more
practical aspect, for the treatment of an erythe-
matous or papulous ekzema must be essentially
different from that of an exudative or of a squamous
ekzema ; and further, if it be your desire to
EEZEMA MARGINATUM. 1 53
minimise the existing sub-divisions, you may regard
them as limited to three only, namely, hypersemic,
exudative, and squamous.
The six varieties of ekzema which we have just
enumerated we have termed essential, in order to
distinguish them from certain subvarieties which
may be considered as accidental, and which are to
be regarded as mere modifications of the essential
pathological forms. We have already drawn your
attention to the difference of position of the hori-
zontal and vertical capillary plexus of the skin;
of the plexus which corresponds with the apparent
and that with the real surface ; of the visible and
of the hidden ; the superficial and the follicular ;
and this difference is exhibited by certain obvious
physical phenomena, which impress a difference of
character on the pathological appearances resulting
from congestion of its vessels. Thus in the in-
stance of the interfollicular plexus there is no inter-
ference with a general and uniform sweUing corre-
spending with the congestion ; but when the folli-
cular plexus is distended, the follicular tube is
pushed upwards above the surrounding level, and
constitutes a papula. We have seen this pheno-
menon illustrated in ekzema papulosum ; and we
see it also in a form of the eruption, which
combines in itself the erythematous and the
papulous type, and which is termed ekzema ma/r'^
ginatum. Ekzema marginatum is an erythematous
blotch, bounded at the circumference by a promi-
nent ridge of papules, sometimes blended together
and sometimes separate. The ridge seems to be pro-
duced by the centrifugal dispersion of the inflamma-
tion ; sometimes the included area regains its healthy
character, and the ridge alone remains ; so/tnetimes
the area retains its redness, and is sprinkled over
with isolated papules or rings, or segments of
rings ; and sometimes the boundary margin be-
comes the point of departure of a belt of ery-
154 SUBVABIETIKS OF EKZKMA.
thema bounded as before by a papular ridge. These
appearances are often very remarkable, and just as
the ekzematous patch is composite in its pathological
nature, so also, and in like manner, it unites the
pruritic symptoms of the papule and the obstinacy
of its habit, with the other characters of ekzema.
It is very chronic, lasting ofl)en for years, and is
situated commonly in the hollows of the body, as
of the perineum and axillaB, but sometimes develops
its rings upon the limbs. Ekzema marginatum is
common in certain parts of India and China, and
particularly in Burmah, from which circumstance
it is denominated Burmese ringworm. But it also
occurs not unfrequently amongst ourselves.
We have also referred to the tendency which
exists in the skin to become condensed by infiltra-
tion, and to crack and chap when subjected to the
ordinary movements of the integument in flexion
and extension : it is in this manner that we have
formed the cracks and fissures of chapped hands,
the rhagades which occur upon the lips, in the com-
missures of the pudendum, around the anus, in the
clefts of the deeper folds of the integument, as
behind the ears and between the buttocks, in the
flexures of joints, and especially in the flexures and
upon the tips of the fingers, between the toes, and
in the palm of the hands. And when, as some-
times happens, this fission of the derma is the most
conspicuous or sole existing sign of ekzema, we
may very fairly term it ekzema Jissuvi.
Occasionally we meet with a very interesting
physiological phenomenon in relation with ekzema,
namely, the appropriation by the skin of the attri-
butes of mucous membrane. Such an occurrence is
met with in deep folds of the integument, as of fat
persons and children, and on surfaces which are
exposed to the combined effects of heat, moisture,
and friction. The most striking instances that we
at this moment call to mind, were present in the
EKZEMA MUCOSUM. EKZEMA (EDEMATOSUM. 1 55
creases of the neck of an infant, between the thighs
of a person of delicate constitution, in the groins,
in the axillas, and between the mammaa and subja-
cent integument of corpulent individuals. In these
cases the cuticle is softened to the state of the
epithelium of a mucous membrane, and is moistened
by a viscous secretion, sometimes transparent, some-
times opalescent, and sometimes muco-purulent.
The special characteristic of the aflfection is the
unbroken state of the epidermis, the morbid secre-
tion being diffused over its surface. To this pecu-
liar form of the disease we have assigned the term
ehzema mucosum ; and not unfrequently, with
ekzema mucosum, rhagades are found in the deepest
part of the groove. This form of ekzema sometimes
attacks the mucous membrane of the prolabium of
the hps ; and the desiccation of the morbid secre-
tion gives rise to a horny case : the homy case is
generally of a dark-brown colour, and resembles,
when removed, one valve of a siUquous pod.
We are unwilling to countenance such needless
terms as ehzema scaMdum and ekzema crustaceum,
for, in a few hours, with the aid of a water-dressing,
a poultice, or a coating of ointment or oil, these
cases may be converted into ekzema ichorosum or
pustulosum, or that compound of the two termed
ekzema impetiginosum. Nevertheless, in compli-
ment to Willan, we may call to mind that monstrous
example of ignorance and neglect, the crusta lactea,
porrigo larvalis, or ekzema larvale, and remind you
that similar instances will occasionally, even at the
present day, be brought under your attention.
But, as we have already said, at your second visit
they will have acquired a right to a more intelligent
and significant term.
Another of the accidental subvarieties of ekzema
takes its origin in an aberration of interstitial exu-
dation. In every form of ekzema there exists a
certain amount of serous infiltration into the tissue
156 SUBVABIETIES OF ERZEMA.
t
of the derma, and often into the tissue beneath the '
derma, the subcutaneous tissue. Not unfrequently, {
and especially in the lower extremities, this inter- ,
stitial exudation prevails to the extent of producing
a complication of ekzema with oedema, or in other
words, an ehiema cddematoswm. Such cases are too
simple and too frequent to need further comment ;
but occasionally the oedema is limited to small
portions of the skin ; and these portions, sometimes
isolated and sometimes in clusters or groups, give
rise to tubercles, often of considerable prominence.
In such a case, there is a general oedema, as also a
partial oedema, and the appearance of the affection
IS altogether so remarkable as to impress itself
strongly on our attention. To this form of mo-
dification of ekzema we have given the name
ekzema tiiberosum.* And, under the designation
ekzema spargosiformef we have described another
example of a similar modification induced in the
tissues of the skin and subcutaneous textures by
intra-exudation, and possibly to some extent by
hyperplasia of connective tissue. The result of
this combined process in the latter instance was
the production of a state of the lower extremities
only distinguishable from spargosis cruralis, the
bouknemia or elephant leg of the Arabians, or
elephantiasis Arabum, by a copious serous transu-
dation from the whole extent of the morbid
surface, t
We have already pointed out that interstitial in-
filtration of the skin giving rise to thickening and
induration, conjoined with a copious formation and
desquamation of cuticle in small abundant scales,
a consequence of prolonged congestion of the
derma, is the essence of the chronic affection
termed psoriasis, an affection sometimes confounded
with lepra, and described with it under the same
♦ Vide Chapter IV. and Index. + Ibid.
EKZEMA SELEBOSUM. EEZEMA NEUBOSUM. 1 57
name. And in the next place we have to remark
that the condensation and hardening of the skin,
in circimiscribed patches, reaches a degree which
we have distinguished as eJczema slderosum (ekzema
coriaceum) . Moreover, there is a third form of
thickening and condensation, in which, as a con-
sequence of chronic hyperaemia, a passive hyper-
trophy of the papillaB of the affected part takes
place and a state is induced which may be com-
pared in structure to a wart, ekzema venrucosum.
Sometimes these patches, both sklerous and ver-
rucous, have an extent of several inches in
diameter ; they are commonly oval in shape, and are
situated for the most part on the limbs. At other
times they are small and circular and somewhat
conical in figure, attended with troublesome
itching and scattered more or less abundantly
upon the limbs, and particularly on those of the
lower extremity.
Another subvariety is created by an aberration
in the kind and in the degree of pain with which
ekzema is accompanied. Usually the morbid sen-
sations of the eruption are itching, tingling,
burning, and smarting, but in certain instances
the sensations are real pain, of a neuralgic character
and often periodic. We have seen this kind of
suffering most commonly in the ichorous form of
the affection, wherein the skin is in a state of
chronic hyperaemia, softened with discharges or
water dressings, deeply red in appearance, ex-
quisitely sensitive, and extremely painful : and upon
this morbid condition we have bestowed the name of
ekzema nev/rosum.
We have thus introduced to you a somewhat ex-
tensive list of subvarieties, each of which has claims
on your attention as illustrating some special cha-
racter or property of the disease. First, there is
that singular centrifugal affection, that compound of
ekzema erythematosum and papulosum, the papules
158 SUBVABIETIES OF EKZEMA.
retiring to the circumference and forming an annular
boundary, ekzema marginatum; secondly, there is
the remarkable tendency of the inflamed derma to
crack, ekzema fissum ; thirdly, we have presented to
us a peculiarity in its habit of secretion, ekzema
mucosum; fourthly, we have called your attention
to the massive crusts which sometimes conceal the
inflamed surfaces ; fifthly, we have interstitial effu-
sion giving rise to ekzema oedematosura, tuber-
osum, and spargosiforme ; sixthly, there is con-
densation and hardening of the derma, producing
psoriasis and ekzema sklerosum ; seventhly, a passive
form of hypertrophy of the papillae cutis is manifested
by ekzema verrucosum ; and, eighthly, a state of
nerve-lesion in ekzema neurosum ; or, if we proceed
to assemble these numerous subvarieties in a table,
we shall find them admitting of detail as follows : —
Ekzema marginatum
Ekzema tuberosum
„ fissum
99
s jargosiforme
„ mucosum
99
sklerosum
„ scabidiim seu
99
verrucosum
crustaceum
99
neurosimi.
oedematosum
Therefore, gentlemen, if we have succeeded in en-
gaging your attention up to this point, you will not
Tje startled by so copious a catalogue, but will per-
ceive how naturally the subforms distinguish them-
selves from the forms in chief. All the forms are
pathological ; the six primary forms claiming to be
regular and the subforms irregular.
But our history of ekzema would be incomplete if
we were to content ourselves with the investigation
of the pathological forms of the disease only. Other
subjects of interest are still before us ; such as the
distribution of the eruption on the general surface of
the body ; and its regional pathology^ in other words,
its especial behaviour in particular parts ; for example,
DISTRIBUTION OP EKZBMA. 1 59
on the head, the pudendum, the hands and feet, and
the joints. To this subject we propose next to give
our attention.
In our previous lecture we discussed the general
phenomena, in other words, the general pathology,
of ekzema ; we then proceeded to found on those
general pathological phenomena a definition of ek-
zema ; and in the next place we submitted to inquiry-
its forms of manifestation, its chief forms and its
accidental forms, or, if you prefer the terms, its
primary and its secondary forms. We have still left
for our consideration some interestins: features of the
affection, relating to its manner of distribution, and
also to its regional peculiarities, before we may ven-
ture to turn our attention to the etiology and thera-
peutics of the disease.
Distribution of Ekzema. — Ekzema in its distri-
tribution may be general or partial. As a general
eruption it is much more rare than the partial or
local forms ; and in its manner of development it
may in some instances break forth like an exanthem,
exanihematoua ekzema ; or, as most frequently hap-
pens, it may begin as a single spot, and other spots
may follow more or less quickly until the greater
part of the body is sprinkled over with ekzematous
blotches: this is the successive form of general
ekzema, ehzema iuccessivum. General ekzema is
most frequently seen in the infant, in whom an
imity of sensibility more commonly pervades the
whole skin, than in the adult ; and, in the adult,
when, as a consequence of debility, the conditions
of irritability of the skin approximate to those of
the infant. But although the eruption may be
general, it does not therefore follow that it should
be uniform, but on the contrary, the law of variety,
and the law of regional modification are rigorously
asserted. Thus in ekzema infantile, there^ may be
no part of the surface of the body on which the
l6o DISTEIBUTION OP BKZKMA.
eruption is not present ; there can therefore be no
question as to its being a general ekzema; but the
forms will differ in different situations, and locahty
will be influential in producing other modifications.
We shall find ekzema erythematosum in several
spots, with scattered examples of ekzema papillo-
sum ; even ekzema yesiculosum may be discovered in
sundry places ; whUe ekzema ichorosum is conspi-
cuous on the cheeks, the scalp, and the flexures of
joints, often associated with ekzema pustulosum;
and ekzema squamosum is only absent because time
has not been given to the eruption to attain the
proper degree of ripening for its manifestation.
Excepting in the infant, general ekzema is so in-
frequent that it may be regarded almost as an ex-
ceptional form of the disease ; the eruption in general
presenting the character of a partial or local affec-
tion. But here, again, it is necessary to observe,
that partial or local ekzema is not limited to a single
region ; it is rarely solitary, but is usually present in
several regions at the same time: it may be the
fingers and the fissuras aurium ; it may be the head
and the flexures of the joints ; it may be the back of
the hands and the circumference of the anus ; or it
may be the fore-arms and the pudendum.
Just as ekzema generate or universale, has its two
principal forms of manifestation and distribution,
namely ekzema exanthematosum and ekzema suc-
cessivum ; so also has ekzema partiale its two go-
verning forms; for example, ekzema diffusum and
ekzema circumscriptum. The most usual form of
partial ekzema is that in which the patch of inflamed
skin fades into the surrounding healthy skin ; and
spreads and diffuses itself in the adjoining integument
without any distinct limit of separation, or possibly
blends with neighbouring patches, and so produces
a blotch of large size, sometimes involving a con-
siderable portion of the trunk of the body, or of a
part or the whole of a limb. It is necessarily irre-
EKZEMA DIFFU8UM ET CIECUMSOBIPTUM. l6l
gular in outline, and has no distinct boundary.
This is ekzema diffusurn ; and with these characters
we find it commonly on the head and face, behind
the ears, in the axilias and groins, and in the flexures
of the joints. And this form of the eruption is apt
to be mistaken for erythema, and sometimes for
erysipelas.
The circumscribed form, ekzema circumscriptum, is
known by characters the opposite of those of the
difiused form ; the patches are more or less definite
and regular in figure (ekzema figuratum) , and gene-
rally isolated. They are, for the most part, oval or
circular in shape, and of variable size, sometimes
several inches in extent, sometimes as small as
pieces of money — hence the term " ekzema nummu-
lare," and sometimes of still smaller dimensions.
While another of the circumscribed forms is remark-
able for possessing an elevated or papulated border,
as in the instance of ekzema marginatum. The
circumscribed figure of the eruption generally indi-
cates a more than usual chronicity of character;
and it is amongst these forms that we most com-
monly meet with illustrations of thickening, harden-
ing, and hypertrophy, as in the instances of ekzema
sklerosum and ekzema verrucosum.
We have already seen enough of this disease to
recognize the fact, that one of the most striking of
the characters of ekzema is its tendency to modifi-
cation : it is modified by age ; it is modified by sex ;
and it is also modified by situation. The ekzema of
infants is veiy commonly general; the ekzema of
the adult and elderly persons is more frequently
partial. In infants we look for the erythematous,
the papulous, and more particularly the ichorous
and pustulous forms of the affection ; in the adult
the disease is more limited in its forms of manifesta-
tion, and less active ; while in old age the squamous
form is most predominant. Ekzema in the adult
female approximates towards the characters of
M
1 62 EKZEMA OF THB SCALP.
ekzema infantfle, and ekzema in the adult male
towards those of ekzema senile. But the modifica-
tions caused by situation are so remarkable as to call
for separate notice, and to make a demand on our
special attention and observation. And for this
purpose we may divide the body into certain regions.
For example, 1. the head, or hairy scalp; 2. the
face, including the ears ; 3. the folds of the skin ;
4. the flexures of joints ; 5. the pudendum and
perineum; 6. the mammsa; and 7. the hands and
feet.
Ekzema capitis. — The most frequent forms of the
disease seen upon the hairy scalp are the erythe-
matous, the ichorous, and the squamous. Vesicles
are very rarely met with, and papulsB still more
seldom^ In th^e ichorous and sup^^g form the
hair is matted with discharges, and this, conjointly
with the desiccated secretions, gives rise to a hardened
crust, which encloses the head as in a case or closely-
fitting cap, detains the secreted fluids, and is exces-
sively ill-smelling and ofiensive, the odour resem-
bling that of valerian. It is, however, only by
neglect that such a state can arise, and by proper
attention it may be completely obviated. More fre-
quently this state of sordid accumulation of desic-
cated discharges and matted hair is limited to a part
only of the head. Sometimes, when the ichorous
exudation is very abundant, it draws the hairs
together like a conical pencil, and from the end of
these cones the limpid discharge appears to distil in
frequent drops ; the discharge dries on the cones,
and forms upon them a thin, glistening sheath, and
to this appearance Alibert gave the fanciful name of
micaceous tinea, tinea amientacea, while the glitter-
ing appearance of the bundles of hairs reminded
him of asbestos, and suggested the term, tinea
asbestina. At other times the exuded secretion dries
into whitish or greyish friable crusts: the broken
fragments of these crusts have been compared to
EKZEliA CAPITIS. 1 63
mortar, and the presence of a number of granules of
broken crust has been dignified by the name of tinea
granulata. Upon such slender threads do the
eccentricities of nomenclature sometimes hang, and,
strangely enough, common ekzema, with these
simple and obviously accidental peculiarities, has
been described as though it were the representative
of distinct varieties or distinct species.
Gentlemen, we cannot forbear impressing upon
you in this place that ekzema is ekzema, and that
ekzema capitis is ekzema capitis, whether it occur in
the infant or in the adult ; and, as ekzema, that it
can only present itself to your notice with the forms
already described, and with which we hope you are
by this time familiar. The instances we have already
adduced of magniloquent nomenclature, will prove
to you that there is reason for our caution, and that
tuL .mientacea, tine, aebestma. and tine, grann-
lata, with a host of porrigos, are nothing more than
examples of a dirty and neglected ekzema capitis ;
an ekzema that a little soap and water properly
applied, or a coating of ointment or oil, would
speedily convert into a tinea mundificata, and thence
ensuing into a tinea curata. But while we are on
this subject, we must call your attention to another
of the vagaries of dermatologists in the matter of
nomenclature. You will naturally inquire : What
has tinea to do with ekzema ? The answer is simple
enough : Nothing at all. Tinea signifies a loss of
hair from the breaking of its shaft close to the
surface of the skin; as though, in fact, it were
eaten away by the larva of the moth or tinea. But
there is no disease of the hair in ekzema, no break-
ing of the hair, and therefore the term is misapplied,
and is consequently absurd. Perhaps we may be
told that tinea is a disease of the head, and ekzema
being in this case a disease of the head, it is there-
fore immaterial what term be employed, provided that
we understand its meaning. Some such argument
M 2
164 EEZEMA OF THE SCALP.
has been used in the instance of psoriasis and lepra.
But it is clear that such arguments, and so loose a
manner of thinking, are wholly unsuited to the
present age, and inadmissible by an educated and
polished profession, and therefore are utterly im-
worthy of being entertained.
When the discharges or the crusts, as the case
may be, are cleared away from the scalp in a case of
ekzema ichorosum, or ekzema ichorosum which, by
neglect, has degenerated into an ekzema crustaceum,
the skin will be found red and inflamed, more or less
tumid, more or less denuded of epidermis, and moist
with exuding secretion. To an aggravated form of
this state of dermatitis Willan applies the term ekzema
rubrum ; and it would be matter of surprise to all
who have the opportunity of observing this disease,
that the roots of the hair should remain so entirely
unaffected, were it not at the same time known that
the pathological operations of ekzema are extremely
superficial, and for the most part confined to the
vascular layer of the derma.
Ekzema squamosum is the most common form of
ekzema of the scalp ; sometimes it is the sequel of
the ichorous form of the affection, and sometimes of
the erythematous ; and it ordinarily presents two
degrees of severity ; in one of these the desquama-
tion consists of very fine, thin, and minute scales,
constituting pityriasis^ while the other presents the
typical character of psoriasis. For example, the
integument is red and thickened by infiltration,
and the scales are thicker and larger, and in every
way coarser. In both these forms there is redness,
slighter in the one, more considerable in the other ;
in both there is pruritus, but most in the latter ; and
in the latter aJso, accompanied with a variable
quantity of ichorous exudation, when the skin has
been severely scratched. Looking to the relative
amount of hyperaamia in these two forms of affec-
tion, as also to the interstitial infiltration of the one
HKZEMA FACIEI. 1 65
and the absence of infiltration in tlie other, we see
an explanation of the finer scales of pityriasis and
the coarser scales of psoriasis ; and we at the same
time recognize the identity of the affection, and
perceive that pityriasis and psoriasis are simply
degrees of squamous dermatitis ; in fact, of ekzema
squamosum of the scalp. And it is to this form of
affection that Willan, following the example of his
predecessors, assigns the term porrigro— porrigo, a
term used by Celsus, being derived from the Latin
word porrum, an onion, because " ut porrum in
tunicsB involucra, ita cutis, velut in squamas resol-
vitur." You see, gentlemen, that the study of
ekzema leads to considerable disappointment for the
lovers of mystery, and that, as searchers after truth,
it affords us another argument for taking it as the
head of our discourse, and as the foundation of a
practical classification. Already, on the scalp alone,
ekzema has routed the artificial classification almost
to destruction, inasmuch as it has represented five
out of a total of eight of the orders founded on the
pathological signs of cutaneous disease, namely,
papulaB, squamsa, exanthemata, pustulse, and vesiculse.
We may add further that pityriasic ekzema capitis is
more chronic than the psoriasic variety, and more
frequently leads to destruction of the hair. The loss
of hair in this instance arises from exhaustion of the
trichogenic ftmction, and the prolonged duration of
the disease is attributable, not so much to its chronic
nature, as to the little inconvenience it occasions the
patient, and his consequent neglect of application for
relief.
Ekzema faciei. — Ekzema of the face offers the
greatest amount of interest in infants, in whom all
the forms of this affection may be observed, some-
times in the erythematous and papulous form con-
stituting strophulus and tooth-rash ; sometimes in the
ichorous form, producing by the desiccation of its
secretions the milk-crust, crusta lactea, the ekzema
1 66 EEZEMA OF THE FACE.
larvale or porrigo larvalis ; and sometimes in the
squamous form. The commonest seat of the affec-
tion is the cheeks and the forehead, and in the
ichorous form, which is attended often with intense
redness and very considerable swelling, a picture is
S reduced which is really alarming and frightful to
ehold ; the head may be swollen to the roundness
of a sphere, the features are flattened and distorted,
the eyes are closed by oedematous infiltration of the
lids, and in some instances the lids are everted, and
the balls of the eyes brought hideously into view.
What a terrible picture I But how easily relieved ;
nay, how easily cured. In general we use the word
" cure " with great circumspection, with extreme
humility, but in this instance we pronounce it
emphatically.
Taken in their order of succession, the first of the
infantile ekzemata is the milk-crust : it would have
been more correct to have termed it the no-milk
crusty for its cause is invariably a deficient or un-
wholesome supply of the natural food of the infant.
Then vaccination, and then dentition, come in for
their share in the causation of the disease ; first,
primary dentition ; secondly, permanent dentition ;
then food supply ; and then puberty, with its
physiological changes. Even the powers of the con-
stitution may be tested by ekzema, as to their
capabilities of resistance ; the erythematous and the
papulous forms accompany power and tone ; the
ichorous form indicates an inferior standard of
vitality ; and the purulent complication of the
ichorous form, the lowest extreme of debility.
Ekzema, in general, gives little or no alarm to the
deeper structures of the body, but ekzema of the
head is frequently attended with enlargement of the
occipital and post-auricular lymphatic glands ; and
the purulent forms of the disease with sub-cutaneous
abscesses besides.
In the youth of both sexes, when the powers of
EEZEMA SULCOBUM. 1 67
the constitution are exhausted, we meet occasionally
with ekzema pustulosum or impetigo ; and it is at
this age also that ekzema labiorum, a sequel of
ekzema infantile, is most troublesome. In the adult,
ekzema squamosum is apt to prevail, and may lay
siege to any of the prominences of the face ; and in
the adult female, and, a little latter in the male, we
find ekzema ichorosum attacking the ears, with its
usual accompaniment of oedematous infiltration.
While, later still, squamous ekzema of the eyelids is
apt to take place, and squamous and ichorous
ekzema of the fissures of the ears.
Ekzema suloobum. — Ekzema has a marked tend-
ency to seize upon the most delicate and sensitive
parts of the skin, and especially those which are
exposed to heat and perspiration and are withdrawn
from the free current of the atmosphere. You may
perhaps object to this remark, that ekzema is very
common on the face and on the hands ; but in
those localities there exist special sources of irrita-
bility having reference to innervation and circulation,
which are absent elsewhere. And, as a rule,
ekzema will be found to be more frequent on the
clothed than on the unclothed parts of the body,
and in the creases or grooves of folds of the skin or
in the hollows of joints than anywhere else. If we
apply this observation to the ground over which we
have just been treading, we shall perceive a reason
for the frequency of ekzema at the commissures of
the eyelids and mouth, at the base of the alas nasi,
around the aperture of the nares and especially in
the groove at the root of the ears. In infants and
fat persons ekzema is oflen met with in the creases
of the neck as well as in those of the trunk, and in
adults of all ages we find the affection in the
hollow of the sternum, in the grooves beneath the
mammaB, in the hollow of the umbilicus, in the
duplicatures of the integument of the abdomen,
and in the fossa of the nates.
1 68 EKZEMA OF THE JOINTS*
Eezeita ABncuLOBUM. — From the frequency, we
might almost say the constancy, of ekzema in the
flexures of the joints, ekzema articulom/m has become
one of the standard terms of dermo-pathology ;
and it is also one of the signs by whicn constitu-
tional or diathetic ekzema is manifested. Most
fi^uent of all it is met with in the hollow of the
popliteal space ; next in the bend of the elbows ;
then in the armpits ; and then in the groins.
Friction between opposed surfaces of the skin,
when it goes no fiirther than to produce redness, is
termed erythema intertrigo ; but the same amount
of friction that would produce erythema in one
person, would, in another, be the cause of an exu-
dation, in fact, an ekzema; even in the first of
these supposed cases, an increase in the quantity of
the friction would convert the erythema intertrigo
into an ekzema erythematosum, and probably an
ekzema ichorosum. In persons in whom an ekze-
matous diathesis prevails, the slightest degree of
friction would be sufficient to occasion an ekzema ;
and the skin of folds or hollow places or surfaces in
contact with each other betrays a natural proneness
to the development of the exudative form of
erythema, or simply ekzema, often under the most
trivial degree of irritation. In the hollows of folds
of the skin the exudation sometimes occurs without
any apparent breach of surface of the epidermis,
and the secretion may very closely resemble mucus
in its character, being viscous and slightly opaque :
this is ekzema mucosum. At other times there
may be fissures of various extent, from which
exudes an ichorous lymph ; or, in more aggravated
cases, there may be present decided excoriation,
with an abundant exudation, and a tendency to
form crusts by the desiccation of the secretion.
This latter is the common character of ekzema
articulorum. While, at a later period, the inflamed
part may assume the properties of ekzema squa-
BKZEMA PUDENDl ET PEBINEI. 1 69
mosum ; the skin may be thickened and infiltrated,
it may split into cracks and fissures on the mere
motion of the joint; it may exude an ichorous
discharge from the rhagades, and the discharge
may be commingled with an efiusion of blood in a
greater or less degree.
One joint only, namely the axilla, deserves to be
singled out from the rest to distinguish some
peculiar features ; and these features are, the occa-
sional enlargement of lymphatic glands, and more
frequently still the formation of hard masses seem-
ingly of condensed and thickened areolar tissue
immediately beneath the skin, and the suppuration
of these masses; sometimes giving rise to super-
ncial abscesses; sometimes opening singly, but
more firequently at several points, and not rarely
establishing fistulous channels, which continue to
pour out pus for a considerable time ; or which,
afi^er its escape, heal up, and break' again and again,
and in this manner are continued for several weeks,
and in some instances for months.
Ekzbma pudendi et perinei. — The pudendum and
perineum are one of the favoured seats of ekzema
both in the female and in the male ; there, especially,
the common exciting causes of ekzema are present
in an excessive degree, for example, heat, perspira-
tion, moisture of excretions, contact of surfaces,
friction, absence of ventilation, and haemorrhoidal
veins ; and the symptoms are aggravated by the
motions of the body, of which the perineum is the
necessary centre. In a fully developed example of
ekzema pudendi, the inflammation occupies the
whole of the external genital organs spreading up-
wards upon the mons pubis in front, extending
backward along the groove of the perineum to that
of the nates, outwards in the glutseo-femoral groove
posteriorly, and along the inguinal grooves ante-
riorly, and for some short distance down the thighs
at either side. But the extent of the disease pre-
I70 EEZEMA MAMMiB.
sents usually the utmost variety ; it may be limited
to the scrotum and root of the penis ; to one side of
the scrotum and the contiguous surface of the
thigh ; to the scroto-crural grooves ; to the peri-
neum; or to the immediate circumference of the
anus ; while in the female the labia alone, or the
labio-crural grooves, may be the seat of the
affection.
In like manner, the disease may present itself
with the threatening characters of an ekzema
erythematosum ; with the fiery redness, the tume-
faction, and the abundant exudation of an ekzema
ichorosum ; with the prurient irritation of an
ekzema squamosum ; or it may alternate throughout
the entire series of forms, one while exhibiting the
calmness of the erythematous type, another while
the fierceness of the oedematous and exudative type ;
and in the third place the inveteracy of the squamous
type. It was an intercrural ekzema in its most
active form that suggested to Willan his picture of
ekzema rubnim. And it is in the pudendal region,
and especially along the boundary-line of its in-
flamed surface, that is developed the papular ridge
which is characteristic of ekzema marginatum. It
must be mentioned also that the suffering attendant
upon ekzema pudendi is very much enhanced by
the formation of rhagades of considerable extent ;
by the burning and throbbing of the ichorous form,
and by the intense itching of the dry or squamous
form. Ekzema of the anus is remarkable for its
itching ; so also is ekzema of the anterior commis-
sure of the vulva ; while another annoying form of
the disease, attended often with incessant pruritus,
is ekzema squamosum prdBputiale. In this latter
affection the prepuce is thickened, hardened, more
or less deeply fissured, and contracted so as to
occasion paraphymoais.
Ekzema mamm^. — The mamma in the female is
the occasional seat of ekzema, and especially the
EEZEMA MANUUH ET PEDUM. I71
mammilla ; the chapped and fissured nipples which
are met with so frequently, are an example of
ekzema. And ekzema of the mammsd may present
all the chief characteristic forms of the complaint ;
it may be erythematous or vesiculous, ichorous or
squamous; but is usually very amenable to treat-
ment. Even the chapped nipple, frequently so
chronic, is by no means difficult of cure, when
nursing can be abstained from, and the macerating
influence of the saliva of the infant avoided.
Ekzema manuum et pedum. — The hands and the
feet are, both of them, extremities of the body, and
therefore their liability to altered nutrition depend-
ent on exhaustion of nerve-force ought to be
nearly similar ; but the one is a clothed and the
other an unclothed organ, and this constitutes an
essential difference in their behaviour under disease,
and gives rise to a series of varied manifestations.
The feet, although in their tissues they may be
debilitated by constant covering, are less exposed to
the influence of irritants, such as extremes of cold
and heat and the irritants of the chemical and
mechanical class, than the hands ; hence, ekzema of
the hands is more common than ekzema of the feet.
Ekzema of the back of the wrists from cold, and
especially from the combination of moisture with
cold, as in the instance of chapped hands, is one of
the most frequent phenomena of domestic life;
others are the so-called ekzema solare from the
action of the rays of the sun upon the back of the
hands ; ekzema from the use of alkaline solutions ;
of acid solutions, as in the manufacture of sulphate
of quinine ; from the contact of sugar, as in the
case of grocers' itch ; of lime, as in the instance of
the bricklayers' itch; of flour, as in the bakers*
itch ; and of friction and maceration of hot soap-
suds, as in the washerwoman's itch. From all these
causes the feet are protected, and are, therefore, less
liable to ekzema. But there is a cause of ekzema in
172 EKZEMA OF THE HANDS.
the feet which is absent in the hands, namely, the
heat, moisture, and attrition which occur between
the toes, and give rise to one of the most trouble-^
some forms of ekzema ichorosum. *
The hands and the feet, and especially the first,
are subject to all the forms of ekzema ; the erythe-
matous, the papulous, the vesiculous, the ichorous,
the pustulous, and the squamous. In their order of
firequency we should place the squamous first on the
list ; secondly, the papulous ; thirdly, the vesicu-
lous; and fourthly, the ichorous and suppurative.
A common cause of ekzema of the hands, namely, i
the acarus scabiei, afibrds an apt illustration of the
greater number of these forms. In the first place
there is more or less of an erythematous condition j
of the skin ; secondly, there are papuldB ; thirdly,
vesicles ; sometimes pustules ; and, frequently,
patches of excoriation corresponding with ekzema
ichorosum ; in certain cases, where the skin is less
sensitive and its indisposition to exudation more
decided, there might also occur ekzema squa-
mosum.
Ekzema of the hands sometimes puts on the
characters of an acute afiection; the hands and
fingers are swollen, they are more or less red ; the
cuticle is raised into minute vesicles, in some places
the cuticle is lifted up in an extensive layer ; there
are breaks here and there, through which an
ichorous exudation takes place ; in parts, the
cuticle has become softened and is rubbed ofi* ; the
exposed derma is intensely red ; it exudes abund-
antly, sometimes a limpid and sometimes a purulent
fluid ; and occasionally the vesicles on the surface
may be filled with pus in lieu of transparent lymph.
This is a picture that you will see frequently in
children, in young females and youths ; sometimes
in the adult female, exhausted by parturition and
long nursing : but never under any other than the
like conditions ; namely, the tissue irritability of
EKZBMA OF THE HAKDS. I 73
childhood or that induced in the adult by exhaus-
tion and debility. It is the ekzema rubrum of
Willan, occurring in the hands ; and it is the
ekzema impetiginodes of the same author.
One of the commonest forms of ekzema manuum
is the ekzema papulosum of the back of the hands ;
the eruption is developed in one or more patches,
and is more or less completely circumscribed. It
consists of a cluster of papulae, dispersed or co-
herent, united by an inflamed and thickened base ;
and is sometimes simply papulous and quiescent,
sometimes moistened by a copious ichorous exuda-
tion ; and sometimes encrusted over with a greyish
and yellowish scab. This form of ekzema is re-
markable for its itching propensities ; at first there
may be nothing more than an itching of the skin ;
the skin is rubbed or scratched, and then small
hard knots or pimples appear ; the pimples enlarge,
the itching is increased, the scratching renewed, and
the pimples become inflamed; the inflammation
spreads from their basis to adjoining pimples, and
a number become united into a single patch by
the intervention of an inflamed and infiltrated base.
It is after infiltration has occurred that the icho-
rous exudation begins ; but not spontaneously, only
after irritation by excessive itching; the patient
has bestowed upon the patch a thorough rubbing,
or torn its surface by an angry scratching. Tlus
is the leichen agrius of Willan ; it is verily ay^ioi^,
angry, fierce, violent; according to a certain form
of nomenclature, it is an ekzema leichenosum or
leichenodes ; but in simple truth it is nothing more
than an ekzema papulosum.
But there is a silent form of ekzema which takes
possession of the skin of the hands and is much
more common than the preceding forms. It begins
with a subdued itching; say on the sides or the
tips of the fingers, along the ulnar border of the
hand, on the ball of the thumb, or in the palm.
174 EKZEMA OF THE HANDS.
The first visible notice of anything wrong is a
dryness and yellowish transparency of the cuticle ;
the altered cuticle cracks and desquamates, some-
times by way of exfoliation, sometimes in small thin
scales ; the derma beneath the scales is somewhat
red and indurated ; it cracks into dry fissures, and
a chronic morbid action is set up, which rarely rises
to the level of inflammation, but is very tormenting
to the patient. It itches, it catches in everything
he touches; moreover it is oflben very sore, very
tender, and sometimes hot and burning. And oc-
casionally, if it be much scratched, it may exude a
little ichorous fluid, and occasionally it may bleed.
You will sometimes meet with this form of ekzema on
the tips of the fingers, where it may be accompanied
with painful cracks. We have seen it several times
in ladies who play upon the harp.
In the palm of the hand, this ekzema squamosum
is known by the name of psoriasis palmaris, and in
truth it is the legitimate psoriasis palmaris, the
direct ofispring of its chief of kin, psora ; psora
being, as we have already pointed out, the ekzema
of modem nomenclature. There are several other
afiections of the palm of the hand, that we need not
more particularly allude to at present, that are also,
but falsely, called psoriasis ; a fact which renders
the correct diagnosis of an ekzema squamosum of
more importance than would otherwise be the case.
Ekzema squamosum sometimes, also, takes pos-
session of the walls of the nails, and besides being
painful and troublesome, disturbs the healthful
formation of the nail. This is especially the case
when the posterior wall, that which contributes
to the production of the surface of the nail, is
afiected. The posterior wall may or may not be
swollen in this instance ; it may or may not be
fissured ; but the surface of the nail is apt to be
discoloured, rough, and marked by numerous hol-
lows, as though it were wormeaten ; and sometimes
CONSTITUTIONAL RELATIONS OF BKZEMA. I 75
the nail is thickened and homy both in colour and
density. This form of disease is ekzema unguium,
a troublesome and vexatious affection.
Ekzema squamosum of the hands may be met
with at every period of life, but is most common in
persons of advanced life ; in such as have a dry
skin, and an exhaustive and nervous temperament.
Constitutional relations op Ekzema. — ^Let us
now turn to another page in the history of ekzema,
and inquire into its relations with the constitution
of the individual. Ekzema may be regarded in the
double light of a disturbed function of the economy
and a disturbed function of the part. It has
therefore no constitutional symptoms of its own,
and any symptoms that may be present in associa-
tion with it must be attributed to the general dis-
order of the economy upon which the ekzema
depends. Very frequently ekzema is substitutive
of some other form of disease, and the symptoms
of that disease cease as soon as the ekzema is
developed, or it may be derivative of a morbid
action taking place within the economy, and a
similar result will follow. Popular observation of
this kind has doubtless been the source of the
prejudice, so common amongst the pubUc, against
a rapid cure of ekzema ; and, corroborated by the
humoralistic doctrine of a past day, has suggested
the dread of transferring the disease from the
skin to some inward part, in other words, of
" driving in *' the disease. Hence we sometimes
hear the stale opinions of medical men, that an
ekzema infantile should not be interfered with,
and sometimes this miserable twaddle goes the
length of assuring the mother of the infant that
it would be easy to cure the local affection, but the
constitution would be certain to suffer. A sounder
theory than humoralism will impose a natural check
to such puerile objections, and will secure a more
wholesome philosophy.
176 DIAGNOSIS OF EKZ£MA.
But although ekzema has nothing specific in its
nature and has no constitutional symptoms, it has
all the capacity for becoming a serious irritant of
the economy, and of increasing the disorder to
which it owed its own proper origin. If disordered
digestion, disordered nutrition, or disordered inner-
vation be the causes of ekzema, these disorders
may be increased by the irritation raging in the
skin ; an irritation which destroys comfort, destroys
sleep, destroys appetite, destroys exercise, and
necessarily lays the foundation of an infinity of
secondary evils. It is well known that in infants,
ekzema is not always limited to the skin ; but
sometimes extends to that inner skin the mucous
membrane, which lines the air-passages ; and in
this way becomes the source of thickening of the
membrane, of obstruction of the air-tubes, and pos-
sibly of dilatation of the air-cells ; for bronchitis at
an early period, and asthma in later age, are by no
means unfrequent companions of ekzema.
Again, by ekzema of the skin, a state of chronic
irritation and exhaustion of function is sometimes
established in that membrane, as a life-long conse-
quence. The adult, who has suffered from ekzema
infantile, is not unfrequently, for ever after, the
victim of a dry, harsh, wrinkled, unsecretins:, or
unperspiriBg tegument; sometimes we haveVc-
ceeded in tracing xeroderma to this source, xero-
derma, the parent of true ichthyosis. And, veiy
constantly, the possession of an ekzematous dia-
thesis is indicate by a shrivelled, dystrophic con-
dition of the skin, maybe of the face ; maybe of the
fingers and hands ; a state which the texture and
appearance of the skin of the rest of the surface of
the body tend to corroborate as appertaining to
ekzema.
DuGNOSis. — ^And now let us say a few words with
regard to the diagnosis of ekzema. Ekzema is a
superficial and chronic inflammation of the skin.
DIAGNOSIS OF EKZBMA. I 77
attended with a ragged and desquamating state of
the epidermis, and with the exudation, or a ten-
dency to exudation, of an ichorous fluid ; the
ichorous fluid being sometimes retained in minute
vesicular elevations of the epidermis, sometimes
free, and sometimes infiltrated in the tissues of the
skin. When all these signs are present together,
and especially the exudation and the broken epi-
dermis, ekzema stands self-confessed ; but we have
also, very frequently, to see that an erythematous
eruption will, at a fixture period, become exudative,
or that a state of desquamation has, at an earlier
period, passed through an exudative stage. In a
word, any doubt as to diagnosis can only arise in
the instance of the erythematous and papulous
forms of the affection, and sometimes, but more
rarely, in the squamous form.
Wherever a doubt does exist, we must fall back
on the other known phenomena of ekzema. Thus,
if there be suspicion of an ekzematous diathesis;
if the patient have any present indication of ekzema
in the known haunts of that afl^ection, as in the
joints, behind the ears, in the head; if he have
previously suffered from ekzema in any shape ;
these may be taken as corroborative proofs in aid
of your diagnosis. Again, another source of veri-
fication is presented in the negative phenomena of
the disease. Ekzema, it will be remembered, is
slow in its progress. It is more superficial than
erysipelas, but deeper than erythema. It is un-
attended with swelling in the beginning, and is
rarely marked by much sweUing throughout its
course. It is pruritic from the first, and the
pruritus increases with its advance. It is rarely
developed with the uniformity of an exanthem. it
is apt to be patchy in one place, and papulous in
another, and each day contributes to reUeve us
from our doubt. Moreover, it is important to
remember, that, unlike the exanthemata, ekzema
N
178 .BTIOLOGT OF EKZEMA.
has no premonitory symptoms, and no concurrent
febrile manifestations.
On the other hatid, gentlemen, ekzema has suf-
ficientljr close resemblances with other affections to
make it necessary that you should use your best
judgment in your inquiry. An erythematous or a
papulous ekzema may resemble a variola, a scarla-
tina, a rubeola, a roseola, an urticaria, an erysipelas,
an erythema, a dermato-syphilis, or a lepra; but
if you are well grounded in the natural history of
the disease, your doubts will soon vanish and you
will learn to decide without hesitation. There is
a moment when a herpes closely resembles an ek-
zema, but in the fully-developed form of either it
would be difficult to make a mistake between them.
The same may be said of pemphigous affections in
their broken state, when they expose to view an
inflamed derma, exuding a copious ichorous dis-
charge ; and a like remark appUes to the circum-
scribed, squamous, and hypertrophous blotches of
ekzema, in relation to the well-known disks of
lepra.
Etiology of Ekzema. — There are few things in
philosophy more remarkable than the change which
has taken place in the medical mind, within the
last few years, as to the signification of the word
disease. At one time it was believed that disease
was something foreign to the organization ; at the
present time it is recognized that disease is nothing
mpre than discordant and untimely action ; it is
the jarring string of the harpsichord; it is, to
travesty a popular phrase for which we are in-
debted to Layard, the right thing in the wrong
place. Very generally, perhaps always, for we do
not at this moment remember an instance to the
contrary, it is a reparative process ; but, alas 1 too
frequently the reparation is a dam by which the
whole fabric is ultimately ruined. And we
cannot place before you a more dire picture of
ETIOLOGT OF EKZBMA. I 79
impending destruction than that of the substitution
of one tissue for another; let us say, nerve sub-
stance for muscle ; vascular tissue for bone ; bone
for vascular structure ; fat for heart-substance ; con-
nective tissue, or any member of the cell family, for
more highly organized structures ; or one or more
of these tissues for skin. Herein lies, in many in-
stances, a terrible realization of the nature of disease.
Such conditions as those now referred to bring
under our consideration the ruling and co-ordinating
and maintaining power of that sublime essence,
LIFE. We may not be scientific enough to put life
into a bottle and weigh it or measure it, for such,
we are told, are the aims of science ; but it
demands of us little philosophy to recognize its
existence, and to note and to observe its laws.
Of life in excess we can form no conception ; but
life in its multiple degrees of declension, from
health downwards to disease and dissolution, is
the daily object of our observation and study. We
have said that disease is '* discordant and imtimely
action " ; that it is the " right thing in the wrong
place " ; we may take a step further and say that
the regulator of discord, of untimely action, of mis-
placed action, is life. Our business, then, as medical
men, is with life, is to sustain life ; and to this one
end to direct all our inquiry and all our energies. K
we were asked : — ^What is disease of the skin ? we
should answer — It is a lowered vitality of the tissue
of the skin, manifesting itself by abnormal action.
If, upon these premises, we further inquire. What
is the cause of disease of the skin ; and a fortiori
of ekzemaP the answer would be — Debility, con-
stitutional and local ; debility of the system and
debility of the skin.
Having now entered upon the question of the
etiology, or the cause, of ekzema, we may repeat
that the skin falls into a condition of disease because
it is weak ; and that the cause of skin disease, or,
N 2
l8o ETIOLOGY OF EKZEMA.
if you will, the cause of ekzema^ is debility. And as
the consideration of " cause " involves a series of
consequences, we may further state, that the skin
is weak either from hereditary quality or from acci-
dental circumstance ; the accidental causes being
constitutional or such as create debility of the skin
through the agency of the system ; and heal or
such as produce debility by direct operation on the
part. Let us look at these causes when displayed
in a tabular form ; we then have : —
ai • J u-vi. (Hereditary
Skin debility | Accidental ( Constitutional
X Local.
Hereditary ekzema is by no means a rare mani-
festation of the disease. We meet with it in infants,
one or other of whose parents is ekzematous ; we
meet with it under similar circumstances in the
adult; or it comes before us as a sequela in the
form of xeroderma or ichthyodes. And we may be
permitted to inquire : — ^What it is that is conveyed
by hereditary transmission from the parent to the
oflFspring ? To this question the simplest of all
answers is evidently the most correct, namely,
tisstie resemblance. Just as the features of the
child have their type in the parent, so also have
its tissues ; a type which is constituted, not of figure
alone, but also of function. We have just traves-
tied the language of a distinguished politician, and
we venture now to travesty, but with a sense of
deeper veneration, a holier writing : — " And the
morbid conditions of the parent shall be visited on
the children " ; for this law is indeed as true in its
bearing upon physical conformation as it is in
relation to the moral attributes of the individual.
But what shall we say to a doctrine that would
convey, as an answer to our question, the idea of
the transmission of a virus ? Why, simply that it
ETIOLOGY OP BKZEALA.. l8r
haa no foundation, is false and obsolete, and only
fit to be trodden under foot. And yet this idea
has prevailed aforetime, although it is now, as we
believe and sincerely trust, utterly extinct.
The accidental causes of ekzema are twofold ;
they are either a part of the constitution of the
individual for the time being, namely, — constitu^
tional; or, they are external and foreign to the
general organism, and operate only on the afiected
part, or, in other words, are local. It will easily
suggest itself to your minds that there may often
be a blending of the two sets of causes in an indi-
vidual case ; and this is actually the fact. Under
these circumstances we should select the more pro-
minent of the phenomena to represent the dominant
cause, while therapeutically we should address om*-
selves to both kinds of causes.
Now, if we assume debility to be a cause pre-
disposing the skin to the operation of morbid
Amotion, we may further inquire, — ^What it is that
predisposes the skin to debility ? In other words, —
What are the remote predisposing cattses of cuta-
neous disease ? We have already settled that
question in relation to hereditity; and we have
now to address ourselves to the remote predis-
posing causes belonging to the accidental constitu-
tional group ; and these we may state to be four in
number, namely : —
Diathesis Assimilative
Nutritive Neurotic.
Diathesis, or tendency, is manifested by the
aptitude of the skin to take on a morbid action
upon the accidental presence of any cause disturbing
the general functions of health. In the possessor
of an ekzematous diathesis, the conditions which
would occasion a dyspepsia, a bronchitis, or a rheu-
matism in persons prone to these separate tenden-
1 82 ETIOLOGY OF EEZEMA.
cies or diatheses, would in him occasion an ekzema.
The diathesis in this case has not been inherited ;
it is acquired ; but in time it becomes so far iden-
tified with the constitution as to be susceptible
of transmission by generation, and in that manner
to be in reality the source of inherited ekzema.
Constantly we meet with examples of accidental
ekzema, as in the instance of congenital ekzema
wherein no predisposition to the disease exists in
the parents. But, unless the disease be thoroughly
cured, it may be, and will be, so far identified
with the tissues of the child as to admit of being
transmitted to the offspring of that child by way
of inheritance. And in a case of this kind we
should have strongly impressed upon our mind the
necessity of promoting a complete and permanent
cure, to prevent such a mischievous result. We
shall ask you, gentlemen, to extend this principle to
other diseases besides ekzema — ex uno disce omnes,
and by this means you will become better and more
useful physicians ; healers in the proper sense of
the word, rather than ** darners " : we have already,
in a previous part of this lecture, told you of the
danger of " dams."
By NCJTBITIVB remote predisposing causes, we mean
a failure of the proper nourishment of the body,
and, you will agree with us, doubtless, in the belief
that few causes would be more potent in the pro-
duction of debility of the constitution and through
the constitution, of debility of the skin. We are
not at present prepared with our figures, and there-
fore we must ask you to accept the very objection-
able adjective " many," when we say that very
many cases of ekzema arise from this cause, par-
ticularly in infants, children, and young persons
generally. Let us offer you one example out of a
multitude. A nursing mother falls short of her
supply of milk ; her infant has to be brought up
by hand, a difficult and hazardous process; the
ETIOLOGY OF BKZEMA. 1 83
artificial food is uncongenial to the sensitive organ-
ism that it is required to nourish; nourishment
fails ; starvation impends. You will admit that
this is not an exaggerated picture ; but what hap-
pens ? The infant is reduced to a state of debility,
nutritive debmty ; an exciting cause steps in as
an untant of the skin, and then those immediate
or proximate changes take place which constitute
ekzema. Do we not weU, therefore, in establishing
a group of causes which take their origin in de-
ficient nutrition ? a group of nutritive causes.*
Assimilative remote predisposing causes give us
a third group, taking their origin in derangements
of digestion and its allied functions, including as-
similation. We prefer to take this wider view of
the nature of these causes, than to speak, as we
might otherwise have done, of dyspeptic ekzema ;
arthritic ekzema; rheumatismal ekzema, and so
forth. In a word, just as we have traced up a
certain group of causes of ekzema to deficiency of
the nutrient element of the body ; so we can trace
up another series of causes to the governing prin-
ciple of the stomach and its dependencies. You
will perceive that these views lead us onwards to
the chief object of medical research, namely, the
treatment of disease ; for if certain diseases are
found to arise from deficiency of nutrient material,
then the supply of nutrient material is the aim
of our treatment ; and, in like manner, if the
important functions of digestion and assimila-
tion are the point of weakness, we address ourselves
directly to them. By a different process of reason-
ing our French colleagues have arrived at similar
results to ourselves ; they have a family of herpes
tides, which are equivalent to a diathetic group ;
a family of scrqfvlides which correspond in some
measure with our nutritive group ; and a family of
• Fic^ Chaptxb lY.
184 ETIOLOGY OF EKZEMA.
arthritides whicli would seem to be tlie representa-
tives of our assimilative group. And just as we
teach the necessity of directing our constitutional
treatment towards the improvement of nutrition
and the strengthening of the assimilative system ;
they enforce the adoption of a special treatment for
herpetism, scrofulism, and arthritism. Put the true
searchers after truth within the Kmits of a ring fence,
and they will all, sooner or later, arrive at the same
altar, although some may reach it upon their bellies,
some upon their heads, and some few upright, in
the image of their Creator.
There is yet a fourth group of remote predis-
posing causes, to which we have given the name
of NEUEono. They are not diathetic, neither are
they dependent upon the mere absence of nutrition ;
nor can the digestive and assimilative ftmctions
be especially blamed; but their essence is irrita-
bility ; irritability taking its origin in nervous
debility ; and on that account we call them nervous
or neurotic. For the subjects of nutritive causes
we should look to infants, to children, to the
growing age of youth, and to the parturient
period ; for the subjects of assimilative causes, we
seek in the mid-period of life, when the material
of nutrition is useless otherwise than as a stimulant ;
when, in consequence, it is present in excess ; and
when, as a further consequence, it undergoes chemi-
cal transformations that become excitants of disease*
While, the neurotic group is supplied by those who
have passed the meridian ; in whom waste has
taken the place of appropriation ; or those at earlier
periods of life, in whom the nervous system has
acquired an ascendency over the organism and
tends to waste its kingdom by excessive, by ill-
regulated, and by morbid activity.
Gentlemen, need we say more with regard to the
remote predisposing causes ; the tenant for life,
represented by the hereditary and the diathetic ; the
ETIOLOGY OF EKZEAIA. 1 85
nutritive as represented by the period of growth ;
the assimilative as represented by the stationary
period ; the neurotic as represented by the wasting
period of existence. All that needs further to bo
said, is a repetition of what we have already men-
tioned in reference to the constitutional and local
causes ; the remote predisposing causes are occa-
sionally combined ; sometimes the combination may
be the nutritive with the hereditary ; the nutritive
with the diathetic ; the diathetic with the assimila-
tive ; or the diathetic with the neurotic. The
relative importance of these combinations you will
easily appreciate.
To descend from the general to the particular,
with a view to illustrate the kind of causes which
may predispose to ekzematous disease; we group
imder the head of nutritive causes : — errors of diet ;
weakly parentage ; excessive growth ; and errors
of hygienic principles. Under the head of as-
similative causes, we place : — deranged diges-
tion ; vicissitudes of cold, heat, and moisture ;
mental disquietude; and constitutional or organic
disease. And as neurotic causes, we assemble to-
gether : — anxiety and affliction ; excessive mental
and physical labour ; ungenial climate ; uterine,
reproductive, and puerperal derangements ; and
nervous shock or fright. And, although it be true,
that all these causes tend to the production of one
and the same disease ; nevertheless, that disease is
not an independent entity, and does not admit of
being treated by itself, but only through the causes
which hatre given it birth.
It may be interesting as an exercise, and will
add to our knowledge of this important disease, to
run over the various predisposing causes which
may be alleged capable of giving rise to ekzema,
and we place before you a list of causes which we
have ourselves oftentimes verified ; arranged in
physiological order j they are : —
1 86
ETIOLOGY OF EKZBMA.
Fbedibposino Causes of Ekzeica.
Weakly parentage
Errora of diet
Errors of hygienic principles,
namely, air, exercise, clean-
liness, clothing, &G.
Vicissitudes of cold, heat, and
moisture
Transition of seasons
Ungenial climate
Vaccination
Dentition
Excessive growth
Excessive labour, mental and
physical
Deranged menstruation
Mental disquietude, anxiety,
affliction
Sexual excesses
Uterine, reproductive, and pu-
erperal derangements
Deranged digestion
Exhaustion from disease
Heemorrhage
Cachexia
Gk>ut and rheumatism
Nervous shock and fright
Local injury.
In determining the cause of a given disease, we
need hardly remind you that we have to consider
the agencies which conduce indirectly, directly, and
immediately to the result which it is sought to
explain ; or, in technical language, the predisposing,
the exciting, and the proximate cause. Thus, if we
take, by way of illustration, an instance of ekzema
infantile, an error of diet may be the predisposing
cause, friction of the skin an exciting cause, and
hypersBmia, with exudation or desquamation, that
is, ekzema, the proximate cause. It is often very
convenient and very instructive so to be able to
dissect the causes of disease, while, on the other
hand, we rarely have the leisure to effect this
analysis in practice ; it is, in fact, the grammar of
medicine ; and although in time, and with the aid of
experience, we learn to talk and to practise without
the presence of our grammar, it is well to be
grounded in grammar, and to be able to fall back
occasionally upon our grammar in moments of
thought and reflection, or under circumstances of
difficulty. It may, however, be as well to remind
you that the predisposing causes are in many
instances only relative in their operation : thus an
error of diet, besides being predisponent, may also
ETIOLOGY OP BKZEMA. 1 87
be excitant ; and the same may be said of hygienic
principles, vicissitudes of temperature, and most of
the others. Again, to return to our first example,
ekzema infantile, — error of diet may be the predis-
posing cause, and cold or heat the exciting cause ;
and fiirthermore, with hereditary diathesis, acquired
diathesis from weakly parentage, or errors of diet or
hygienic principles as a predisposing cause, vaccina-
tion or dentition may become the exciting cause. In
fact, in this as in most of the examples of medical
philosophy, science is the servant of knowledge ;
science feeds the furnace and greases the engine,
but knowledge is the acting mind, and directs the
course and navigation of the ship.
We will now, gentlemen, direct your attention to
another group of causes, in this instance exciting
causes, or such as directly excite the disease we are
now studying. The causes we have heretofore con-
sidered prepare the way for the present group ; they
predispose, these excite; but you will be able to
form a better judgment of them by seeing them
displayed in a tabular form, thus : —
Exciting Causes op Ekzema.
Local Group.
Cold Chemical irritants
Heat Mechanical irritants
Moisture Varicose veins
Friction Traumatic injury.
Gonstitutional Oroup.
Unwholesome food, Certain medicines.
You will see that the exciting causes of ekzema
belong chiefly to the class of local irritants and are
especially concerned in the production of the local
Ws of the disease, and tL remarks which we
have made heretofore on the relative character of
causes are particularly applicable to the present
l88 ETIOLOGY OP EKZBMA.
group. For example, cold and Jheat and moisture
are frequent predisposing causes, and they are also,
under other circumstances, common exciting causes.
Need we remind you of the chapped wrists and
hands of cold weather, ekzema erythematosum et
fissum ; of ekzematous eruption engendered by the
direct agency of heat, as in ekzema solare ; or of
that very common cause of ekzema resulting from
the combined influence of heat and moisture, as in
the case of ekzema axillare and ekzema perinaai ?
Then we have ekzema resulting from clothing and
bedding of too heating a quality, and especially
when heat and perspiration are united ; ekzema from
the flow of the tears, of saliva, of discharges upon
the skin, and ekzema mamillarum. And then there
is a yet more striking and homely example of the
irritant consequences of combined moisture and
heat in the instance of the common poultice; a
large number of ekzematous legs owe their origin
solely to the apparently harmless, but in reality
dangerous, poultice.
Besides these we have an active exciting cause of
ekzema in friction, and especially in that more severe
form of friction to which itching incites, namely,
scratching. Hebra has the credit of making the
remark that the eruption of scabies, which
is an ekzema, is due, less to the direct irrita-
tion of the acarus than to the scratching to which
its titillation necessarily leads. We need not accept
this statement as a fact, but it is convenient as an
illustration. Then follows the extensive family of
the irritants — the mechanical irritants, such as
sugar, flour, brick-dust, and lime, in the instance of
the grocer's itch, the baker's itch, and the brick-
layer's itch ; and the chemical irritants, for example,
— alkalies, acids, tincture of arnica, cantharides,
and croton oil.
Varicose disease of the veins of the lower ex-
tremity is a common cause of local ekzema ; disten-
ETIOLOGY OF EKZEMA. 1 89
sion of the minute venules of the skin occasions
itching ; the nails are brought into requisition to
relieve the pruritus, papulaa result from the increase
of irritation caused by the scratching, and a papular
ekzema is forthwith established. It may be ques-
tioned, as in the case of scabies, whether the varicose
veins, as well as the acarus, may not also be regarded
as a predisposing cause and the scratching the real
exciting cause. Again, a scratch, an abrasion, or a
leech-bite ; the puncture of the ears for earrings, or
the slight operation for vaccination, have also been
known to be the starting-point of an ekzema, and in
this sense a traumatic cause.
Constitutional exciting causes are evidenced by
disturbance of the stomach occasioned by unwhole-
some food, and also by certain medicines, such as
opium, mercury, and copaiba. The hydrargyria of
Alley, or erythema mercuriale, was an ekzema ; and
the eruption caused by copaiba in certain constitu-
tions is well known, and is apt to degenerate into
ekzema.
The doctrine that we have advanced in respect of
the nature of ekzema, namely, that a causa morbi in
the system, failing the condition of an exciting cause
in any other of the organs of the body, may, in the
presence of such exciting cause in the skin, be
manifested by that membrane, will prepare you for the
observation that ekzema is very frequently stibstitutive
of some other disorder of the economy. Sometimes
ekzema follows or takes the place of a bronchitis ;
sometimes of a derangement of the digestive
functions, commonly denominated a bilious attack ;
sometimes of a fit of gout or rheumatism ; some-
times of haemorrhoids, and so forth.* In practice
you will see this association so frequently, that it
will teach you, perhaps more than anything else, the
principle of treatment of this disease, and it will
♦ Fide Chapter IV.
I90 ETIOLOGY OF EKZEMA.
act as a warning against trusting too exclusively to
local treatment. Often it will occur to you that
your patient is perfectly sound, like a good horse,
wind and limb ; but in what way is perfect health
consistent with a troublesome ekzema ? Why, in no
other way that we can understand, barring the
existence of locally morbid tissues, than through the
absorption by the ekzema of the whole of the caiisa
morbi previously smouldering in the economy.
The facts, however, as to the mbatitutive attributes
of an ekzema are overwhelming ; but we are not
equally convinced of its derivative eCFects. The theory
that regards ekzema infantile as an outlet or safety-
valve that is not to be disturbed, necessarily treats
of the eruptive aflfection as a derivation of some-
thing which it may be necessary to remove from the
system, the idlest possible quality of medical moon-
shine ; a kind of routine lunacy only too common
amongst mankind. That there is a causa morbi there
can be no question, and happy the individual in
whom a causa morbi is absent at any time; the
essence of that causa morbi is debihty, and nothing
can be more unphilosophical than to assume that an
existing debility is not to be removed ; or that its
removal, by curing an existing disease, predisposes
to another and a more serious disease. The mode
of viewing ekzema, whatever its form, and whether
occurring in the infant or in the adult, is exactly
that in which we should regard every other com-
plaint, whether it be a bronchitis, a pneimionia, a
diarrhoea, or any kind of disease, namely, as a thing
to be cured, if we are able, with all the speed that
we can bring to bear upon the proceeding, and in
the most direct and certain manner, and without
respect to ulterior events. We are often told by
the mother of an ekzematous infant : — My doctor
says he can cure the disease, but then the disease
will be driven in, and the child will have something
worse. There are clearly two fallacies in this state-
ETIOLOGY OF EKZEMA. I9I
ment, the first being that the doctor can " cure the
disease/' for of a certainty, if he could he would ;
and the other fallacy is that " a driving in " is
possible, or that any other disease would result fi'om
the cure of the ekzema. We may repeat that ekzema
is a debility; to cure the ekzema is to cure the
debility, and consequently to make the weakly child
strong and healthy.
Gentlemen, — ^we opened our inquiry into the
nature and quaUties of ekzema by impressing upon
you the necessity of a thorough knowledge of this
one disease, not only on account of its own in-
dividual importance, but also because it must be
regarded as the type of cutaneous disease in general,
and the standard with which all other diseases of the
skin are to be compared. We have therefore pursued
the subject of its etiology at considerable length, more
lengthily possibly than may have consorted with your
patience ; nevertheless the subject is far from being
exhausted, and will well repay a personal examina-
tion for yourselves. For the present we deem it
expedient to dismiss it, and conclude with a summary
more easy of being borne in remembrance than our
previous lengthened detail. The cause of ekzema
is debility, sometimes inherent or diathetic, some-
times hereditary, and sometimes accidental or
acquired. Every condition which tends to produce
debility is therefore a cause of ekzema. It may be
that the cause is a direct excitant, or it may be a
predisponent requiring the ulterior stimulus of an
excitant. So that, in ekzema, as in most other
diseases, two factors are necessary to the production
of the affection ; first, a condition of the body
favourable to morbid action, and, secondly, an excitor
capable of setting up morbid action. We will illus-
trate this point by one or two popular examples, in
order to impress the matter more forcibly on your
recollection. You know the encrusted ekzema of
infants, termed crusta lactea^ a state of the disease
192 £TIOL0GY OF EEZEMA.
which conveys in its name both its cause and the
effect of that cause. Insufficient or bad milk is the
occasion of debility ; and, secondly, insufficient or
bad milk deranges the stomach, and throws out an
eruption on the skin. Again, we hear of ekzema
from dentition, and of the very general impression
amongst medical men that such an eruption is not
to be treated. Let us see how the case stands in this
instance : painful dentition causes want of rest, dis-
turbance of the digestive organs, debility ; painftil
dentition is therefore a predisposing cause ; then an
exciting cause, such as cold or heat and moisture,
steps in, and ekzema is established. Now, gentlemen,
can you conceive any objection to removing, if you
cauy the predisposing cause, or the exciting cause,
even if you dread to cure the proximate cause, that
is, the disease ? We think not ; neither do we think
that you would lose your aplomb of self-respect, if,
in honestly allaying the causes, you inadvertently
cure the disease. Or, let us take another case of
still more importance as far as being thoroughly
understood is concerned, namely, ekzema from vac-
cination. Vaccinia, as you well know, is a modified
small-pox ; the vaccine fever always occasions more
or less debility, consequently a state favourable to
the invasion of ekzema ; in other words, vaccination,
with perfectly pure lymph, is a predisposing cause
of ekzema ; and another factor, namely, an exciting
cause, completes the nosogenetic circle. Or, the
case may stand thus : the child is hereditarily
ekzematous, and then the mere puncture of vaccina-
tion becomes in itself the exciting cause. We know
the care which vaccinators usually evince in the
selection of subjects for vaccination, and to this
fact is to be attributed the extreme rarity of
ekzema after vaccination ; but with all the c^re they
can adopt, an accident of this kind will sometimes
happen. A lady brought to us, a short time back,
an ekzematous child, in whom vaccination had
PROGNOSIS OF EKZBMA. 1 93
brought out vaccinella, in other words, an eruption
of umbilicated vesicles resembling those of small-
pox ; and we have recorded, in our writings, similar
examples. But more frequently, the reverse of this
occurrence is experienced, and the ekzematous
diathesis generally refuses to respond to the vaccine
impregnation.
Pbognosis op Eezema. — ^And now, gentlemen, we
will leave the important question of cause and pass
on to that of prognostics. You will be consulted by
mothers whose children are in a deplorable state
from ekzema, and who may have been some time
suflTering before they come under your notice, and
they wiU put to you two questions : — Is there danger
to life ? Is there danger of deformity ? And to
both of these questions you may answer in the nega-
tive. Ekzema is a disease of the ^^ summa cutis "
of the most superficial stratum of the derma, a
disease in which the secreting faculty is in excess ; a
kind of catarrh of the external skin ; a disease in
which disruption and separation of the epidermis,
with profusion, accumulation, and desiccation of
secretions, together with a moderate amount of
oedematous swelling, are the essential characters ;
there is neither deep inflammation nor destruction of
tissue, and therefore all these appearances clear away
like an exuviated cuticle, when a cure is effected, and
leave no trace of their presence behind them. In one
instance only, which lately fell under our notice, there
was superficial sphacelus of the skin, with sloughing,
extreme exhaustion, and a fatal termination of the
case ; but these bad symptoms occurred onlv as the
consequence of mismanagement. A second instance
of death from ekzema in an infant is all that we can
remember to have met with ; and there also mis-
management was the causa vera of the misfortune.
When it is remembered that not only the outer
skin, but also the mucous membrane is very com-
monly affected in ekzema, and especially the mucous
104 PROGNOSIS Of EKZEMA.
membrane of the lungs, it is matter of surprise that
a fatal termination of the disease is so very rare.
We have seen this combination several times fatal in
the adult, but in such cases bronchitis and pneu-
monia were the more frequent cause of death.
Nevertheless, although we can speak hopefully of
ekzema in regard to the ultimate result, there are
several points in its history that mark it as an
inveterate disease, and often a life-long torment.
When it owes its existence to a diathesis, and is
developed in infancy, it is wont to interfere very
seriously with, the nutritive fiinctions of the skin.
The skin is apt to become dry and hard and harsh,
susceptible of irritation from trivial causes; the
normal secretions of the skin are more or less sus-
pended or arrested ; the cuticle is unsound, and that
state of the integument is engendered which we
have termed xeroderma, a first stage of ichthyosis.
Like all diseases of the catarrhal class, ekzema is
prone to be very chronic as to its duration ; it drags
its weary length slowly along ; it is apt to become a
habit ; and from the presence of itching as a leading
symptom, two of the most active of the causes of
the disease, namely, friction and scratching, are per-
petually in operation in keeping up the disease.
Another of the phenomena of ekzema, a tendency to
recurrence, is also to be borne in mind in drawing
our prognostic of its issue. Ekzema is apt to recur
annually, for example, in the winter or summer of
the year ; sometimes twice in the year, as in the
spring and at the fall ; and at other times at periods
of several years. Again, its association with a mal-
assimilative diathesis, such as gout or rheumatism,
would very much influence our decision ; or its con-
nection with some chronic and permanent disease of
the local class, such as varicose veins. But possibly
ekzema is, under no circumstances, more inveterate,
next to its diathetic origin, than when it is asso-
ciated with a weak and irritable nervous system —
TEJiAtMfiNT OP EKiEMA. t^S
for example, in that group of the affection which we
have distinguished as neurotic ekzemata.
In conclusion, looking to the many causes which
contribute to render ekzema a more than usually
chronic and inveterate affection, and taking jinto
consideration the circumstance that it is necessarily
a disease of tardy movement towards cure, prone to
repeated and vexatious exacerbation and relapse, we
may venture to deliver the general verdict — ^that
ekzema is not dangerous to life, that it is always
susceptible of mitigation, and generally admits of
permanent cure.
Tbeatment op Ekzema. — ^We have directed your
attention to a series of questions which have pre-
sented themselves to our notice in the course of our
study of ekzema. We began with the inquiry : —
What is ekzema ? Then : How is it known ? And
further : How is it to be distinguished from other
diseases P We next proceeded to the examination of
its causes, and then to consider its consequences ;
these various questions comprising the definition^ the
description^ the diagnosis ^ the etiology, and the pro-
gnosis of the disease. We have now to take the final
step of considering : What are the means which con-
duce to its cure ? In other words : What is the
treatment to be adopted for its cure ?
The first and almost the chief thing that attracts
the attention in ekzema is the local affection ; it is
on account of this that the patient applies to you for
relief, and often himself sees nothing else that re-
quires treatment. Nevertheless, thanks to the po-
pular prevalence of humoralistic views, he is ready
to suspect and to acknowledge that there must be
something wrong in an organization that is unable
to extend its protection to the most distant limits of
its territory and is incapable of resisting the irrita-
tive influence of ordinary stimulants applied to the
skin, and he is prepared to accept in aid of the local
2
196 TREATMENT OF EKZEMA.
treatment, a treatment adapted to give energy and
strength to the constitution ; in other words, a con-
stitutional treatment.
Let us take as an illustration of these views an
example that we have appealed to often before,
namely ekzema infantile. An infant is covered with
an eruption of ekzema ; the cause of that efuption is
an error of diet; we should be ill-performing our
duty if we were to content ourselves with a local
treatment to the skin, without making an endeavour
to remove the cause by modification or improvement
of the diet. It may happen that a mere change of
diet — say, a wet-nurse, or Liebig's food, or cod-liver
oil — ^may be suflBcient for our purpose ; but it is also
not improbable that deficient nourishment, pain, and
want of rest, may have engendered a state of con-
stitutional disorder, which will render necessary a
recourse to tonic medicines such as phosphoric or
hydrochloric acid, or iron, or arsenic. Or, if we
take the most simple instance of local ekzema, and
examine the constitution searchingly, we shall dis-
cover evidence of deficiency of nutritive power;
otherwise, nutritive debility. You may accept it as
certain, and beyond the reach of question, that dis-
ease cannot fix itself upon a healthy organism ; and
that the presence of local disease is a proof of a
debiUty of organization, a debility that medical
treatment may in most instances relieve, and in
many also cure.
We think that you will agree with us that ekzema,
like most other diseases attended with a local mani-
festation, calls for a constitutional as well as for a
local treatment. In fact, ekzema difiers from no
other disease of the organization, excepting in this,
that from its position at the surface of the body, it
is inevitably exposed to the perpetual influence and
irritation of the atmosphere.
The LOCAL TBEiXMENT OF EKZEMA may be summed up
in a few comprehensive words i-^allay irritationy and
TfiEATMENT OF EEZEMA. 1 97
restore the weakened tissues to the normal standard of
health. The most complete mode of allaying irrita'
tion is to exclude the atmospherical air without
•nterference with the transpiration of the skin. The
nethod of restoration of the skin to its normal
health is by the judicious use of stimulant remedies.
Stimulants, you will remember, when administered
internally are termed tonics, so that the external
treatment which we propose for the corroboration
of the tissues of the skin, is eminently tonic.
Daniel Turner, the first of BngHsh dermopatho-
logists,* left behind him a reputation for his v/aguen^
turn de lapide calarnvnaret the famous Turner's cerate;
and we hope to be able to leave behind us an equal
reputation for the benzoated ointment of oxide of
zinc ; at last, and apparently with some reluctance,
provided with a place in the British Pharmacopoeia,
upon whose pages it sheds unwonted lustre, t Now,
the oxide of zinc ointment, properly benzoated, and
made of pure materials, pure oxide of zinc and pure
lard, is the most perfect local application for ekzema
at present known ; and, indeed, is so perfect, that we
doubt the possibility of its ever being excelled. It
is suitable for every form and every stage of the
disease, but most of all for the dry forms ; and it
should be applied in a twofold manner, namely, in
substance with the point of the finger, or a thin
spatula, or the hand, so as to distribute it imiformly
over the morbid surface ; and, spread on some soft
material such as lint, cambric, or fine flannel. Em-
ployed in this way, the oxide of zinc ointment has all
the advantages and most of the uses of the poultice,
without the objectionable qualities of the latter, the
dirt, the fermentation, the saturating moisture, and
the decomposition. And it fulfils the purpose which
* Tomer flourifihed in the early part of the eighteenth centuiy,
about 1710.
t Journal of Cutaneous MsdicinE; vol. i. p. 401.
198 TBEATMKNT OF EKZEMA.
it was Bought to aocomplisli, it excludes the atmo-
sphere without preventing transpiration ; it keeps
the surface upon which it is apphed soft and flexible,
and it gives nature time to effect the reparative pro-
cesses needed by the skin. Sometimes the dressing,
if the diseased surface be of small extent, may be
kept in its place by strips of adhesive plaster ; some-
times, and when possible this is always desirable, it
is maintained in its place by the moderate pressure
of a bandage either of elastic cotton or of Domett's
flannel. But there are situations in which a bandage
could not conveniently be applied, such as the face
and the general surface of the body ; and others in
which a dressing of any kind would be objectionable,
as behind the ears, in the axillaa, and in the region
of the pudendum ; and in all these cases we must
trust to the reapplication of the ointment as fre-
quently as it may chance to be rubbed off.*
It may be laid down as an axiom of cutaneous
medicine that ekzema, in its active stages, should
never be washed ; one of the first instructions which
you give to the mother of an infant suffering under
ekzema infantile is to avoid washing the eruption ;
discharges may be absorbed by a soft napkin, adjacent
surfaces may be wiped with a similar material, dirty
ointment or loosened crusts may be lightly brushed
away ; but for the nonce no water should be em-
ployed. Your aim should be to preserve the inflamed
* Dr. Sikfi Durkee,of Boston, United States, places first amongst
his local remedies for the treatment of ekzema infantile a lotion of bi-
carbonate of soda, containing a drachm of the salt to 1 2 or 1 6 ounces
of water ; and applied by means of folds of linen. He speaks of
this lotion as being sedative, and allaying pruritus and infiamma-
tion; and relies upon it especially for the removal of crusts.
Other remedies to which he gives a preference are — the oxide of
zinc ointment ; an ointment of carbonate of lead with prepared
chalk ; a liniment of glycerine, oxide of zinc, and camphor ; a
solution of chloride of zinc, two and a half grains to the ounce ;
cream with liquor plumbi, vi xy. ad J j. ; a chloroform ointment^
5 j. ad J j. ; and carron oil.
TREATMENT OF EKZEMA. 1 99
surface as tranquil as possible ; to give Nature, of
whom medicine is only the handmaiden — ^perhaps
we may be permitted to say the maid-of-all-work,
since it seems to be the fashion of the day to dis-
countenance the special investigation of disease — to
give Nature the opportunity of accomplishing her
cure after her own fashion and without unmannerly
restraint. We have said that the office of the zinc
ointment is to sheath and protect the morbid sur-
face ; but it performs another and very important
function, namely, that of creating an artificifid layer,
to take the place, for the time being, of the lost
cuticle ; and this concretion 6f the ointment should
be studiously promoted by applying fresh and fresh
ointment as often as that previously applied has
become dried up or has been accidentally wiped
away. A scab or thin crust — ^not such a crust as
would detain secretions on the part and be a source
of offence — ^is Nature's "court-plaster" that we
must learn of good time to respect. Officious Physic
and meddlesome Surgery are two very n[uschievous
and dangerous allies.
Gentlemen, we say again and again, that the local
treatment of ekzema, in its more active and therefore
most troublesome stages, requires no other remedy
than the benzoated oxide of zinc ointment, and that
by the use of the oxide of zinc ointment alone
the first of the indications for the treatment of
ekzema will be accomplished, namely, that of allaying
irritation. But you mvst be provided with a good
article, and you must learn to know its use. We
will now pass on to another consideration, also of
much importance. When your dressings are pro-
perly applied and adjusted with nicety, they should
remain undisturbed for as long a period as possible,
— say for twenty-four hours or even longer. But
here you will find a difficulty in the management of
infants; their habitual restlessness will disturb
dressings, will rub off the ointment, and it will
200 TREATMENT OP EKZEMA.
require patience to replace them; but there is no
alternative, the thing must be done, and you must
bring all your inventive faculty to bear upon the
problem. We may, however, mention in this place that
there are two regions of the body where the oxide of
zinc ointment is unsuitable, namely, on the eyelids ;
for in that situation, getting upon the conjunctiva,
it creates irritation and gives pain; and on the
scalp, where it would tend to mat the hair together,
and prevent a necessary condition in the treatment
of ekzema, namely, perfect cleanliness. In both
these situations you should substitute the nitric
oxide of mercury ointment for the zinc ointment,
diluted in the proportion of one part to three of
benzoated lard.
And now, gentlemen, if we impress upon you
very strongly the value of the benzoated zinc oint-
ment in ekzema as the mainstay of your local treat-
ment, we must also ask you to keep your weather-
eye open to the teachings of the first principles of
medicine. There may be great local heat of surface;
there may be inveterate itching; there may even
be considerable pain. Heat, itching, and pain the
benzoated zinc ointment will generally allay ; but if
it fail to accomplish that purpose, there are certain
agencies which you may superadd to your treat-
ment, but always without disturbing, or with as
little disturbance as possible to, the zinc ointment.
For the relief of heat you may apply a spirit or
ether lotion to the heated surface by means of a fold
of cambric more usitato ; for the relief of itching you
may use, in a similar manner, an emulsion of bitter
almonds, with hydrocyanic acid and spirits of wine ;
and for the relief of pain, you may apply a fomen-
tation of poppy-heads. We believe that you will
hardly need more at this stage of the disease.
There are certain indications that will tell you when
one or other of these symptoms may be expected :
heat is usually associated with redness and swelling,
TREATMENT OF EKZEMA. 201
and is apt to come on at night, particularly in
infants ; it is often the precursor of ichorous dis-
charge ; itching also precedes a copious effusion of
ichorous secretion, and is a frequent accompani-
ment of the papulous form of the eruption ; while
pain, of an aching character, is the associate of a
deep red and venous coloration of the morbid skin,
and is more common in the pudendum than else-
where. It may be that there are parts of the skin
on which the eruption is scattered and itchy, to
which the almond emulsion with hydrocyanic acid
would prove a more agreeable application than the
zinc ointment ; and certain other parts which are
moist and exuding, for which an absorbent powder
would be more suitable, — such as that of oxide of
zinc one part, starch three parts, with a proportion
of camphor, consisting of ten or fifteen grains to
the ounce. In using the latter, however, it will be
needful to take heed to the moment when the surface
has become dry, and when the demulcent ointment
will be required to be substituted.
In what we have said to you, gentlemen, up to
this time, we have had in our mind that special and
uncomplicated type of the affdbtion, ekzema infan-
tile ; but the same general principles apply to the
disease, whatever be the age of the individual.
You will sometimes meet with instances, although
very rarely in the infant, in which there appears to
be an intolerance of fatty applications ; but even in
these cases, where they exist, we arc inclined to
ascribe the phenomenon rather to mismanagement
or mistrust, or possibly, to an impure ointment,
than to any positive repugnance on the part of the
skin. Eat is a natural product of the slan, and its
natural lubricator and protector, and we should
therefore refer the repugnance where it existed, to a
morbid state of sensibility and undue irritability of
the skin ; and, consequently, to a state which would
in most instances give way to a steady and prudent
use and continuance of the remedy.
202 TREATMENT OF EKZEMA.
As we are now considering the most simple and
uncomplicated form of ekzema, and ekzema in its
active and, as far as is customary in this affection,
in its acute stage, and especially the ekzema of
infants, we will now complete the picture of the
disease by a few words on the constitutional con-
dition of the patient. The morbid manifestations
of ekzema are a strong evidence of an extensively
disordered nerve-tissue; the constitutional symp-
toms manifest the same tendency. Let us, then,
see what we have further to do for our patient.
We have prescribed the zinc ointment; we have
shown what our remedy is ; what is to be expected
of it ; how it is to be used. We have ordered that
there shall be no bathing, and as little interference
and meddling with our patient as possible. We
have endeavoured to show that our patient needs
repose, quiet, rest, and proper and nutritious food
without stint or limit. What else is to be done ?
Shall we purge him or physic him ? God forbid.
K the bowels are confined, we may help them with
a little magnesia and rhubarb, or manna, or castor
oil ; if he be emaciat^ed and exhibit a tendency to
waste, we may check^is prostration by cod-liver oil ;
but the one and almost indispensable remedy is the
nerve-restorer, arsenic. Try two minims of the liquor
arsenicalis three times a day in the combination known
as our ferro-arsenical mixture ; adopt as much care
and vigilance as you please in its exhibition ; but
do it, and obey ; heed not the twaddling of igno-
rance, but Usten to the voice of judgment and
experience. We will subjoin the formula, printed a
hundred times, lest it may have escaped your
memory : — ft Vini ferri, 3iss ; Syrupi simplicis, 3iij ;
Liquoris arsenicalis, 3j ; Aquas anethi, 3\j • Misce.
One drachm will give you two minims of liquor
arsenicalis. It may be administered pure, and just
at the end of the meal, so as to be mixed with the
meal in the stomach. Gentlemen, you have done
TREATMENT OF EKZEMA. 203
your duty sans peur et sans reproche. Just one
word more. If the medicine disagree, stop it.
We now pass on to the second part of the propo-
sition, namely, that after allaying irritation, which
is equivalent to removing the local affection, we
should aim at restoring the weakened tissues of the
skin to a normal state of health. Ekzema in the
infant, when properly treated and judiciously
managed, and barring the accidents of a re-excite-
ment of the disease by vaccination, dentition, and
the ordinary infantile disorders, rarely assumes a
chronic character ; and therefore, when the eruption
has subsided, there remains nothing further to be
done than to effect as far as possible the restoration
of the healthy tone of the skin. And this leads us
to say a few words on the subject of prophylaxis.
It is a curious paradox, but one not difficult of ex-
planation, that whereas nothing contributes more
to the injury of the skin, when the latter is in a
state of disease, than exposure to the atmosphere ;
so nothing, on the other hand, conduces so much
to its perfection, when in a state of health, as
plentiful ventilation. The prophylaxis of the skin
of the infant may be summed up in four words —
soap, water, air, and moderation of temperature ;
and it may be doubted whether these hygienic con-
ditions being properly adjusted, even errors of diet
would be capable of exerting influence sufficient for
the induction of ekzema. We shall leave it to
gynaikologists to arrange in what manner and by
what means infants may be rendered hardy without
injury to their organization ; but we have no hesita-
tion m saying, that when that happy consummation
shall be arrived at, ekzema mfantile will be in-
finitely more rare than it is at present. Now, as is
well known, ekzema infantile is much more common
in large cities and towns than it is in agricultural
districts, and amongst the middle and the highest
classes than amongst those who are most exposed
204 TfiEATKENT OF EEZEMA.
to vicissitudes of every kind. If we had to select
for your inspection and ensample of a healthy infant
skin, we should not seek for it in the metropolis,
but amongst the rude villagers of our country side,
and especially in the bleak but modified climate of
the sea-coast.
The same remarks apply to the adult. How
frequently we find that ekzema accompanies the
clinical state of the individual, the hot bedding of
the parturient female, the prolonged decubitus of
the invalid, or the permanent bed-life of the aged
and infirm. And our clothing is hardly less objec-
tionable, tending in general to accumulate heat
where heat is already in excess ; for example, in the
axillas, in the pudendum especially, around the neck
in men and around the waist in women. The skin
is an air-breathing organ and we sufi^Dcate it ; we
do not sufficiently ventilate it. We look upon the
morning cold bath as indispensable to health, and
we recommend strongly the exposure of the skin
for a time to the air, after the manner of Pliny
when practicable ; but, in the absence of the appli-
ances of the luxurious Roman, then, in our dressing-
room, with the window wide open, if possible.
Next to the mere water comes the tonic action of
soap ; and water and soap are within the reach of
everybody. We could tell you how the most deli-
cate organization could be made to bear a cold bath
or a cold douche ; we could tell you how the per-
spiring body could equally bear the downpour of
the shower douche. This is merely a question of
the judicious blending of temperatures, of the hot
and the cold, and although certainly not foreign to
the question of the prophylaxis of the body, yet
too copious a subject for a dissertation on the
treatment of ekzema, — for the present our real
business. But we must not quit the subject of the
bath without .admonishing you that rough friction
to the skin is not only useless^ but even injurious^
TBEATMENT OP EKZEMA. 205
and that all the contrivances of rough bath-towels
and flesh-gloves and flesh-brushes are the barbar-
isms of a people who fail to comprehend the genius
of the bath. Let your towels be soflj, your friction
moderate, but ventilate the skin by exposure to
the air as much as you please.
We have heretofore, gentlemen, engaged your
attention with the treatment of ekzema in an active
stage. You know that ekzema is essentially a
chronic disease and that we do not admit an acute
form of the affection ; but there is a period during
which it is active, another during which it is
passive ; and then, again, an intermediate, a transi-
tional period, during which the active and the passive
are apt, each to manifest itself for a time, and to
constitute a very obstinate and sometimes a very
perplexing disease. You must bring science and
art both to your aid, in the management of
ekzema. We nave already discussed the applica-
tion of science in the use of the oxide of zinc
ointment, and the manner of employing it, in the
administration of arsenic and the way of co-
ordinating it ; we will now address ourselves to the
art of managing the transitional period of the
disease, until a true prophylaxis admits of being
adopted.
When the inflamed skin underneath the pellicle of
dried and concreted zinc ointment has healed, and a
new and firm cuticle has formed, we may commence
with the use of very gentle friction with the palm of
the hand : if this moderate friction should occasion
discharge, a little more zinc ointment will be neces*
sary ; of course not so much as at first, and with a
difierent object, namely, that of simply moistening
the parched and angry skin. The gentle friction
may be repeated night and morning, and each time,
if the skin will bear it, increased a little in force ;
and, after the frictions, the tender surface should be
dusted over with some harmless powder, such as
206 TBEATMENT OP EKZEMA.
zinc with starch ; starcli alone ; lycopodium, maize-
flour, or simple wheaten flour. Then again, after a
few days, a gentle washing with Castile soap may be
attempted ; at first with tepid water ; then with
cold water ; and later still, if this progressive method
should prove successful, with a mildly stimulating
soap such as that of the juniper tar or of carbolic
acid. It is important, moreover, that after the
ablution is completed, the soap should be rinsed
thoroughly off; and that the skin should be tho-
roughly dried with a soft towel, and that friction
during the drying process should be avoided. In
the beginning, after the drying of the skin is com-
pleted, the tender surface may be dusted over with
one of the sheathing powders already mentioned,
and, later on, when the skin will bear it, it may be
left without any such protective covering and Simply
guarded against rough friction and rough usage.
You will see, gentlemen, that we are still dwelling
on ekzema in&ntile; for the same principles that
apply to it, apply equally to the ekzema of the
adult ; and in fact, it is as necessary to use all your
foresight and vour tenderness in the case of the
adult as it is in the case of the infant or of the
child.
Another hardening process that may be adopted
with the view of strengthening the skin is the use
of soap with firm friction to the tender part, and
subsequently sheathing it with the demulcent oint-
ment. And, again, a very valuable means, the
employment of cold water in the form of a douche,
projected by a garden syringe when no more con-
venient apparatus is at hand, or from the spout of
a watering-pot or of a jug.
In the transitional and passive periods of ekzema,
there is one symptom that is extremely troublesome, .
and that will demand all your ingenuity and care to
mitigate, namely, pruritus ; and pniritus is asso-
ciated with a greater or lesser degree of infiltration
TBBATMBNT OP EEZEMA. 207
of the skin, that we must use our best exertions to
disperse. In fact, the pruritus, in a majority of
instances, is a consequence of the infiltration, and
therefore a radical treatment points to the necessity
of removing the objective rather than the subjective,
of the cause rather than the effect. When pruritus
is a neurotic phenomenon, our best palliatives are,
hydrocyanic acid and tar ; when it depends on dry-
ness and desquamation, the benzoated oxide of zinc
ointment, a lotion of borax and oil, a glycyrion of
tannin, or glycerine combined with the nitric oxide
or nitrate of mercury, may be used ; but for infiltra-
tion in various degrees, stimulant or alkaline
applications are necessary, ranging in strength from
the mildest up to the strongest.
As an antipruritic, the lotion of emulsion of bitter
almonds twenty or thirty kernels to six ounces of
water, dilute hydrocyanic acid, two drachms, and
spirit of wine, fourteen drachms, is an admirable
one, cooling and soothing at the same time. Some-
times borax may be made to take the place of the
hydrocyanic acid and the spirit of wine omitted ; or
the original lotion may be rendered stimulant by
the addition of perchloride of mercury, from one
to two grains to the ounce. But this, in limine,
with regard to the use of lotions ; however agree-
able they may be for the moment, they are all,
unless they contain oil or glycerine, apt to leave
behind them a certain degree of dryness or perhaps
add to the dryness they were intended to mitigate,
for dryness of itself may be an incidental cause of
pruritus. Hence, conjointly with the lotion, we
recommend a smear of the oxide of zinc ointment
or one of the milder stimulant ointments ; that is
to say, that as soon as the lotion is dried, a smear
with the ointment should follow.
Borax is an antipruritic when it is combined with
oil or glycerine so as to form an emulsion : thus,
two drachms of borax, with six of benzoated oil or
208 TREATMENT OF EEZEMA.
glycerine, and seven ounces of emulsion of bitter
almonds, form an elegant and useful lotion ; but
glycerine is uncertain in its operation on the integu-
ment, and is sometimes, instead of being a sedative,
an irritant of the skin. Our antipruritic resources
are, as you will perceive, very limited ; sometimes
a solution of carbonate of soda, a drachm to the
eight ounces ; or of carbonate of ammonia of the
same strength in camphor julep, is very soothing ;
or, tincture of opium with spirits of wine and
camphor mixture; and sometimes we shall derive
advantage from a lotion of sulphuret of potassium ;
a diluted aconite liniment ; or a liniment of aconite
with belladonna.
But a more potent antipruritic remedy, although
at the same time stimulant, is to be met with in tar,
with its hydrocarbon extracts, carbolic acid and
kreosote. And we have nothing more competent to
quell a raging pruritus than Hebra's famous lotion,
composed of oleum picis juniperi,* sapo mollis, and
alkohol, of each an ounce, diluted more or less con-
siderably with water, a pint or even a half-pint.
Carbolic acid and kreosote may be combined with
distilled vinegar or glycerine, and used in a diluted
form, one or two drachms to the half-pint ; or with
oil in various degrees of concentration.
Gentlemen, we have shown you how you should
deal with the inflammatory or active stage of ekze-
ma, and how you should meet the requirements of
pruritus proceeding from nerve-irritation or dryness ;
there are two other morbid conditions which we
have now to mention, — ^namely, infiltration giving
rise to condensation and thickening, and nervous
irritability. In moderate states of infiltration, the
milder forms of stimulant remedies will be found
sufficient ; such as the nitric oxide of mercury oint-
ment, diluted or pure ; the citrine ointment, diluted
* PjroligneouB oil of juniper ; or, huile de Cade ; oleum cadinum.
TEEATMENT OP EKZEMA. 2O9
or pure; or the ointments of tar and kreosote.
These remedies should be either well rubbed into the
affected skin morning or night ; or, the latter should
first of all be well washed with the juniper tar soap,
and then the ointments should be used. Sometimes,
and especially in the case of the lower limb, advan-
tage will be derived from a thorough friction of the
skin with soil soap ; and as soon as a little smarting
sensation is produced by the process, the soap
should be rinsed off, and the skin dried and anointed
with the zinc ointment. This process may be
repeated once or twice in the day, u the excitement
be not too severe. Sometimes after the washing
and inunction it may be desirable to place straps
spread with the zinc ointment in an^ imbricated
position around the limb ; and bind up the whole
with a carefully adjusted roller. It is in cases such
as these, particularly when they have their origin in
varicose veins, that the method of bandaging made
use of by Devergie is likely to be successful ;
namely, a compress and roller soaked in a solution
of dextrine in boiling water, four ounces to the
quart. This form of bandage requires that there
should not be much exudation from the skin ; the
roller must not be applied too tightly ; and it must
be left on the limb until it becomes slack, which
happens in four or five days ; and then it may be
repeated as before until the cure is effected.
The natural history of ekzema teaches us that
severe pruritus generally precedes the excretion of
a copious exudation from the skin, and that the
exudation at once relieves the itching : this principle
has been taken advantage of by Hebra, for the
purpose of frimishing an additional remedy and an
additional means of treatment ; in a word, a remedy,
which by application to the thickened and con-
densed skin, shall cause the infiltrated fluids to be
poured out upon the surface in the same way that
Natm*e performs the act in ekzema ichorosum.
p
2IO TBEATMENT OF EEZEMA.
The remedy which Hebra recommends is the
potassa fusa variously diluted, according to the
effect that is intended to be produced. Very com-
monly he uses a solution of equal quantities of
caustic potash and water, and we have pursued
the same practice with infinite advantage ; in fact,
it may be truly said that some of the more con-
densed and hardened forms of ekzema will yield to
no other means. The solution is painted on the
surface by means of a sponge brush ; the viscous
ichor is seen to ooze forth from the thickened skin
even in a few seconds ; the bloated tissue cells are
are made to disgorge their excessive contents ; and
in a few minutes, one of the most passive and inve-
terate forms of the affection is transformed into an
active stage, and becomes amenably to the mUder
principle of treatment applicable to the mflammatory
condition of the disease.
If there be one thing that distinguishes ekzema
more than another, it is nervous irritability — ^a con-
dition easily understood when we remember that
ekzema is an inflammation of a part of the body
abounding in nerves, and that the papillary stratum
of the derma is a stroma composed almost entirely
of a capillary rete and nerve plexuses. To this
special organization are to be referred the teasing
and violent pruritus that accompanies this affection ;
its sympathies with states of the economy; its
exacerbations ; its sometimes frenzied torments ;
and its not unfrequent intolerance of every remedy
that can be proposed for its relief. We have evi-
dence that such is the case by the comfort which is
often given by an application that a few days
before drove the patient distracted, and by
the pain and distress frequently caused by the
most soothing remedies, and, first among these,
by the oxide of zinc ointment. When this state
of nervous irritability prevails (and it may be
present in various degrees, from the slightest up
TREATMENT OP EKZEMA. 211
to the most confirmed) — when every known ap-
plication creates pain or awakens dread and
alarm — our only resource, but a most valuable
one, is nitrate of silver, in solution, of various
strength, from two grains to the ounce up to a
drachm, and dissolved, as the case may be, in dis-
tilled water or in nitrous ether. Such a solution
painted over an inflamed and irritable surface, acts
like a charm ; from bearing nothing the ekzema wiU
bear everything; and a dressing with the zinc oint-
ment becomes its greatest solace. But it may
happen, and very probably will do so, that the
irritability will in the course of time return, in which
case the remedy should be repeated ; and it may be
repeated again and again, and for as long a period
as the nervous irritability presents an obstacle to
the cure of the eruption. All that we ask of you is,
that you master the principle ; that you assure
yourselves that the evil you are contending with is,
m fact, nervous irritability; and that you employ
the remedy — not because you have heard that it is a
good thing, not because you have known it to be
useful in a previous case — ^mere empirical reasons, —
but with the direct object of subduing that irrita-
bility by the best means that the iatrium chiru/rgicum
affords.
Gentlemen, you must take this as a sketch of the
general principles of topical therapeutics as applic-
able to ekzema in general. There is a special treat-
ment suitable to particular forms and to particular
cases ; and these we may have occasion to advert to
hereafter ; at present, and to complete the treatment
of the subject in hand, it will be necessary to take a
glance at the constitutional therapeutics of this im-
portant disease. We have already laid down the
general axiom that support of the powers of the
system must be the main object of our labours, and
to this end the functions of the body should be
regulated ; such faults of debility as we are able to
p 2
212 TBEATMEin? OF EEZEHA.
find should be redressed ; and that we should com-
plete our work, if need be, with the aid of a medicine
which, from its known vsduable agency on the skin,
has acquired the reputation of being a cutaneous
specific, namely, arsenic. In the majority of cases
nothing could be more injudicious than beginning
our treatment with arsenic, because there are always
certain general indications to be fulfilled, to which
arsenic is unadapted, and the fulfilment of which
clears the way for the use of that excellent and
admirable remedy.
It is now that you will perceive the advantage of
such a grouping of ekzematous disease as we have
set forth when discussing the causes of this afiection ;
for example, nutritive, assimilative, and neurotic;
and having determined approximatively under which
of these groups your patient should be classed, you
will then put in practice a treatment that is to im-
prove nutrition, or digestion and assimilation, or
mnervation, as the case may be. K you decide that
the causes of the disease are simply nutritive, your
treatment should be, good and proper food and
arsenic ; if in your opinion the digestive and assimi-
lative organs are at fault, then arsenic would be
inappropriate ; and if the symptoms lean in the
direction of a neurotic debility, the digestive func-
tions being regular, there can be no obstacle in the
way of your beginning arsenic at once. Hereditary
and congenital ekzema generally fall under the
nutritive class, and acquired ekzema under the head
of assimilative or neurotic. In the neurotic forms
of ekzema, and particularly when accompanied with
pruritus. Dr. Frazer advises the use of strychnia
m doses ranging between -^ and -3^ of a grain,
three times in the day, combined with phosphoric
or nitric acid, and infusion of orange-peel or cloves.
There are few medicines of a tonic character that
come to our aid in the treatment of infants and
children suffering under ekzema beyond cod-Uver
TREATMENT OF EKZEMA. 213
oil, wine of iron, phosphate of iron, and arsenic.
As age advances into youth we have the further
help of vegetable bitters, of the mineral acids, and
quiuine ; and in adult life the field of tonics expands
somewhat more : there are the citrate of iron and
quinine, strychnine, and phosphoric acid ; and at the
head of all fdcile prmceps stands arsenic, of which
the British Pharmacopoeia affords a copious variety
of forms — arsenip with potash, arsenic with soda,
and arsenic with hydrochloric acid. There is one
preparation of arsenic that you wiU never want in
the treatment of ekzema, and we caution you to
avoid it, namely, the triple solution of Donovan,
the Uquor hydriodatis hydrargyri, et arsenici.
In further assertion of the importance of such a
division qf causes as is expressed by the terms
nutritive, asshnilative, and neurotic, we may observe
that you will frequently meet with cases that will
tempt you to the use of such expressions as dys-
peptic ekzema, gouty ekzema, rheumatismal ekzema;
such distinctions as these are utterly uncalled for in
practice, but they point a moral ; they show that,
in the treatment of such cases, you must always
have before your eye the dyspeptic, the arthritic,
and the rheumatismal tendency or diathesis, and all
these we iaclude under the general denomination of
assimilative. And, if we suppose such a case, we
should begin our treatment with nitro-muriatic acid
and a bitter, such as gentian, or calumba, or orange-
peel, and a pill consisting of the compound colocynth
extract, massa hydrargyri, and extract of henbane,
every second or third night, as the case may be ; and
in the case of an arthritic or rheumatismal complica-
tion we should not fail to prescribe a grain of the
acetous extract of colchicum every night. In other
cases, where more debility of the mucous membrane
seemed to be present, or after, by the previous
course, we had secured a healthy action of the liver,
we know of no remedy so perfect as the citrate
214 TREATMENT OF EEZEMA.
of iron and quinine. And in younger persons
with some little feverisliness of system we should
prefer small doses of sulphate of magnesia with
sulphate of quinme and sulphuric acid, either in
combination with infusion of roses or infusion of
orange-peel.
We have no fear of your retahating upon us with
the remark that this treatment is nothing more than
would be adapted to any case in« which assimilative
debility was present in the system: our answer
would be simply, Exactly so ; it is this that we
have led you to expect ; this is the very gist and
essence of our teachings ; we declare that ekzema,
as well as other cutaneous affections, is to be
treated precisely upon the same principle as diseases
in general. -Aiid if we have recourse to arsenic
more frequently than in other diseases, it is only
that it has been proved to be an excellent remedy,
and has enjoyed and enjoys a reputation in the
treatment of a considerable number of diseases
besides those of the skin.
The form of arsenic to be selected in your treat-
ment is of very secondary importance ; you may
take the potash solution of Fowler, the soda solu-
tion of Pearson, or the acid solution of de Valangin.
Now that the British Pharmacopoeia has equalized
the strength of liquor arsenicalis and of the acid
solution, the dose of these two preparations will be
the same; the liquor sodas arseniatis of Pearson
being somewhat weaker. You will, however, find
an advantage in departing fi*om the formula of the
British Pharmacopoeia by omitting the tincture of
lavender, the flavour of which is generally disagree-
able to the patient, and the more so, as he is ordered
to take the medicine with his meals. We have
always advocated small doses of arsenic, and in a
long practice we have seen no reason to depart from
that principle ; but we have no hesitation in pre-
scribing it for infants of a few weeks old. It is
TBEATMENT OF EEZEMA. 215
a medicine whicli seems almost expressly adapted
for them, it answers so well ; and in a short time
after taking it, the improvement in their condition
and nutritive power is often very remarkable.
The dose of the arsenical solution for the infant
is one or two minims three times a day ; and for
the adult, three or four minims. We make a dis-
tinction between a tonic dose of arsenic, which we
believe should be as small as is here directed, and
an alterative dose as required for lepra, which may
mount up to five or six minims. But we have a
good deal to learn yet with regard to the therapeu-
tical properties of arsenic. Our favourite method
of administering the remedy is by the ferro-arsenical
mixture, of which we have just stated to you the
formula ; the strength of arsenic is to be regulated
by varying the proportions of the liquor arsenicahs
and the syrup, and you will find a convenience in
always writing the formula in the same way ; for
example, the first and the fourth line are to remain
stationary, the variations are to be made only in the
two intermediate constituents, the syrup and the
liquor arsenicalis, which together should make four
drachms. Half a drachm of liquor arsenicalis in this
formula will give one minim for a dose, and each
additionial half-drachm will increase the dose by a
single minim. The convenience we refer to is not
a small one, namely, the avoidance of the possibility
of making a mistake in the quantity. Dr. Durkee
combines the iodide of potash with liquor arsenicahs
in the treatment of ekzema infantile, two grains of
the former to one minim of the latter. His favourite
remedy, however, is the syrupus iodidi ferri, which
he regards as laxative, diuretic, and antipruritic, and
administers in doses of five to fifteen minims three
times in the day.
Having, then, to deal with a medicine that requires
care in the handling, we do our best to hem it round
with defences ; we are exact in our formula ; exact
2l6 TREATMENT OF EKZEMA.
in the dose, careM as to the time of administration ;
and anxious in our observation of its effects. You
will remember that the arsenical dose should be
small, in order that it may not disgust the taste by
its quantity, — ^we limit it to one drachm ; it should
be administered with the meal, in order that it may
be mingled with the chyme in the stomach aud
transmitted with the chyme to the chyle, and thence
into the system with the nutrient material of the
food ; and it should be administered at or towards
the end of the meal, to insure its not being brought
in contact with the mucous membrane. Moreover,
we watch narrowly to see that it occasions no nausea,
no gripes, and no prostration of power : these are
its primary effects when it disagrees with the sys-
tem ; and there are sundry subsequent effects, such
as a puffy swelling of the eyehds, the cheeks, or
limbs ; and later still, congestion of the vessels of
the conjunctiva.
We must confess to have seen very much benefit
result in certain chronic cases of ekzema from the
use of small doses of the perchloride of mercury ;
but our customary success with tonics, with which
Plummer's pill and small doses of blue pill have
been frequently conjoined, and arsenic, has pre-
vented us from giving special attention to, no doubt,
a valuable remedy. Dr. Frazer, in an excellent prac-
tical paper on ekzema, pubhshed in the Journal of
Cutaneous Medicins (vol. i., p. 63, 1868), advocates
very warmly the merits of the perchloride, which
he prescribes in doses of -j^: *o iV of a grain three
times a day in decoction of cinchona ; and some-
times in infusion of cinchona combined with decoc-
tion of cetraria islandica. Dr. Durkee is also favour-
able to the same remedy, which he recommends in
doses rising from ^ to ^ of a grain in cases of
ekzema infantile, and administered once or twice
daily. The perchloride of mercury has of late times
received much praise from a variety of sources, and
TREATMENT OF BKZEMA. 21/
we hear of it as a restorer of nutrition, of appetite,
and strength; an improver of the complexion of
the skin and muscular power ; and a help to the
growth of the body.
( 2lS )
CHAPTER m.
Ekzematous Affections.
The term Ekzematous affections, or, in other
words, ekzema and its allies, suggests the idea,
which experience proves to be correct, that there
exist certain modifications of ekzema apart from its
ordinary manner of development, apart from the
phases of difference which naturally belong to it
and which we have already very amply considered.
Ekzema, be it remembered, presents to our obser-
vation as its pathological type an affection of the
surface of the derma, and an affection of its folli-
cular portion ; an exudation both intrinsic and ex*
trinsic, the nature of the exudation being a limpid,
viscous ichor, or a fully elaborated pus ; and a
desquamation which one while is the simple exfolia-
tion of the normal epidermis, and another while
the product of desiccated secretions. Now, it so
happens that one or other of these processes may
exist so entirely alone that the general term ekzema
ceases to be applicable, and we find a convenience
in having recourse to other terms. This occurs
where the eruption is one of papulae solely, in which
case we have at hand the word leichen ; or where it
is solely one of superficial pustules, which we ex-
{)ress by the term impetigo. Both the papulsB of
eichen and the pustulsB of impetigo may be so
intimately commingled with the other pathological
lesions of ekzema, as to constitute a part only of
the whole ; or they may exist in a form so distinctly
separate, that, but for previous observation and
BKZEMATOUS AFFECTIONS. 219
experience, we might be led to regard them as
distinct diseases. It is thus that we include, under
the denomination of ekzematous affections, not
ekzema alone, but likewise leichen and impetigo.
Then there is an affection which is papular, vesi-
cular, pustulous, and squamous, often presenting
together and at the same time all the forms which
we have now named, often possessing them sepa-
rately, but differing from the typical ekzema chiefly
in the nature of its cause, namely, a minute animal-
cule, the acarus, which Kves and burrows in the
epidermis and is a true parasite of the skin. This
is the disease scabies; which, but for its living
cause, would be an ordinary ekzema; but which,
in consideration of its pathological phenomena, must
nevertheless be regarded as an ekzematous affec-
tion ; and, moreover, very frequently runs its course
as an ekzematous affection after the vera causa has
been removed.
There is another affection that, so far as its cause
and certain of its lesions are concerned, might be
regarded as belonging to the ekzematous family,
and so we have considered it hitherto ; that affec-
tion is the gutta rosea. Like constitutional ekzema,
it taSes its origin in derangement of assimilation ;
it presents a multiple lesion consisting of hyper-
SBmia, infiltration, exudation, and suppuration ; and
it yields ta the same method of therapeutical treat-
ment. But the progress of dermatology has ren-
dered necessary the foundation of a new group of
cutaneous affections, namely, those of the follicular
system ; and this group will absorb the gutta rosea
and withdraw it from the ekzematous affections,
bringing it, by virtue of its principal pathological
seat, into relation with a disease with which it has
hitherto been classified and somewhat confoimded,
namely, akne.
In our foregone review of the ekzematous affec-
tions, we have endeavoured to show that ekzema, in
220 EKZEMATOUS AFFECTIONS.
certain of its forms, and 'at a chronic period of its
existence, has received the pseudonyms of pityriasis
and psoriasis. We have now only to add, that the
other members of the ekzematous family, besides
ekzema itself, are leichen, impetigo, and scabies.
Gutta rosea, for the reasons already given, we shall
omit, and reserve it for consideration in conjunc-
tion with a highly important group of disorders,—
namely, the follicular affections of the skin.
Leichen.
Leichen,* since the days of Willan, has been
universally recognized as the denomination of a
papular eruption of the skin ; and, indeed, as em-
ployed by hmi, was principally assigned to the form
of eruption which in our own time we regard as
an ekzema papulosum. At present we apply the
term to an eruption of papulas, in which all other
signs of ekzema are absent, and which exhibits no
tendency to degenerate subsequently into ekzema.
The true papula is a prominence produced by
hypersBmia and infiltration of the coats of a follicle
of the skin ; while its breadth is governed by the
extent to which the hyperaBmia and infiltration
spread into the adjoining tissue. The simplest idea
that can be given of a leichen is that state of erec-
tion of the follicles of the skin which is termed
cutis anserma. Cutis anserina is a physiological
leichen, the prominence of the papules being pro-
duced partly by muscular action and partly by
contraction of the inter-follicular capillary vessels ;
but when this same erection of the folUcles is occa-
sioned by turgescence of the capillary vessels, infil-
tration, and hypertrophy, the leichen is patholo-
gical. Such, in fact, is the leichen tropicus, or
* Leichen, in ihe Greek, XuxriVi being spelt in the second
syllable with 17, should be pronounced leich&L
FORMS OP LEICHEN. 221
prickly heat, a papular eruption which is sometimes
almost as transient as cutis anserina. Pathologically,
it will be seen that leichen encroaches in a certain
measure on the territory of diseases of the follicles,
and some little judgment will be needed in defining
the exact boundary of the two.
Leichen is very generally a scattered eruption,
disseminated more or less thickly or sparsely;
sometimes it is equally remarkable for an aggregated
and clustered or circumscribed character ; and some-
times, in common with other cutaneous eruptions,' it
has a tendency to centi-ifiigal or serpiginous growth.
Very commonly it is pruriginous, and sometimes it is
remarkable for the figure of the papulae, for their
colour^ and for their development around the shaft of
the hairs. This diversity of character has suggested
the names by which its forms or varieties are known,
as also the number of those varieties. For example,
the scattered forms of the eruption are represented
by leichen simplex and leichen tropicus, as well as
by leichen pruriginosus, leichen urticatus, and
leichen strophulosus. The aggregated forms have
received the names of leichen circumscriptus, and
leichen annulatus or circinatus, with its subvariety
gyratus. The serpiginous form is represented by
leichen annulatus ; and the pruriginous forms by
leichen tropicus^ leichen pruriginosus, and leichen
urticatus. The forms exhibiting a pecuharity of
figure are leichen strophulosus, leichen urticatus,
and leichen planus. Colour is illustrated by leichen
lividus ; and seat, in relation to the hairs, by leichen
pilaris. In a tabular scheme we may arrange these
varieties of leichen as follows : —
Simplex, Urticatus,
Tropicus Strophulosus,
Circumscriptus, Planus,
Annulatus s. circinatus Lividus,
Pruriginosus, Pilaris.
2 22 EKZEMATOUS AFFKCTIONS.
Leiohen simplex is an eruption of small pimples,
conical in shape, somewhat less than a line in
diameter, more or less red in colour, and generally
extremely itchy. They are distributed scantily or
abundantly over a part, and less frequently over the
whole of the body. They are sometimes dispersed
at uniform distance, like the follicles themselves ;
and at other times are grouped in corymbose clus-
ters. Sometimes they are distinct, and at other
times united into a patch of variable extent by an
erythematous base. From the very nature of their
pathological seat they must always be distinct, ex-
cepting where they are, as it were, blended by an
infiltrated or oedematous base, in which case their
discrete character is partially lost. Leichen simplex
is very commonly symptomatic of disordered diges-
tion and assimilation ; is frequently met with in the
spring and autumn season of the year, and espe-
cially during the summer season ; and its concurrent
symptoms are sometimes suflBciently severe to sug-
gest the idea of a leichen febrilis. At other times
the eruption is due to local causes, and is more or
less partial ; limited, for example, to the region of
the body covered by a heating article of clothing.
Like other forms of chronic eruption, the pimples
of leichen are apt to be reinforced from day to day
by successive crops ; they remain prominent for
several days, and then gradually subside, sometimes
without any disturbance of the cuticle, at other
times with desquamation. The eruption is liable
also to be aggravated by the means adopted for the
rehef of the itching, sometimes by friction and some-
times by scratching, more or less violent. And
when these local injuries have been severe, the part
is apt to put on the semblance of ekzema.
Leichen tropicus, or prickly heat, is a leichen
simplex provoked by the irritant action of excessive
heat of atmosphere; and although common in
LEICHBN CIECmtSCBIPTUS. 223
tropical climates and rare in our own, it is
nevertheless occasionally imported from southern
countries, or prevails amongst ourselves during
a very hot season. Like its milder prototype, it
occurs on the clothed parts of the body, and is very
rarely seen on the face and on the hands. Its
pimples are red, and for the most part without red-
bases, and there is an absence of interfollicular
suffusion, excepting where severe friction or scratch-
ing has been employed for the relief of the pruritus.
The latter symptom, however, supplies the pre-
dominating character of the disease ; it is always
violent, and generally makes its attack in par-
oxysms ; is excited and aggravated by the stimulus
of food, by the heat of dress and bedclothing, and
thoroughly destroys comfort and rest. The form
of the pruritus is expressed in the popular name of
the affection, namely, prickly heat; but there is
also, combined with this prickling, a varied amount
of itching and stinging. In our own cUmate leichen
tropicus has a duration of several weeks ; in the
tropics it is apt to continue until the constitution
has become habituated to the climate, or until the
climate undergoes a favourable change.
Leichen ciecumscbiptus. — Leichen simplex, and its
tropical representative, leichen tropicus, are both
either general or partial ; but the term "circumscrip-
tus '* introduces us to an eruption which is purely
local, and limited to one or more isolated spots,
generally of a circular figure, abruptly circum-
scribed, varying in diameter from one or two to
several inches in extent, and studded all over with
thickly-set pimples, the pimples of the circumfer-
ence of the patch being somewhat larger and better
defined than those of the centre. In these circum-
scribed leichenous patches there is generally some
degree of suffusion which unites the bases of the
papulsd. The interpapular portion of the skin is
224 EEZEMATOUS AFFECTIONS.
wrinkled, and there exists more or less epidermic
exfoliation.
Leichen aknulatus seu cibcinatus calls our atten-
tion to another not uncommon phenomenon of
dermal'pathology, namely, the erpetic or serpiginous
tendency of cutaneous disease. The patches of
leichen circumscriptus are stationary, or, if they
exhibit any disposition to increase, their enlarge-
ment is slow, and the area of the patch undergoes
very little change. Occasionally, however, the
papules subside in the centre, and the circumscribed
patch is converted into a ring, bounded by a border
of variable width. This is an example of the cir-
cumscribed form of the eruption passing into that
of the annulate. But the true leichen annulatus
develops its annulate character from the very first.
Two or three or more papulae are seen to be united
by a suffused base, the base extends by the circum-
ference, the papulae subside, new papulae appear at
the margin, generally a single row, and so the ring
is estabhshed. The area of the ring quickly loses
its redness and becomes yellowish, it is slightly
wrinkled, and throws off a mealy exfoliation. The
circles range in size from a quarter of an inch to
several inches ; they are often numerous, as upon
the chest and upon the back, and occasionally the
latter region is covered almost entirely by an assem-
blage of these rings blended confusedly together,
the area of the broad patch being made up of
broken segments of rings, separate papules, and a
yellowish-brown, wrinkled, and furfuraceous base,
and the boundary being constituted of segments of
rings partly smooth and partly papular, a. few bright
red papules overtopping the rest every here and
there. This kind of eruption is like the rest of the
family of leichen, highly pruritic, and is often
associated with a form of pityriasis of the scalp. To
the irregular and confused figures resulting from the
LBICHEN PEUEIGINOSUS. * 225
blending of a number of circles or segments of
circles, the term leichen gyratus has, very character-
istically, been applied.
The annulate variety of leichen now described is
remarkable for its apparently feeble hold upon the
skin, for its superficial and fugitive nature; but
there is another annulate form, which is less rapid
in its serpiginous growth, which aflTects the follicles
more deeply, and which throws up a stronger margin
of papulse, and papulaa of a larger size and more
persistent character. This form of the eruption is
met with sometimes at the root of the neck, upon
the shoulders, and upon the chest, and sometimes
around the circumference of the perineum. In the
latter situation it entitles itself to the designation of
leichen marginatuSy and in some instances, doubtless,
has been mistaken for ekzema marginatum. It is in
this latter variety of eruption that the phytiform
degeneration of the epithelium of the foUicles was
discovered by Kobner, and described by him and
by Dr. M *Call Anderson ; and this important fact,
together with its extreme obstinacy, serves to bring
it into the category of follicular diseases.
Leichen peitbiginosus. — The papulae which are
excited upon the skin by scabies are remarkable for
their itchy propensity ; and these papulsB, of a pale
colour, sparsely scattered over the surface, and often
only discoverable after the act of scratching, will
frequently continue for several weeks subsequently
to the local cause of scabies, the acarus being de-
stroyed. At other times they are the indication of a
lingering, perhaps a solitary acarus in the epidermis,
but not detectible after the closest search ; and
again, they may be present where no scabies, and,
consequently, no acarus, has existed. In the latter
form these scantily distributed papulae constitute the
prurigo mitis of Willan, such is their persistency,
and such the severity of the itching by which they
Q
226 ' EEZEMATOUS AFFECTIONS.
are accompanied. They are found dispersed over
every region of the body, but are most frequent on
the abdomen and limbs, on the front of the forearm,
the inner side of the thigh, and behind the inner
ankle ; and when they have been much scratched
or torn they are apt to be covered vrith a small
brown or blackish scab.
^ Lbichen UETiOATiJS 18 another variety of pruri-
ginous leichen, partaking, as its name implies, of
the papular character of leichen, and also presenting
the tubercular prominence of urticaria. It is an
eruption common to children and rarely seen in the
adult, and consists of large papulsB, sometimes
sparsely scattered, sometimes occurring in clusters
of three or four, and dispersed over the whole body,
but most abundantly upon the shoulders, the loins,
the abdomen, and the limbs. In general appearance
the papulaB resemble the bite of the bed-bug ; they
are surrounded by a broad areola of redness ; when
scratched the central papule looks bleached, like the
wheal of urticaria, and when the head of the pimple
is torn off it becomes surmounted by a small brown
or black scab. The eruption is successive, a few
pimples appearing every night, and their develcip-
ment being attended with excessive pruritus. They
are excited by emotion and also by the warmth of
bed ; their itching destroys sleep, and after a while
they endanger the health of the child by prolonged
irritation. The eruption is always obstinate, last-
ing for many months, and sometimes extremely
rebellious.
Leiohen STROPHULOsas is a papular rash met with
on the dehcate skin of infants, and occupies a
separate position rather in compliment to Willan
than for any practical end. The papulae are pro-
portionately larger in infants than in the adult, and
present some variety in distribution, in colour, and
LBICHEN TLANUS. 22/
in duration. The strophulus interti/nctuSf or red
gum, and strophulus confertus^ the rank red gum, or
tooth-rash, would seem, by their name, to have been
associated in the mind of Willan with the develop-
ment of the teeth, a fruitful source of infantile irri-
tation ; while the term strophulus is suggestive of
disorder of the alimentary canal. Strophulus inter-
tinctus is a commingling of bright red papulae, red
puncta, and erythematous blotches, in patches of
variable size, commonly met with on the cheeks, but
also not unfrequently distributed upon the body and
limbs. Strophulus confertus consists of papulae
which are less vividly red and more uniformly
distributed, and which, whenever they occur in
aggregated patches, take on the exudative charac-
ter of ekzema. Strophulus volaticus is simply
a more transient form of the preceding; and
strophulus albidus and strophulus candidus are
distinguished by the absence of redness, wholly or
in part.
Leiohbn planus is a very remarkable form of
eruption, consisting of papulae which are broad at
the base, flat and seemingly glazed on the summit,
slightly umbilicated, of a dull purplish-red colour at
first, in certain situations discrete and isolated,
in others, united by a hyperaemic and infiltrated base
into patches of variable extent. The eruption is
chronic in its course, generally symmetrical, some-
times itchy and sometimes free from pruritus, and
leaves at its decline a deep brown stain on the skin.
Heat and exhaustion are its common exciting causes ;
it occurs for the most part at the mid-period of life,
and its favourite localities of development are the
front of the forearm, especially just above the wrist,
the loins, the abdomen, the hips, the knees, and
grooves of the skin produced by the pressure of
dress, for example, of the stays and of the garters ;
occasionally we have met with it also on the palm of
Q 2
228 EKZEMATOUS AFFECTIONS.
the hands, the sole of the foot, the tongiie, and the
buccal membrane of the mouth.
The purplish-red colour; the discrete distribu-
tion ; the flat, somewhat depressed, summit ; smooth,
hom-like or glazed surface, and central hilum, the
aperture of a follicle choked with epithelial exuvise,
are the pathognomonic characters of this eruption
in its papular state ; and even in its aggregate and
diffused form these pathological characteristics are
not wholly effaced. In the latter condition the
patches bear a close resemblance to lepra; the
affected skin is thickened and somewhat raised, and
coated over with a rough but thin layer of scales of
broken epidermis mingled with the exuviated epithe-
lium of the follicles. The squamous matter, how-
ever, is not white as in lepra, but yellowish and
greyish, and a careful inspection detects without
difficulty an obvious difference. Moreover, around
the circumference of the patches may always be
seen a few isolated papulae presenting the ordinary
discrete type.
The pathological essence of leichen planus is
inflammation of a follicle attended with accumula-
tion and impaction of its epithelium; the glazed
summit of the papule is not a scale, and in the dis-
crete form of the eruption it subsides with the rest
of the papule ; but in the aggregated patches it is
thrown off by exfoliation, in common with the inter-
papular epidermis and the epithelial exuviae of the
foUicle. In this state, if a portion of scale be care-
fully raised, it may be seen to be studded upon its
under surface with conical cylinders which have
been drawn out of the tubes of the foUicles.
There would seem to be good reason for belief
that the leichen planus of ourselves is identical with
the leichen ruber of Hebra, the structiu*e of the
papule in one case and its colour in the other being
taken as the specific character of the eruption. If^
however, this surmise be correct, leichen planus is
IMPETIGO. 229
more common in England than in Austria, and at
the same time very much milder in its course. With
us it must be regarded as a trivial affection, whereas,
in the practice of Hebra, it was always grave and
very commonly fatal.*
Leichen lividus and leighek pilaris are simple
follicular papules, in the one instance distinguished
by a purple or livid colour, resulting from retarded
circulation ; in the other, by embracing the shaft of
a hair at its issue from the skin. Both these forms
are seen the most commonly in the lower extremities,
and especially below the knee ; and leichen lividus
is sometimes associated with the petechia of
purpura.
Impetigo.
Ekzema, leichen, impetigo, scabies, — ^herein is a
heterogeneity of terminology that at first sight is
somewhat perplexing ; ekzema and leichen, both of
them Greek; impetigo and scabies, both Latin.
Moreover, there can hardly exist a doubt that im-
petigo and scabies, as used by the Latins, were
exactly synonymous with the ekzema of the Greeks.
But we shall best serve the purpose of elucidating
the problem, not by creating unnecessary difficulties,
but by defining, with all the precision we are able,
the scope of these several terms as they are employed
at the present day. Ekzema, as we have seen, is
characterized by several pathological lesions, of
which two are papulation and pustulation. Leichen
and impetigo represent these latter lesions when
they are present alone: leichen is a papule, and
impetigo a pustule. When, however, leichen and
impetigo constitute a part of ekzema, the forms are
known by the names of ekzema papulosum or ekzema
* Journal of Cutakj^ub Medicikb, vol. III., page 54 ; also
page 117.
230 EKZEMATOUS AFFECTIOxVS.
leiclienodes, and ekzema pustulosum or ekzema
impetiginodes. Thus it is that we are enabled to
perceive the close alliance of these several affections,
distinguished by such a diversity of terms ; and by
the same means we acquire our strongest argument
for considering them in the aggregate as ekzematous
affections.
By the word " pustule," at the present day, we
mean a vesicle containing pus ; but the term was
in use long before the matter of pus was identified
or understood, and is employed by Celsus to signify
an eruption of prominence merely, giving rise to
unevenness or roughness, and wholly independent
of the nature of its contents, being sometimes a
solid papule, sometimes a vesicle, and sometimes a
vesico-pustule. Now, however, we recognize two
principal kinds of pustule, — one superficial, a sero-
pustule or muco-pustule, termed psydrakiouj hterally
a cold or non-inflammatory pustule ; and phlyzahion^
a more deeply-rooted or inflammatory pustule. The
former is the pustule of impetigo ; the latter, that of
ekthyma.
Impetigo, therefore, is an eruption of superficial
pustules, of minute size, developed on an inflamma-
tory base, of a pale yellow colour, drying up in the
course of a few days into an amber-coloured scab, or
forming a crust of considerable thickness by conti-
nued secretion of a purulent fluid. The purulent
secretion varies in its tint of colour and also in its
density, being sometimes brightly yellow, sometimes
of a cream-like hue ; sometimes thick and viscous,
sometimes diffluent and serous. The yellow colour
of the crusts suggested to the Greeks the idea of
dried honey, which they expressed by the term meli-
tagra. And the scabs and crusts remain adherent
to the inflamed surface for one or two weeks and
then fall off, leaving behind them no permanent
trace of their existence.
This eruption presents us with two principal
IMPETIGO. 231
varieties, namely, impetigo figurata and impetigo
sparsa ; impetigo figurata being an aggravated form
of the disease, consisting of circumscribed patches
of various extent ; and impetigo sparsa, a scattered
form, in which the eruption is dispersed in single
pustules, or in small clusters of pustules, more or
less extensively over different regions of the body.
A common seat of impetigo is the face, where it
may occur in small circular patches an inch or two
in diameter, situated near the angles of the mouth
or nose, or it may cover the entire surface of the
face.
Impetigo makes its appearance in the form of
small red spots, which rapidly coalesce ; in the
centre of each red spot there speedily rises up a
minute pustule; the pustules increase quickly in
size ; and if there be several or many pustules, they
constitute a coherent cluster, surrounded by other
red spots and incipient pustules, and sometimes
bounded by an abrupt border. There prevails in
impetigo a decided tendency on the part of the pus-
tules to spread by the circumference; sometimes
the spreading periphery assumes a semi-pustular or
vesicular character ; and then we have presented to
us a form of the eruption which is termed impetigo
phlyktaenodes.
Impetigo is an eruption evincing a lower degree
of power than either ekzema or leichen, and is met
with chiefly at the nutritive period of life ; in weakly
children ; among the debilitated and cachectic in
youth and in the adult; and among the poorer
classes. One of its forms, namely, impetigo phlyk-
taenodes, is frequently epidemic, prevailing in dis-
tricts and famihes, and leading to the suspicion of
contagion. Such cases are met with not unfi*e-
quently among the out-patients of hospitals, but are
rare amongst the wealthier classes ; and the common
occurrence of the eruption in several children of a
family at the same time has induced Dr. Tilbury Fox
232 EEZEMATOUS AFFECTIONS.
to regard it as contagiousi and to give it a name
expressive of contagiousness, namely, "impetigo
contagiosa."
SOABIES.
None of our terms has been more diverted from
its original signification than the word scabies. In
the language of the Latins it stood as the repre-
sentative of the psora of the Greeks ; the disease
implied by the terms psora and scabies was the
same ; but, by degrees, it has fallen from its high
estate, and is limited at present to that condition of
irritation and eruption of the skin which is induced
by the presence in the epidermis of the acarus sca-
biei, the sarcoptes hominis of Latreille.
The eruption of scabies is one of a multiple lesion;
there are papulas, vesiculaa, pustulaa, and desquama-
tion, sometimes all of these together, at other times
one only or two, the precise form of the lesion being
governed by the temperament, the age, and the
state of health of the patient. In the infant, abound-
ing in fluids and endowed with weak and sensitive
tissues, vesiculae, giving out a viscous and colourless
exudation when broken, may predominate, with here
and there a sprinkling of vesico-pustules and a scat-
tered papulous rash distributed over the general
surface of the body and limbs. In the adult, with
drier and firmer solids and less irritability of tissue,
the eruption may be chiefly papulous ; while, in the
cachectic, the leading feature of the eruption may
be the development of vesico-pustules. The amount,
therefore, and the kind of eruption, are not to be
regarded as evincing a greater or less severity of
the disease, but merely the degree of sensitiveness,
of irritability, of the organization of the individual.
It is worthy of note that in scabies there exist
two forms of irritation ; the one, a direct irritation,
corresponds with the habitat of the acarus; the
SCABfES. 233
other is indirect, if you will, sympathetic or propa-
gated, and is evinced at a distance from the focus of
the cause. The habitat of the acarus is the hands ;
in the infant the feet as well as the hands ; and,
next to the hands, the organs of generation, the
podex, and the boundaries of the axilla, parts which
are easily reached and are subject to be touched by
the hands, the hands being thi original source from
which and by which the animalcule is conveyed.
These considerations weigh with us in forming our
diagnosis : a suspicious eruption, papulous and pru-
ritic, be it ever so abundant upon the body and
limbs, loses its claim at once to be regarded as
scabies unless it be present also upon the hands.
The state of the hands is our first inquiry, our first
investigation, in establishing the diagnosis of scabies;
and if there be no eruption on the hands, a primd
facie case is made out against the presumption of
scabies.
Let us glance for a moment at the natural history
of the acarus in its relations with the skin. The
animalcule is of three kinds, the impregnated female,
the young of both sexes, and the male, and the
habits of these three members of the same family
are widely difierent. The impregnated female bears
away our chief interest in connexion with the de-
velopment and maintenance of the disease, and is
the object of our search for the confirmation of our
diagnosis. Impelled by the maternal instinct she
seeks the hands to excavate her burrow for the
deposit of her ova, for the security of her young, —
and well knows the adept where to find her, — ^not in
the exposed regions of the hand, where danger of
extinction might impend, but in the grooves of
flexion, and especially between the fingers. And
even here there is a diflbrence between the soft,
moist hand of infancy and the homy palm of the
adult. In the adult our search would commence
with the soft skin of the interdigital surfaces ; then
234 EKZBHATOUS AFFEOTIONS.
we should examine the ulnar border of the hand ;
and, lastly, the grooves of flexion of the wrist. But
in infancy and childhood we should be content with
the palm of the hand for our observation, where the
epidermis is thickest, and we should expect to find
the burrows starting from the grooves of flexion and
extending their gentle curves and zigzags into the
open space. In the feet also, in infants, the burrows
are to be sought for in the thickest portions of
the epidermis, in the sole, and upon the borders of
the foot.
Cuniculus is the burrow of the rabbit, but the
cuniculi of the acarus are more artistic than those of
the burrowincr mammal. The mother acarus begins
her operations, when she can, from one of the
grooves of motion of the skin, which, like the trench
of the besieger, protects her from danger while she
opens the ground ; she then bores steadily onwards
parallel with the surface, until she reaches a distance
of safety and convenience ; here she constructs a
vaulted cave, wherein she deposits two pairs of ova,
and perforates the vault of her chamber that she
may breathe easily herself, and that through the
opening her young may receive air as soon as they
are hatched. This being accomplished, probably
the operation of a single night, she pushes her
tunnel onwards the following night, until space for
another chamber, ventilated from above as before, is
obtained, and here a second double pair of ova are
deposited ; and so she goes on, night after night,
until her tunnel has reached a length of half an inch,
and until she has deposited probably from twenty to
forty or fifty ova.
There is nothing so important to the medical man,
in connexion with scabies, as the recognition of the
cuniculus of the acarus. It is easy enough, having
found the cuniculus, to discover and capture the
animalcule, the indisputable proof of scabies ; but
for ordinary diagnosis the demonstration of the
ACABUS SCABIEI. 235
acarus is altogether unnecessary, the cuniculus is
the really important pathognomonic evidence. There-
fore it is not too much to require of the student of
dermatology that he should make himself thoroughly
at home with the appearance of the cuniculus of the
acarus, and, like a true sportsman, be famiUar with
the characteristic tracks of his game. Let us look
once again over our guiding points, at the outside
features of the lair of our prey. On the skin of the
interdigital surface of the fingers, on the ulnar border
of the hand, on the folds of flexion of the wrist, and,
more distinctly still, along the embankment of the
lines of motion of the palm of the hand of infants
and children, we shall see, in scabies, a whitish,
almost glistening line, fluted somewhat like a string
of beads, more or less curved in its course, start-
ing at right angles fi^om the grooves of motion,
terminated abruptly by a slightly bulbous end, and
ranging in length from two or three lines to half an
inch. Such is the cuniculus scabiei, and if it be
inspected more closely, it may be seen that it is not
strictly white, but greyish in appearance, the grey-
ness resulting from the presence of a blackish matter
in the cimiciHus, the faeces of the animalcule : then,
if of any standing, the proximate end of the cuniculus
is ragged from the wearing away of its roof; some-
times it is marked by a series of black spots, occa-
sioned by the intrusion of dirt into its air-holes;
sometimes it crosses the dome of a vesicle, and may
be seen traversing the epidermic wall ; and some-
times, when such a vesicle has dried up, there may
be seen a circular area bounded by a ragged edge,
the remains of its base, and the cuniculus appears to
be a continuation of this area.
But suppose we want to dislodge the acarus, to
exhibit her to the outside world, we then fix our
attention on the slightly bulbous end of the cuni-
culus. It is remarkable for its whiteness ; it looks
as if it had within it a little white globe, and this
236 EKZEMATOUS AFls'EOTIONS.
little wliite globe, bounded at the extreme end of tbe
cuniculus by a reddish-brown semi-lunar streak, thick
in tbe middle and tapering to the ends. This little
white globe is in reality the animalcule, and the
reddish-brown semilune the chytinous covering of
its head and arms. Puncture the dome of epidermis
at this point with a fine needle, and briskly twitch
it up, so as to tear the dome, and the acarus will be
brought into view ; we have now nothing further to
do than to insert the needle into the open cavity,
and the acarus will cling to it firmly. The creature
will appear at the tip of the needle like a minute
white globe, and with the utmost ease may be trans-
ferred to the nail, or to a glass slide, to be examined
with the microscope.
But the study of the cuniculus teaches us yet
another lesson : the grubbing and boring of the
acarus necessarily excite an irritation of the derma
at the seat of the operation ; the irritation is mani-
fested by the development of a serous vesicle,
sometimes a sero-purulent vesicle, and the cuniculus
is lifted upwards away from the derma, and may be
seen as a linear streak in the layer of epidermis
which constitutes the wall of the vesicle. It is pro-
bable that in this way both the cuniculus and the
acarus are sometimes destroyed, but at other times
the acarus escapes the sudden upheavement, and
continues her work beyond the hmit of the vesicle.
Occasionally the irritation caused by the operations
of the acarus excites the formation of a similar
vesicle in the immediate neighbourhood of the cuni-
culus, sometimes several ; and the irritation propa-
gated from cuniculus and vesicle or vesicles, causes
others to be produced at a distance, and so, by a
propagated irritation, more active in some subjects
than in others, the cuniculus becomes associated
with vesicles, and the disease scabies is esta-
bUshed.
We have now only described the phenomena
ACARUS SCABIEI. 237
attendant upon the presence of a single acarus ; but
if you will suppose the existence of several of these
causes of irritation — and you have only to wait until
the progeny of one of the cuniculi is hatched to
have ample grounds for such supposition, — ^you will
understand how the irritation caused by the pre-
sence of acari in and on the epidermis may produce
irritation in the immediate neighbourhood of their
haunts, and that the irritation may be propagated
to the most distant points of the surface of the
body. And, further, that the irritation will be
manifested by vesicles, by vesico-pustules, by papulsB,
by scratches inflicted in the efforts to relieve the
itching of the skin, and by a broken and ragged
state of the epidermis.
But hitherto we have taken no notice of the
}roung acari and of the males ; the former of these
inger in the neighbourhood of the parental haunts,
nestling in the cuniculi and in hollows of the broken
skin. While the males — fewer in number than the
females — are endowed with remarkable activity and
energy, and rove over the whole surface of the body
in search of the unimpregnated female. Another
curious and practical example of the habits of the
acari is, that they repose during the day and
indulge their activity in the evening and during the
night. Hence our presumption that each of the
moniliform flutings of the cuniculus is the work of
a single night; hence also the exasperation of
pruritus in the evening and in bed; and hence,
besides, a more important matter, the greater
liability of transmission of the disease by bedfellows
and during the night.
The diversity of consequences produced by the
acarus in different individuals — ^in other words, the
difference in severity of the scabies — ^is very remark-
able : in one person a few papules, in another the
most violent torment; in some exciting a leichen
pruriginosus, prolonged for several months; in
238 EEZEMATOUS AFFECTIONS.
others a troublesome ekzema ; and in others, again,
a phlyktsBnoid eruption, approaching to pemphigus.
And these secondary effects may continue afler the
primary disease has subsided, and when every
acarus is destroyed. Nevertheless, we have occa-
sionally met with cases in which the phenomena of
secondary scabies have been prolonged for a con-
siderable period, and wherein, after careful search,
a single acarus has been discovered, not, as usual,
upon the hands, but upon the border of the axilla,
or upon some part of the genital apparatus.
The day has gone by since mention used to be
made of varieties of scabies ; but Willan and Bate-
man describe four kinds of the disease, founded on
the popular terms, " rank, watery, pocky, and scor-
butic ; " or, in technical language, scabies " papuli-
formis, lymphatica, purulenta, and cachectica.'' At
present we abandon all such distinctions, and regard
the differences in proportion of papulaa, vesiculae,
and pustulaB, and the graver or slighter forms of
eruption, as the mere accident of the constitution of
the patient.
Diagnosis of EhzeToatous Affections.
The attention which is devoted by dermo-patholo-
gists to diagnosis evinces a wholesome spirit of
scientific inquiry, although it may not be actually
necessary for the therapeutical management of the
disease ; and the close and precise discrimination
upon which diagnosis is founded is nowhere more
important than in the exact determination and
differentiation of the ekzematous affections ; and
this, not only with the view to establish their special
pathognomonic characters, but also to lay the
foundation of a negative diagnosis in reference to
other diseases. The question may sometimes arise,
is it ekzema ? is it lepra ? is it syphilis ? And when
this difficulty obtrudes in greatest force, it is con-
DIAGNOSIS OP EKZEMATOUS AFFECTIONS. 239
venient by negative signs to eliminate first one
and then another of the doubtful affections, until
that which remains stands alone, and establishes
thereby its unmistakable identity. We have already
called your attention to the multiple characters of
ekzema ; we have shown that one or other of those
signs may be absent without disestablishing the
diagnosis of ekzema; we have seen that the most
pathognomonic of the characters of ekzema is exu-
dation, whether extrastitial or intrastitial ; and we
have also shown that the separate existence or
isolation of one of the lesions of ekzema — for
example, its papulaa or its pustulas — ^is recognised as
a special affection under the name of leichen or
impetigo. And, furthermore, that one or more of
the lesions of ekzema due to a particular cause,
namely, the presence of an animalcule in the epi-
dermis, is the disease scabies.
In the diagnosis of leichen you will have to bear
in mind not only its papular character, but also the
absence of other signs indicative of ekzema. You
must remember the pathological seat of its papulae,
their sometimes dispersion and sometimes aggrega-
tion. Their occasional special relation to the hairs,
or to an exuviative epithelial affection of the follicles,
and their frequent variety of colour. The eruption,
moreover, is sometimes concentric and circum-
scribed, sometimes centrifugal and annulate ; com-
monly pniriginous ; sometimes partaking of the
neurotic character of urticaria, or modified by the
seat of its manifestation, and also by age. The
point of greatest moment in the diagnosis of leichen
is one which is as yet not ripe for our consideration,
namely, its distinction from other forms of foUicuHtis,
originating in different causes. For example, you
are sure to fail in your early attempts to distinguish
leichen annulatus from tinea or phytosis annidata ;
and your failure will not be your own, but attri-
butable to the present state of dermatology. To
240 EKZEMATOUS AFFECTIONS.
this subject we intend to give our full attention at
some future and not very distant day.
The diagnosis of impetigo is expressed in a very
few words, namely, a suverficial vesicle containing
purulent fluid. Just as the presence of pus in con-
nection with the pathological disorganization of
ekzema, whether the pus be simply a product of the
morbidly secreting surface, or be developed in the
form of minute pustules in the circumferential inte-
gument, is the pathognomonic feature of ekzema
impetiginodes or ekzema pustulosum; so the pre-
sence of superficial pustules or vesico-pustules, apart
from any other of the lesions of ekzema, is the
characteristic of impetigo. Its occurrence in figured
clusters on one or more regions of the body, or its
scattered distribution, is self-evident ; while its
assumption of the vesicular type in a debilitated
stat-e of the tissues of the skin is made manifest in
impetigo phlyktsenodes. Dried pus, again, or the
combination of pus with a viscous mucopurulent
fluid, gives the yellow, the dried honey colour, to the
crusts and scabs of impetigo.
In the diagnosis of scabies, on the other hand, we
neither look for vesicles nor pustules as the primary
indication of the disease : indeed, both may be
absent. Our attention is chiefly drawn to the
papulas, to the marks of scratching apparent on the
skin, to the ragged condition of the cuticle in the
haunts of the acarus ; to the subjective symptoms,
the itching at night, the pruritus of the wrists, the
prevalence of a similar affection among other mem-
bers of the family of the patient, and, lastly, the
detection of cuniculi.
Gaiise of Ekzematous Affections.
We have already gone so extensively into the
cause of ekzema that little remains to be said with
especial reference to leichen and impetigo. Scabies
(
I
ETIOLOGY AND PROGNOSIS. 24 1
is especially interesting to us as teaching the kind and
the amount of pathological alteration of the tissues
of the skin that may be occasioned by a purely local
cause ; in demonstrating the activity of propagation
of irritation by means of the skin ; and the tenacious
continuance of irritation, even when the exciting
cause is withdrawn. The causes of leichen are one
while locals as in the instance of the eruption oc-
casioned by the use of garments made of a rough
or heating material, and to some extent in leichen
tropicus ; and another while, and more commonly,
constitutional, depending, in fact, upon causes which
are identical with those of ekzema. Leichen planus
would seem to be the combined result of debility of
the skin and disorder of the functions of assimi-
lation.
Prognosis of EJczematous Affections.
Although the ekzematous family includes some of
the most severe of the affections of the skin, yet
none are especially grave, apparently for the reaso
that the skin is not a vital organ, and its derange-
ments are not so seriously felt by the economy as
those of other organs, the lungs, for example, the fiver
and kidneys, or the alimentary canal. Ekzematous
affections, with the single exception of scabies,
originate in debility, in debility of tissue accom-
panied with more or less of general debility, and
derangement of the functions of assimilation and
secretion. This complication naturally tends to
render ekzematous affections chronic, and often
serious ; but, unless attended with excessive pruritus,
they exert very little influence upon the constitution,
and are to be considered more in the light of indica-
tions of a disordered and enfeebled system than as
exercising any direct influence upon the life of the
patient.
242 EKZEMATOUS AFFECTIONS.
Therapeutical Treatment of the Ekzematous Affections.
Mucli that lias been said witli regard to the
separate treatment of ekzema will apply equally to
that of leichen and impetigo. The indications to be
observed are, in the first place, the constitutional
state of the patient ; and, secondly, the local con-
dition of the skin. The constitutional state of the
patient may present disturbance of the digestive,
assimilative, and emunctory functions, or a condition
of simple debility ; or both these states may be
present in unequal proportion. The local condition,
on the other hand, may be one of inflammation or
mere irritability.
Upon this general principle we may regulate our
salines, aperients, and alteratives, on the one hand ;
and our tonics on the other ; and locally, our re-
fingerants, our sedatives, and our stimulants.
In leichen simplex and leichen tropicus, the two
most active forms of the eruption, we shall derive
advantage from the use of effervescent salines and
saline aperients. Sometimes the state of secretion
of the liver may be suggestive of a moderate use of
blue pill or grey powder. And we may complete
our work with an alkaline or acid tonic, or with
citrate of quinine and iron. Our local remedies in
these cases are dusting powders, a lotion of aqua
calcis with oxide of zinc and calamine powder, a
lotion of bicarbonate of ammonia or soda, or one of
acetate of lead. If the pruritus be troublesome, an
emulsion of bitter almonds with hydrocyanic acid ;
and if the skin be abraded and irritated by the action
of the nails, the benzoated oxide of zinc ointment with
spirit of wine, spirit of camphor, or carbolic acid.
Leichen circumscriptus, leichen annulatus, leichen
pilaris, and leichen lividus, are all of them chronic
lorms of eruption, and, besides the necessary means
for regulating the digestive, the assimilative, and
THBEAPEUTIOAL TREATMENT. 243
emunctory functions, require tonic remedies, possibly
arsenic, and the use of tonic or stimulant local
remedies, such as the lotion of bitter almonds with
perchloride of mercury, a lotion of sulphuret of
potash; or zinc, mercurial, or sulphur ointments ; the
zinc ointment being combined with carbolic acid ;
the mercurial ointments being those of the white or
red precipitate, considerably diluted, and the sulphur
ointment that of the sulphuret of potash. One or
two applications of tincture of iodine will often
disperse local patches of circimiscribed or annulate
leichen without further treatment.
Leichen pruriginosus, so often a sequel of scabies,
may be one of those theoretical cases in which un-
impregnated female acari, or soUtary males, are
alone left upon the skin. It will often yield to the
unguentum staphisagrias, unguentum potassas sul-
phuratse, or to a lotion of the perchloride of mercury
in emulsion of bitter almonds.
Leichen planus, besides constitutional treatment
to regulate unhealthy function of whatever kind,
may require the ferro-arsenical mixture. While,
locally, its most important remedies are the bitter
almond emulsion with perchloride of mercury (gr. ij.
ad 5j.), the unguentum potassas sulphuratsB, and the
solution of the pentesulphide of calcium or solutio
sulphuris cum calce.
Leichen strophulosus and leichen urticatus are
both eruptions of infancy, and in both a regulative
and tonic treatment are required. A perchloride of
mercury solution in emulsion of bitter almonds is
best suited for the former, while a lotion of juniper
tar with soft soap and alkohol is almost specific for
relieving the pruritus of leichen urticatus ; and, where
the latter fails, the unguentum staphisagriad is
indicated.
In impetigo, besides the restoration of the ftmc-
tions to the healthy standard, tonics are imperatively
called for, and especially chalybeates and the citrate
B 2
244 EKZEMATOUS APFEOTIONS.
of iron and quinine^ and, after the use of these,
arsenic will often be found useful. The best local
applications are the lotion of lime-water with oxide
of zinc and calamine, or the ointment of zinc with
carbolic acid (gr. v. ad Jj.). The latter is especially
suited to the phlyktaenoid form of the eruption.
Scabies may be cured with a word, and that word
is sulphur. Bub a little sulphur ointment, made
flagrant by the addition of oil of chamomile,
thoroughly into the hands night and morning, and
wash the rest of the body with sulphur soap,
and at the end of a few days the cure is complete,
and with a sound skin. Where the use of the sulphur
ointment in the morning would be inconvenient, use
dry sulphur instead. And, besides the cure, the
patient is saved the danger of communicating infec-
tion from the first moment of applying the remedy.
The blundering old days of confining a patient to
the blankets for a week or more, and excoriating his
skin with a twice-daily inunction of sulphur and
hellebore, have long since ceased to exist ; and
modem conundrums are not worth the trouble of a
thought. From the palace to the pigsty there is
no more perfect, cleanly, and certain method of
treatment of scabies than the sulphur cure as adapted
to the better class of society. The oil of chamomile
not only disguises the smell of the sulphur, but by
its own odour is destructive of the acarus. And if
the smell of the sulphur be really an objection, we
have in reserve a valuable application, the unguentum
staphisagrisB of Bourguignon.
The prejudice against the ** sulphur cure " has
given rise to a variety of suggestions of other
methods that are still avh judice and not yet gene-
rally accepted. In a few instances we have made
use of the styrax cure, but we are not yet prepared
to venture an opinion with regard to it. The best
form of application of this remedy is that proposed
by Dr. Bchultze, which consists of one ounce of
THERAPEUTICAL TREATMENT. 245
liquid styrax, two drachms of spirits of wine, and
one of olive oil. These substances are to be blended
thoroughly together, and the resulting compound is
sufficient for two applications. It must be careftilly
smeared over every part of the skin, with the excep-
tion of the head, and repeated in twelve or twenty-
four hours. Care must be taken that no part of the
skin is allowed to escape ; and the liniment must not
be disturbed for several days, when a thorough
ablution puts an end to the treatment. This lini-
ment is wholly unirritating to the skin, and has no
tendency to excite ekzema, as is the case with the
sulphur ointment.
Dr. Silad Durkee, of Boston, conceives that much
of the therapeutical value of the sulphur applica-
tions is due to the solvent action of the alkali, which
is usually combined with them ; and he proposes,
instead of using sulphur at all, to rub soft soap
thoroughly into the affected parts of the skin. The
soap should be left on the skin until it produces a
" severe smarting or tingling sensation,*' and then
washed off with warm water. One application, he
says, will frequently suffice for the cure, but sometimes
two or^three may be required ; in which case the sapo-
nation should be repeated every third or fourth night.
The possible irritant effect of the remedy needs to be
watched ; it is sometimes very considerable, and for
infants and young children an ointment is to be pre-
ferred consisting of ten or fifteen graixis of the
iodide of potassium to the ounce of lard.
There is a curious and barbarous method of treat-
ment of scabies practised in the Belgian army, which
is called a speedy cure, and is attributed to the
Medical Director-ueneral, Vlemingkx. The detail of
the method is amusing, and serves to point a moral
and complete a tale. The process is to rub the
patient down with soft soap lor half an hour ; then
to wash off the soft soap and no little of the epider-
mis during another half-hour ; in the next plaice to
246 EKZBMATOUS AFPECTIOKS.
scrub him with the solutio sulphuris c. calce for a
third half-hour ; and, lastly, to wash oflF the solutio
sulphuris c. calce, make him dress, and send him
back to his military quarters.
( 247 )
CHAPTER IV.
ESSATS, NOTESy AND CaSES^ ILLUSTBATIYE OF EeZEMA.
I.
Eezema Infantile.*
Infants at the breast and young children are
peculiarly subject to ekzema, and in them it is apt
to assume the severest form presented by cutaneous
disease. In young infants it commences at the end
of the first month or six weeks,t and unless sub-
mitted to proper treatment may continue for months
and years — ^in fact, it may lay the foundation of a
cutaneous disease, which may be prolonged in a
chronic form until manhood, or may hang about
the patient for the remainder of his days.
Ekzema infantile, like ekzema adultorum, origi-
nates in malassimilation, and with good reason is
commonly ascribed to a faulty secretion of milk on
the part of the mother : but when once established,
it is not remedied, as might be expected, by the
withdrawal of the cause and the substitution of a
different and less faulty food. Unsuccessful attempts
to cure the disease probably carry the child on to
the period of cutting the teeth ; then the continu-
* This Essay was read at the annual meeting of the British
Medical Association, on the 31st of July, 1856 ; and must there-
fore be taken as the expression of the author's opinions fourteen
years ago. It is reprinted from the British Medical Journal
of the corresponding date.
t Vide succeeding Essay No. II. of the present Chapter.
248 EEZEUA INFANTILE.
ance of the disease is attributed to dentition — ^this
time without so good reason — and hopes are raised
that when the milk-teeth are perfected, the disease
will subside. The milk-teeth are all cut, but,
still the ekzema lingers, and then a new light of
prophecy beams upon the little patient : when pu-
berty arrives, then certainly the disease will go :
but puberty possesses as little of the physician's art
as change of food, or completed primary dentition :
and so the malady becomes perpetuated. I have
seen this picture in life so frequently, that I could
not refrain from sketching it.
It is remarkable how trivial an exciting cause
may become the origin of this distressing malady.
A lady, six weeks after her confinement, travelled by
the railroad from London to the sea-coast, carrying
with her her infant. The mother was chilled by
the journey, was feverish during the night; her
infant was feverish the following day and threw
out an eruption of ekzema ; the child was brought
to me some months afterwards. Recently, a neigh-
bour brought me her infant covered with ekzema
from head to foot. The child was a few months
old. In her confinement the mother lost her hus-
band under painful circumstances ; the distress
caused by this affliction was transmitted to the
offspring as an ekzema rubrum. How small is the
cause of malassimilation in these cases, which may
be taken as the type of the whole family ; how
easily is the assimilative function of infants dis-
turbed ; how difficult is it often to be restored.
When cutaneous eruption attacks an infant under
these circumstances, it revels in all the typical and
modified forms of cutaneous disease. At the same
moment, and on the same child, may be seen ery-
thema, leichen, strophulus, ekzema, impetigo, pity-
riasis, and psoriasis : and an observant nurse seems
to take a special delight in pointing out the various
diseases which pervade the flesh of the poor little
EKZEMA INFANTILE. 249
sufferer. In certain parts of the body erythema is
apt to prevail ; but a broken or cracked state of
the skin, with however small a degree of ichorous
oozing, must determine the case to be ekzema. On
the back, leichen is apt to predominate : on the
head, in the bends of the joints, and on the puden-
dum, ekzema: on the cheeks and ears, ekzema
impetiginodes ; all on the same skin, and in gross
defiance of the orders, genera, and species of the
Plenckio-Willanean method of classification.*
The predominance of one or other of the typical
forms of cutaneous eruption, is determined by the
condition and temperament of the infant. The
child may present every shade of variation of ap-
pearance, from a state difficult to distinguish fi:om
complete health, to one in which the little thing is
attenuated and shrivelled up, and looks like a
wizened old man. In the former extreme, however
ruddy and fiiU the child may seem, there is evidence
of an existing weakness, in the softness of its
muscles ; but with that exception, no trace of
disorder of constitutional health can be discovered.
Next to softness of muscles comes pallor, in a slight
degree, then an increasing whiteness of the eye,
attributable to progressive anaemia : then follows
emaciation ; the skin shows signs of wrinkles, be-
comes dry and discoloured, and ultimately sordid.
With these, the outward signs of the disease,
malassimilation in fact, there is rarely any disturb-
ance, or but little, of the digestive organs; the
child takes its food well, and is not particularly
restless or fi^etftil. Sometimes the motions are
green, sometimes mingled with an excess of mucus,
and sometimes white from suspended biliary secre-
tion : but there is nothing beyond the commonest
* It m&j be nnnecessary to mention that at present these pre-
sumed separate affections are regarded as forms of ekzema under
the names of— erythematosum, papulosam, vesiculosum, ichorosum,
postulosum, and squamosum.
250 EKZEMA INFANTILE.
gastro-intestinal derangement, and that in a very
insignificant degree.
The eruption usually commences as a patch or
blotch of shghtly raised pimples ; the patch is
itchy, is rubbed, increases in size, becomes more in-
flamed, the cuticle is lifted up in more or less defined
vesicles, which are usually broken by Motion ; and
the surface becomes excoriated, somewhat swollen,
and pours out an ichorous secretion, varying, from
a mere oozing, to an excess which wets through
everything that is applied to it. With the increase
of irritation consequent on the excessive secretion
and the congestion which gives rise to it, the patch
spreads ; where the eruption commenced by several
blotches, they probably run into one ; the ichorous
discharge also increases the local disease, by irri-
tating the parts over which it flows. The case up
to this time is one of inflammatory ekzema, or
eJczema ruhrum; the state of ekzema simplex has
hardly existed, and is only to be seen occasionally ;
but the disease still runs on, its violence increases,
and the morbid secretion, fi'om being a transparent
and colourless ichor, like water in appearance, be-
comes slightly opaque (tinea mucosa), milky, then
yellowish and semi-purulent, and the case is trans-
formed into ekzema impetiginodes ; or the discharge
may take on a still more decidedly purulent character,
while small pustules are developed on the red and
tumefied skin around the patch, and then the case is
one of impetigo. Thus the plus or minus of these
pathological conditions is irrespective of the cause
or essential nature of the disease ; in other words,
the disease being the same, it may, according to
the temperament or constitution of the child, be an
erythema verging upon ekzema ; an ekzema ru-
brum ; an ekzema verging on impetigo, or ekzema
impetiginodes ; or, the pustular element being in
excess, it may be an impetigo. Again, as I have
before said, whatever the predominating character
EKZBMA INFANTILE. 25 I
may be, whether erythema, leichen, ekzema, or im-
petigo, there will always be present in a greater or
less degree, some or the whole of the other forms
sprinkled over the body ; a simple erythema here,
an erythema with strophulus or leichen there; a
few scattered vesicles of ekzema in a third place, or
a few congregated psydracious pustules of impetigo
in a fourth.
In this description of the general characters of
ekzema infantile, I suppose the eruption to be com-
paratively undisturbed ; but that is rarely the case
— the great heat, the prickling, the tingUng, the
intense itching which accompany the disease, render
abstinence from rubbing and scratching impossible ;
hence these have to be added to the causes of aggra-
vation of the local disorder. Again, the burning heat
of the skin on the one hand, and exposure to the
atmosphere on the other, tend to desiccate the siir-
face very rapidly ; the contents of the vesicles, in the
simplest form of the affection, dry up into a thin
transparent amber-coloured crust. In ekzema ru-
brum with a more copious discharge, the crust is less
transparent and thicker; and in ekzema impetigi-
nodes it is still further increased in thickness, is
lighter both in colour and texture, and uneven in
surface; while in impetigo, from the desiccated
matter being pus, it is thickest of all, and has the
appearance of dried honey : this circumstance has
given the name of melitagra to the latter disease.
As may be supposed, the crust presents considerable
variety of appearance, according to the prevalence of
accidental circumstances in a greater or less degree,
such as accumulation of secretion, amount of desic-
cation, &c. Not unfrequently, as a consequence of
pressure or friction, blood is mingled with the dis-
charges, and the crusts become coloured of various
hues, from a lightish brown to a positive black.
Again, a variety of colour results from the age of
the crust — that which has been longest formed being
252 EEZEMA INFANTILE.
usually lighter than the rest : and another difference
occurs when the original crust is broken, and a new
discharge issues from between the severed frag-
ments.
Sometimes this terrible disease attacks the whole
body of the child, and the little thing has scarcely a
patch of sound skin on its entire surface, being
covered from head to foot with erythema, excoria-
tions, and scabs of every variety of size and thick-
ness, giving out an offensive valerianic odour, which
has been compared to the urine of cats. But more
frequently it is Umited to one or more regions of the
body ; the commonest seat of the eruption being the
head and face, the front of the chest, the umbilicus,
the pudendal region, and the flexures of the joints.
On the head the eruption is complicated by the pre-
sence of hair, which entangles the discharges, and
the crusts are apt to form, in consequence, of con-
siderable thickness, sometimes including the whole
scalp in a thick, rugged, yellowish, and discoloured
cap. At other times, when the discharge is less
abundant, it dries up into a friable crust, which,
broken into small fragments by scratching and rub-
bing, has been compared to particles of mortar dis-
persed amongst the hair, and has received the name
of tinea granulata ; many of these particles of crust,
being pierced by the hairs, have the appearance of a
string of rude beads. Later in the history of the
eruption, and when it has become decidedly chronic,
when erythema of the scalp with copious ftirfurace-
ous desquamation are the leading characters of the
disease, it has been tei*med tinea furfuracea ; and
later still, when, with a slighter degree of erythema,
the epidermal exfoliation is mealy, the case is one of
pityriasis capitis.
When the ears are attacked, they become much
swollen, and give forth an excessive quantity of
ichorous secretion, which may be seen distilling from
the pores of the skin, and standing in drops on the
BKZBMA INFANTILE. 253
inflamed and excoriated surface. When the disease
fixes on the face, it is also attended with swelling,
and often gives the child a bloated and frightful
appearance, every feature being distorted ; and the
deformity is increased by the production of a thick
discoloured scab, which forms a mask, sometimes to
the entire face. This huge unnatural mask covering
the child's face suggested the term larvalis given to
one of his species of porrigo by Willan ; only that, in-
stead of porrigo la/rvalis^ it should have been ekzema
larvalej or impetigo larvalis. Again, from occurring
at the milk-period of life, this extraordinary crust,
whether arising from the desiccated secretions of
ekzema rubrum, ekzema impetiginodes, or impetigo
proper, has received the name of milk-crust or crusta
lactea.
The inflammation of the scalp and face is apt to
produce, as one of its secondary efiects, enlargement
and sometimes suppuration of the lymphatic glands ;
thus, we find the gland situated behind the ear, the
occipital, the submental, and cervical lymphatic
glands, swollen and painfiil. And not unfrequently,
in a pyogenic diathesis, there are superficial ab-
scesses in the neighbourhood of these glands.
The pudendal region, both in the male and female
infant, is, not imcommonly, the seat of the eruption :
it being determined to that region, partly by the
heat and moisture resulting from its function, and
partly by the thinness and delicacy of the skin. For
the latter reason, it is commonly met with in the
flexures of the elbows and knees, and sometimes in
the axillae. In the flexures of the joints the inflamed
skin is apt to crack into fissures of considerable
length and depth, and the cracks often bleed, the
blood mingling with the excessive ichorous secretion
poured out by the denuded skin.
The general character of ekzema infantile is to
form patches of considerable size, several inches
square, and to attack, as I have already explained, a
254 EEZEMA INFANTILE.
whole region at once, such as the head, face, &c. ;
but, in addition to this, and sometimes without these
extensive patches, the eruption appears in rounded
blotches, from half an inch to two inches in diameter,
sprinkled upon the skin in various parts, as upon the
trunk, neck, arms, and legs. These patches are
identical with the circumscribed patches which are
seen upon the skin in leichen agrius, and the erup-
tion has more the character of the latter disease than
of ekzema rubrum. The blotches are raised, thick-
ened, papulated, excessively irritable, discharging
but a small quantity of ichorous fluid, and covered,
when desiccated, with thin squamous laminated
crusts.
Ekzema infantile, when left to itself, has no natural
tendency to resolution or spontaneous cure. On the
contrary, it merges progressively into a chronic
form, and undergoes that kind of modification which .
is common to cutaneous disease when passing from \
an acute to a chronic stage. By degrees the ichorous
discharge diminishes, and the eruption retires to cer-
tain situations, where it continues to linger, some-
times subsiding into a state of calm, and sometimes
breaking out afresh like a slumbering volcano. The
situations on which it most commonly retreats, are
the scalp, the eyelids, the ears, particularly the back
of the ears, the integument around the mouth, the
armpits, the groins, and the bend of the elbows,
wrists, knees, ankles. The parts of the skin over
which it has passed are arid and parched ; and the
fountains of moisture, the natural secretions of the
skin, the perspiratory and sebaceous secretions, are
dried up. On the scalp, the dried and parched skin,
continually throwing off a furfuraceous desquama-
tion, presents the common characters of ^pityriasis
capitis^ and not only is the skin left in a state of
parched exhaustion, but the hair also is dried up and
scanty in quantity, and its growth is arrested.
The dry, parched, hot, fevered, state of the skin,
EKZEMA INFANTILE. 255
which is the common sequel of ekzema infantile, is a
sign of the disorganization and extreme disturbance
of fiinction, which the skin has undergone. Even
where there was no eruption, the cuticle is rugged,
and constantly thrown off as a mealy exfoliation ;
but where the eruption existed, as around the eye-
lids, upon the ears, around the mouth, and in the
bend of the joints, the skin is more or less red,
thickened, uneven, cracked, and chapped, and the
ichorous secretion having ceased, it throws off per-
petually scales of dried cuticle of various size, some
being mealy, others furfuraceous, and others as large
as the finger-nail. This, then, is a case of genuine
psoriasis ; ekzema infantile has therefore become, as
the mere result of continuance, chronic ekzema in-
fantile, or, in other words, psoriasis infantilis.
This process of constant exfoliation is necessarily
attended with pruritus, which is often very consi-
derable; the inflamed part is then rubbed and
scratched, and fi*om time to time the ichorous secre-
tion is reproduced.
I have noted that in the early outbreak of the
eruption, the only trace of deteriorated condition
that may be present in the child, is a feeling of soft-
ness of the muscles, and a slight degree of paleness
of the skin and of the conjunctiva : in fact, the dis-
cernment of these trivial but nevertheless significant
signs is a matter of observation and tact; .later,
however, in the progress of the disease, these signs
become sufficiently obvious to attract the attention
of the unobservant ; and, later still, the poor Uttle
child is strangely altered fi*om its normal state ;
malassimilation, kakochymia, are traced in conspi-
cuous lines on every part of the surface, in every
feature. The Umbs are thin, showing out the pro-
minence of the joints, the muscles are soft and flabby,
the skin is soft and pasty, or discoloured and shri-
velled : there is an expression of care, anxiety, of
thought, upon the little face ; from the general
256 EEZEMA INFANTILE.
emaciation of the body, the head looks larger than
natural ; as I before observed, one is struck by the
senile look of the child : the mucous membrane of
the conjunctiva and mouth is pale, and above all is
the strangely white, pearly, anaemic eye, sometimes
dull and listless, and sometimes bright and clear.
The eye tells an eloquent tale of defective nutrition.
I have remarked, that the symptoms of internal
disorder are but trifling at the commencement of the
disease, and far from being severe during its course;
they attract little of the attention of the mother of
the child, or of the medical man. The great, the
urgent symptom of the whole, is the teasing, the
intense, the violent itching ; sometimes the itching is
constant with frequent exacerbations, sometimes there
are intervals of repose, which are apt to be disturbed
by any change of temperature, and then a violent
attack of pruritus recommences ; but the crowning
suffering of all occurs at night ; the child is often
frantic with itching, it scratches with all its force,
digging its little nails into the flesh, while the blood
and ichor run down in streams. At last, worn out
with suffering and exhaustion the child sleeps, pro-
bably to be awakened again several times in the
night, by the repetition of a similar agony. This
constant suffering naturally wears away the child's
powers, and, added to the malassimilation, brings
about that state of atrophy which I have previously
described. But it is nevertheless remarkable how
little the strength and spirits of the child are affected
by these desperate paroxysms of suffering. In the
morning, after a night of distress, the little thing is
fresh and lively, eager for its food, and ready for the
battle of the day ; while the nurse or mother is lan-
guid and powerless from watching and anxiety.
Not unfrequently in ekzema infantile, the mucous
membrane of the mouth and nose, of the air- tubes,
and lungs, and of the alimentary canal, participates
in the disease, and is either affected simultaneously
BKZEMA INFANTILE. 257
with the skin, or takes a vicarious part. The affec-
tion of the alimentary canal gives rise to diarrhoea,
and the production of mucus in large quantities, and
sometimes of coagulated lymph. The affection of
the mucous membrane of the mouth and nose is
shown by redness, sometimes aphthae and augmented
secretion; and the ekzematous congestion of the
mucous membrane of the air-tubes produces bron-
chitis in various degrees, accompanied with hoarse-
ness from thickening of the mucous lining of the
larynx, and an excessive accumulation of phlegm
throughout the lungs. This latter symptom is one
which is calculated to give us some anxiety, and
requires dexterous management ; but it is less severe
than common bronchitis, and is often as sudden in
getting well, as in its attack. When the mucous
membrane of the mouth and air-passages is affected,
hoarseness is a conspicuous and striking feature of
the complaint ; the hoarse cry is unmistakeable, and
18 sometimes the first and only sign of the conges-
tion of the mucous membrane. It is a sign as dia-
gnostic of congestion of the respiratory mucous
membrane, as is whiteness of the eye of general
anasmia.
In the treatment of ekzema infantile, the three
great principles which I have on every occasion
advocated as the law of treatment of cutaneous
disease, namely, elimination^ restoration ofpower^ and
alleviation of local distress ^ are to be put in force,
but with a change in their order. Elimination must
always go first: but in ekzema infantile, I would
place sdleviation of local distress second ; and
restoration of power third. Thus the principles
of treatment, the indications for treatment being
settled, let us consider the means.
For elimination^ the remedy is calomel or grey
powder : I prefer the former ; one grain of calomel
rubbed down with one grain of white sugar, or
sugar of milk, is the dose for the yoimgest infant ;
s
258 EKZEMA INFANTILE.
for a child a year old, a grain and a half; for a
child two years old, two grains. Of course this
dose is modified according to the apparent strength
of the child in the first instance, and in accordance
with the action of the medicine in the second ; the
object to be attained being such a dose as wiU pro-
duce an efficient relief to the alimentary canal, and
moreover such an amount of rehef as shall act as a
diversion to the morbid secreting action taking
place in the skin — ^in other words, as shall divert
the morbid secretions of the skin into their more
natural and proper channel, the alimentary canal.
For this purpose, calomel excels every other medi-
cine ; fi'om its small bulk it is convenient for exhi-
bition, merely requiring to be dropped into the
child's mouth. It stimulates the liver to an in-
creased flow of bile, and in children it always acts
most kindly on the alimentary canal. Again, a free
action of the alimentary canal being secured, all
probability of retrocession of the eruption by the
remedies required for the second indication is at an
end, and the mother's and the nurse's alarms lest
the disease should be driven in are set at rest. A
free clearance of the stomach and bowels is there-
fore a primary, a necessary step, at the very com-
mencement of the treatment. After the first dose,
the calomel may be repeated according to circum-
stances; once a week, twice a week, every other
night for a few times, even every night for two or
three nights if it be absolutely necessary. In my
own practice, I usually find once a week sufficient ;
and I am guided to the repetition of the dose by the
state of the little patient. If there be any fever-
ishness, fractiousness, irritability of temper, any
increase of pruritus, inaction of the bowels, morbid
secretion of the bowels, or threatened congestion of
the mucous membrane of the air-tubes, then the
calomel powder is to be administered at once without
hesitation and without delay. The mother or nurse
EKZEMA INFANTILE. 259
soon learns the moment for a powder, and, what-
ever prejudices they may have to the name of
calomel, they are always ready to resort to it after
they have once seen its action in this disease. As
I have already said, I have no objection to the
mercury with chalk, beyond the fact of its being
more bulky and less agreeable to swallow, while it
certainly possesses no recommendation which can
render it superior to calomel. Sometimes I find one
or two grains of nitrate of potash a useful addition
to the calomel and sugar.*
Having disposed of the first indication, and cleared
out of the system any acrid matters that might
be rebellious and capable of exciting irritation
and feverishness ; having moreover unloaded the
blood-vessels of some of their watery and solvent
elements by the same remedy ; we may now have
recourse to our means of alleviating the local dis-
tressj in other words, of soothing and heaUng the
eruption, subduing the pruritus, and arresting the
morbid discharge. We can do all this by the ben-
zoated ointment of oxide of zinc t rubbed down
with spirits of wine in the proportion of a drachm to
the ounce. This ointment should be applied abun-
dantly, and gently distributed upon the surface,
until every part of the eruption has a complete
coating Komtment should be applied moving
and night, and if accidentally rubbed off, or used
upon parts exposed to the air and friction, it may
be repeated more frequently. When once applied,
* It will be seen in the chapter on Ekzema, and also in the
succeeding paper on Ekzema Infantile, that my views as to the
neoesaitj for elimination are considerablj modified since the publi-
cation of these opinions ; and that at present I very constantly
commence the restorative treatment without any preliminary eli-
minatory preparation.
t For the formula for preparing this ointment, see the Phaam A-
CEUTiCAL JouBKAL, No. 5, for November, 1854, since admitted
into the British Pharmacopceia.
s2
26o £KZEHA mFANTILE.
the ointment should be considered as a permanent
dressing to the inflamed skin, and never removed
until the skin is healed, unless special conditions
arise which render such process necessary. To
ensure undisturbed possession to the ointment, a
piece of linen rag should be laid over it and main-
tained in position in any convenient manner. Thus,
when the eruption covers more or less of the entire
body, I have a little shirt made of old linen, with
sleeves for the arms and legs, and with means of
being fastened closely round the legs, and, if neces-
sary, closed over the hands and feet. This little
dress is to be worn constantly, night and day, and
for a week together, if necessary. It is intended as
a mere envelope or dressing to the inflamed and irri-
tated skin ; and its saturation with ointment, which
necessarily ensues, only contributes to its greater
utility in that capacity. Where the eruption is
chiefly confined to the arms or legs, linen sleeves
will be sufficient for the purpose. On the face,
no other covering than the ointment is necessary,
but the latter should therefore be used the more
largely.
Where the oxide of zinc ointment is employed
in the manner now described, the formation of
crusts on the eruption is prevented, in consequence
of the exclusion of the atmosphere and the conse-
quent absence of the medium of desiccation. And
when crusts are already formed, the object to be
attained is to soften the crusts by saturating them
thoroughly with the ointment, and then by gentle
friction to displace them and substitute a thin
stratum of the ointment in their place. When the
eruption passes from the acute into the chronic state,
and the process of exfoliation of the cuticle is
active, gentle friction of the skin with the ointment
is even more desirable than in the acute stage of
the disease, and at the same time very grateM to
the little patient. On the scalp the ointment should
EKZEMA INFANTILE. 26 1
be applied in the direction of the hair, to avoid mat-
ting ; and as soon as the oozing of ichorous dis*
charge has somewhat subsided, the hair should be
gently brushed. I am rigorous in enforcing the
non-disturbance of the ointment ; but sometimes my
aides cany their instructions beyond the proper
point, and accumulate the ointment too thickly over
a given part, retaining thereby the secretions, and
interfering with the cure. In this case, if the
finger be pressed upon such an accumulated plate of
the ointment, the morbid fluids will be seen to ooze
up between its chinks or around its edges, and
the source of evil is detected. When such an
occurrence takes place, the whole of the ointment
should be carefiiUy washed off the part with the
yolk of eggf and, after drying the skin, fresh
ointment should be applied. This excessive accu-
mulation of the ointment takes place the most
frequently on the scalp, and is encouraged by the
matting of the hair : a reason for keeping the hair
brushed whenever the nature of the eruption permits.
Another of my instructions is, to avoid washing
the inflamed skin ; it may be wiped with a soft
napkin to remove exudations or secretions; but
washing is unnecessary, indeed injurious, as tending
to irritate the skin, and to increase the pruritus and
inflammation afterwards. While the washing lasts
and the irritated skin is softened by the water, the
part is relieved and comforted, but the drying which
follows, more than avenges the temporary solace of
the ablution. On the same principle, I never order
or recommend lotions in this eruption.
In cases of chronic ekzema infantile^ that is,
pityriasis capitis and psoriasis partium aUarum, the
stimulant properties of the nitric oxide and nitrate
of mercury ointments may be brought into opera-
tion. The former is specific for pityriasis capitis,
in the proportion of one part to three of lard ; and
the latter, variously diluted, from one part in eight
262 EKZEMA INFANTILE.
to equal parts, may be used for the chronic ekzema
or psoriasis of other parts, particularly of the
eyelids. But even in the chronic state of the
disease, the benzoated ointment of oxide of zinc
will be found to be an invaluable and indispensable
remedy. In the parched state of the skin left by
the chronic disease, glycerine may be found of use,
as an emollient ; but when any inflammation exists,
it generally proves irritant, as compared with the
zinc ointment.
We now come to the remaining indication in the
treatment of ekzema infantile, namely restoration of
power; in other words, to correct malassimilation
and restore the system to its normal and healthy
condition. For this purpose, the great remedy is that
admirable alterative tonic, arsenic. It is remarkable
how well infants of the earliest age bear this medicine,
and how rapidly in them it exerts its tonic and
assimilative effects. As an efifective harmless tonic,
arsenic stands alone and without its peer in this
vexatious disease. Indeed, in ekzema infantile it is
specific ; it cures rapidly, perfectly, unfailingly. It
would be difficult to say as much for any other
medicine in relation to any other disease ; and I
pronounce this eulogium on arsenic after a large
experience. The preparation of arsenic which I
select is Fowler's solution, the dose two minims to
an infant from a month to a year old, repeated
three times in the day, with or directly after meals ;
and as malassimilation is always attended with
anaBmia in a greater or less degree, I conjoin with
the two minims of Fowler's solution fifteen of vinum
ferri ; my formula being as follows : —
R Vini ferri, ^iss ; syrupi tolutani, siij ; Uquoris
arsenicalis, 3j ; aquaB anethi, 3\j' ^' ^^^^
nustura.
The dose of this medicine is one drachm, with or
directly after meals, three times a day.
EKZBMA INFANTILE. 263
With these three remedies, namely, the calomel
powder when requisite, the benzoated oxide of zinc
ointment, and the ferro-arsenical mixture, represent-
ing as they do the three indications for treatment of
ekzema infantile, I regard the cure as certain and
rapid, and failure impossible ; and if success were not
complete, I should seek for the cause, not in the
remedies, but in the mode of administering them.
So confident am I of success, that I have often un-
dertaken the treatment of this disease, without
seeing the patient, and at hundreds of miles' dis-
tance ; being satisfied for my only aide, with the
vigilance of an intelligent mother or nurse. I have
never known any evil effects, present or future,
result from this treatment ; but I never fail to give
strict injunctions that if the medicine appear to dis-
agree with the child it should be given less frequently,
eay twice instead of three times a day, or suspended
instantly if the child appear ill ; moreover, that, in
the event of such an occurrence, the calomel powder
should be immediately resorted to. The period of
continuance of the remedies must be left to the
judgment of the medical man : the treatment some-
times occupies three weeks and sometimes more;
and if a recurrence of the eruption should take
place, the treatment must be recommenced, and
conducted on the same principle and with the like
precautions.
The diet of the child, while under this treatment,
must be carefully inquired into : it should be good,
wholesome, and nutritious. The leading constitu-
tional indication is to nourish properly, and this idea
should be carried out in the food as well as in the
medicine. I find the juice of meat of great value
in these cases, and it may be given either alone as
beef or mutton tea, or mixed with the other food.
The consideration of diet and food brings me to
an important dietetic medicine, which is of great
value in this disease, when the latter is attended
264 KKZEMA INFANTILE.
with emaciation, and in the chronic stage ; in acute
cases it is less applicable ; I mean the cod-liver oil.
The child will often take the oil greedily in its
natural state, and its good effects on nutrition are
speedily made apparent ; it may be given with
safety to the youngest infant. In children some-
what older, and particularly in chronic cases, the
cod-liver oil chocolate becomes a useM ingredient
of diet.
When I have wished to avail myself of the excel-
lent properties of the cod-liver oil in conjunction
with arsenic, I have often found the following for-
mula a convenient vehicle for its use —
R Olei morrhuae, Jij ; vitelli ovi, j ; liquoris arseni-
calis, TT|.lxiv ; syrupi simplicis, sij ; aqusB fon-
tansB, q. s. ad Jiv. M. Fiat mistura.
The dose is a drachm three times a day, with or
directly after meals.
Where ekzema infantile is comphcated with diar-
rhoea or congestion of the mucous membrane of the
air-tubes or lungs, the arsenical remedy should be
instantly suspended, the calomel powder imme-
diately administered, and the ordinary antiphlogistic
remedies adopted, magnesia and aromatic confection
for diarrhoea; and ipecacuhana for the bronchitio
or pulmonary congestion. Where the air-tubes are
loaded with phlegm, an emetic is useftil ; and a
poultice to the chest and abdomen will be found a
useful auxiUary.
In concluding my observations on ekzema infan-
tile and its treatment, I must repeat that I know of
no cases in the whole catalogue of disorders of the
human frame, in which the disease itself is more
unpromising in appearance and distressing in its
effects, and at the same time more amenable and
tractable under the treatment now laid down, than
is this disease.
( 265 )
11.
Statistics of Eezema Infantile.
In our review of the work of Dr. Silas Durkee,
entitled " Contributions to Dermatology," our atten-
tion was attracted by two paragraphs having
reference to ekzema infantile. The pairagraphs are
as follows : — " 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 earlier." " In a majority of cases
of infantile, ekzema the disease is traceable to
hereditary predisposition." These statements ac-
corded so little with our own experience of the
disease in England that we were induced to have
recourse to our case-book ; the only one which we
happened to have at hand was that of 1868, and we
proceeded to examine the cases of ekzema which had
fallen under our care during that year, with the
view of selecting from them the cases of infantile
ekzema, and putting the latter to the test of
numerical investigation.
Our total number of new cases of ekzema in 1868
was 535, and of this number 34 were examples of
ekzema infantile. These figures will yield a per-
centage to cases of all kinds of thirty- three per cent,
for ekzema in general, and of a little over one and a
half per cent, for ekzema infantile alone ; while the
relative proportions of ekzema infantile to ekzema in
general will be about one in sixteen.
Turning now to the thirty-four cases of ekzema
infantile, we find the proportion of males to females
to be 22 of the former to 12 of the latter. This
difference, that is to say, nearly twice as many males
as females, we look upon as accidental, since we
cannot conceive the existence of anything in the
266 EEZEMA INFANTILE.
organization of the sexes at that early age which
could predispose one sex to ekzematous disease
more than the other. It will require further research
to establish this point.
Our attention, in the next place, was devoted to
the age of the patients at the time of the outbreak of
the disease. This period we found to range between
eighteen days and fifteen months. In the greatest
number, namely 9 (including one of eleven weeks),
the eruption occurred at the third month ; the next
greatest number, namely 7, was met with at the
second month ; the number 4 representing the sixth
month. Or we may put it thus :-during the first
three months, inclusive, the number was 21 ; during
the second three months, inclusive, the number was
7 ; during the next six months, inclusive, the number
was 4, leaving out 2 occurring at the fifteenth
month. Or, again : — during the first six months,
inclusive, the figures were 28, and for the whole of
the remainder only 6. This, we apprehend, must
dispose of Dr. Durkee*s first statement, certainly as
far as England is concerned, and among the
wealthier classes ; it wiU remain therefore to be
shown in what manner, if at all, the United States
of America differ in this respect from England.
The dv/ration of the eruption at the time of con-
sultation varied fi:om two weeks to four years and a
half; thus, between two weeks and one month there
were 3 cases ; between one month and three months,
8 ; between three months and six months, 9 ; and
between six months and four years and a half, 14.
It is not to be presumed, however, that the patients
were neglected during this interval, our register
simply recording the period of existence of the
disease at the time of application to ourselves. The
instance of consultation at two weeks was an illus-
tration of the fable of the " burnt child " (Case 25) ;
the mother had had an infant who had suffered from
this disease previously, and knew and dreaded its
EKZEMA INFANTILE. 267
consequences. These periods also mark another
fact, namely, the tendency which exists on the part
of ekzema to become chronic if left without treat-
ment, or if treated improperly, or left to the chance
of the vis medicatrix naturoe. And the cases are
suggestive of another phenomenon, bearing upon
the migratory changes accomplished by time on the
course of the disease. Thus, in Case 12, the early
attack of the eruption at six months made its
appearance on the face, whereas, at the time of con-
Bultation the seat of the disease was the lower
extremities.
The occupation of the head by the eruption in
ekzema infantile is one of the most constant of its
phenomena, and the cases before us illustrate that
fact very conclusively ; thus, of twenty-four cases of
which the seat of the eruption is named, 21 occupied
the head and 2 only the extremities, one of the latter
being also associated with eruption on the neck.
The part of the head most frequently attacked was
the scalp, of which the examples were 13 ; aflFection
of the face occurred in 12 cases. The scalp was
alone affected in 6 cases, the face alone in 4 ; the
combinations being as follows : — scalp and face, 4 ;
scalp and trunk, 2 ; scalp, face, and trunk, 1 ; face
and scalp, 4; face and trunk, 4; and extremities
and neck, 1. Moreover, the part of the trunk the
most frequently invaded was the chest and shoulders.
At a later period, and in subsequent attacks or
recurrences of the disease, a tendency to migration
is observed, as in Case 12, wherein the primary out-
break occupied the face, and the latest the lower
extremities. So also in children of a more advanced
age, and in adults who have suffered from ekzema
infantile, it is very usual to find the disease limited
to the joints (ekzema articulorum) ; to the lips (ekzema
labiorum), or to some local and circumscribed site.
The forms of ekzema met with in the infant are
generally four, namely : erythematous, ichorous,
268 EKZBMA INFANTILE.
pustulous, and papulous ; although a single form is
very rarely found alone ; and when we speak of an
ekzema erythematosum or ekzema ichorosum we
intend to signify only an eruption in which the ery-
thema or the ichorous exudation is the predominant
character, and the same with reference to ekzema
pustulosum and ekzema papulosum. With this
reservation, we find in the cases before us ekzema
erythematosum appearing 14 times ; ekzema ichoro-
sum, 10 ; ekzema pustulosum, 7; and papulosum only
thrice, although the latter is very commonly inter-
mingled with ekzema erythematosum, and not un-
frequently shows itself in association with the ekzema
erythematosum which surrounds the other forms.
As a complication of ekzema infantile, fiirunculi
are by no means uncommon, and a close association
exists between Airunculosis and ekzematosis. In the
small number of thirty-four cases, four examples of
boils must be admitted to be a very considerable
proportion. In one instance the boils may be re-
garded as hereditary, the mother being subject to
them, and suflFering from an attack while suckUng
her child. In two of the remaining cases the mother
is mentioned as being of delicate and weakly health.
The other complications met with in our thirty-four
cases are four in number, making the total of com-
phcations eight. In one of the cases there existed
superficial abscesses ; in another, in addition to the
ekzema, pneumonia, cerebral irritability, and leukaB-
mia; in a third there was diarrhoea ; while in the
fourth there was local inflammation with abscess
excited by vaccination. With ekzema capiUitii,
enlarged sub-occipital and auricular glands are one
of the most frequent phenomena. Occasionally the
cervical glands are affected ; and sometimes hyper-
trophy of the lympathic glands is associated with
subcutaneous abscess.
If we inquire into the caibse of ekzema in the cases
before us, we meet with five which are predominant
EKZEMA INFANTILE. 269
in their influence : the first of these is /ood, insuf-
ficient or improper ; the second, temperature ; the
third, diathesis; the fourth, irritation set up in the
organism by dentition; and the fifth, the irritation of
vaticination. The numbers that we set down to four
of these causes, taken separately, are : — food, 19 ;
diathesis, 6 ; dentition, 5 ; and vaccination, 3. But
as, firom their nature, the causes are sometimes
associated, we find food in conjunction with
diathesis amounting to 6 ; and food in conjunction
with vaccination to 1 ; making a total of 26 in
which food plays a primary part.
If we look at the ages of the patients in conjunc-
tion with the causes, we may assume that during the
first six months of life the causes may very fairly be
divided between food, temperature, diathesis, and
vaccination ; while dentition is very unlikely to come
into operation until six months are completed. And
if we look at the figures in illustration of this view,
we shall have the number of patients aged six
months and under amounting to 28, and above six
months to 6 only ; that is to say, to one more than
we assign expressly to dentition.
Then, as to the causes themselves, diathesis is
solely a predisposing cause ; food, again, is a pre-
disposing cause, but, in a less degree, an exciting
cause ; so also is temperature ; dentition is both pre-
disposing and exciting ; while vaccination is chiefly
an exciting cause. Thus, we may range on the side
of predisposing causes, diathesis, food, and tempera-
ture ; and on the side of exciting causes, dentition
and vaccination.
We will endeavour to illustrate these points by
reference to the cases before us ; for example, taking,
in the first instance, food:- — in Case 3, the mo-
ther's milk failed when the infant was a fortnight
old, in consequence of a shock. Again, Case 14, the
infant, seven weeks old, was taken during very cold
weather a long railway journey, and there can be no
270 EKZBMA INFANTILE.
doubt that the mother's milk suffered in conse-
?uence, for the eruption broke out a few days later,
n Case 9, again, there was considerable disorder of
the alimentary canal, at first constipation, and sub-
sequently diarrhoea, for which the infant's food must
be held responsible. In another case, of ekzema
capitis, that came recently under our notice, the
mother suckled her child regularly, but the infant
fell away in health, and then it was discovered that
the mother possessed a totally inefficient supply of
milk. Then, in cases 6, 7, 5, and 21, the natural
food having failed, the infant was brought up by
hand, always a hazardous experiment, from the age
of three weeks, two months, and three months
respectively.
The influence of temperature ^ and especially cold,
in the production of ekzema is shown in the more
frequent outbreak of the eruption in the colder
months of the year than in the warmer months.
Thus, of the 34 cases under consideration, 11
appeared in December, and 4 in January; and,
taking the whole number, 20 occurred in the colder
months of the year, and 14 in the warmer months.
This point, like others, is suggestive of interesting
considerations, but demands Airther research and
investigation.
The mere presence of an attack of ekzema in an
individual is not in itself sufficient to set up a
diathesis in the offspring. Ekzema is almost as
imiversal as dyspepsia, and, like dyspepsia, may be
purely accidental ; while both may be so far engrmed
upon the constitution as to be susceptible of trans-
mission by hereditary descent to the children. We
recognize, therefore, diathesis and hereditary trans-
mission, but simply look upon them as an occasional
cause of the disease. Cases 2, 8, 25, and 28 are
examples of hereditary diathesis, as is shown, not
by the presence of ekzema in the mother, although
that sometimes occurs, but by the previous mani-
EKZEMA INFANTILE. 27 1
festation of ekzema in others of the children of the
same parent. In Case 8, four children out of nine
had suflFered from the same aflFection, and in the two
other cases a previous child had also suflTered. In
this particular there is no exact regularity, and it
is difficult to say why one or two children out of a
family should be attacked, or why one or two or
more children should be passed over. In Case 25
the child's wet-nurse lost her milk ; another wet-
nurse, a remarkably healthy woman, was procured,
and a week afterwards the infant was attacked. The
new milk was better than that which preceded it ; it
deranged the functions of digestion ; the balance
between the recipient and the thing received was
disturbed, and the new and better milk virtually
acted the part of an exciting cause of ekzema,
showing how food may be an excitant as well as
a predisponent.
It has always been our aim to prove that the
essence of ekzema is debility. Debility may be pro-
pagated, and such debility may become a diathesis
favouring the occurrence of ekzema. The associa-
tion of fiirunculosis with ekzema, and axillary
abscess with ekzema, is a well-established fact ; and
all these points are illustrated in the cases before us.
Cases 8 and 24 are both of them examples of a
delicate and weakly parent. Cases 19, 24, and 27
combine furunculi with ekzema ; in Case 19 the
mother was subject to frequent attacks of boils ; one
of these attacks occurred when her infant was four
months old, and subsequently to this occurrence
boils broke out upon the child's skin. In Case 26
the mother was suflFering from abscesses in both
axillae at the time of the eruption of ekzema in her
child.
Vaccination we have always regarded as an excit-
ing cause, requiring for the production of the morbid
phenomena which sometimes accompany and follow
it, a morbidly susceptible state of the organism, that
272 EEZEMA INFANTILE.
is to say, a diathesis ; and the diathesis may be the
consequence either of inherited or of acquired
debility. Cases 1, 20, and 32 are examples of
ekzema immediately following vaccination, and
excited, as we believe, by the constitutional irrita-
tion set up by the vaccine fever. In Case 32 the
influence of perverted food was superadded to the
vaccination ; for example, the arm became inflamed,
abscesses formed, ana at the fourth month the
infant was weaned from the breast and brought up
by hand. At the fifth month ekzema burst forth
upon the face. Case 2 is an instance of diathetic
and hereditary ekzema, aggravated by vaccination,
and still further aggravated by alteration of food.
The eruption appeared at the eleventh week, the
child was vaccinated at the twelfth, and was weaned
at the fourteenth week.
The term, " milk-rash," or more correctly, " milk-
crust " or crusta lactea, bears witness to the relation-
ship between food and ekzema; while the terms
"red gum " and " tooth rash " point to dentition as
a cause of the disease — a cause which, in our
opinion, has been too exclusively recognized and
adopted. Irritation from cutting the teeth ought
not to come into existence until the sixth month is
completed ; and yet, as we have just seen, twenty-
eight out of thirty-four cases of ekzema infantile
occur within the limit of six months, and only six
beyond it. And out of the entire number we find
only five that we can legitimately ascribe to denti-
tion: — these five cases being Nos. 11, 13, 16, 30,
33. The age of outbreak of the eruption in these
cases was seven months in one instance, eight
months in two, nine months in one, And fifteen
months in the remaining one. In Case 33 the child
had four attacks of the eruption, each being as-
sociated with the cutting of teeth. And we remem-
ber a mother one day saying to us that her child
always cut its teeth with a rash, just as we know in
EKZEMA INFANTILE. 273
some instances the cutting of teeth is accompanied
with a fit of convulsions.
Cold, besides being a constitutional cause, may
also be local or traumatic. We have no illustra-
tion of its local eflTects in our present group of cases ;
but in Case 19 we see an example of a traumatic
cause operating upon a pre-existing diathesis. The
child's mother had never experienced ekzema, but
she was subject to a congeneric affection, namely,
furunculosis ; the child inherited the fiirimcular
diathesis ; it was then vaccinated ; next followed a
catarrh; for the catarrh the mother rubbed some
camphor liniment into the child's cheeks ; and upon
the stimulus of the liniment, a traumatic irritant,
the ekzema sprung into existence.
We will now turn our attention to the treatment
of these thirty-four cases, simply premising that as
food and temperature stand at the head of the
efficient causes of the disease, they must receive our
first consideration. And, this being done, we shall
proceed to enumerate the constituents of the Phar-
macopoeia employed, in the order of frequency of use
of the various remedies. These latter were as
follows : — Internally. 1. Liquor arsenicalis with
steel wine, in the formula known as our ferro-
arsenical mixture; 2. mixture of magnesia, rhubarb,
syrup of tolu, and dill- water; 3. calomel and sugar,
one grain each ; 4. cod-liver oil ; 5. syrup of the
phosphate of iron ; while extemcUly, we prescribed —
6. benzoated ointment of zinc, sometimes alone, and
sometimes with spirits of wine, spirits of camphor,
or carbolic acid ; 7. powder of oxide of zinc, starch,
and camphor ; 8. red precipitate ointment, diluted ;
9. white precipitate ointment, diluted ; 10. citrine
ointment, diluted ; 11. tar lotion ; 12. lotio plumbi ;
and 13. lotio boracis cum oleo.
In 30 out of the 34 cases the ferro-arsenical
mixture was prescribed ; for 22 cases in two-minim
doses ; 6 cases, one minim ; and in 2 cases, three
T
2 74 EKZ15MA INFANTILE.
minims ; all three times a day, with meals. In 18
of the 22 cases it was ordered at the first visit,
and consequently without any preparation of the
patient ; in three cases it was commenced at the
second, and in one case at the third visit. In two
cases only was it necessary to suspend the arsenic,
and then merely because it interfered with the
appetite of the patient. The mixture of magnesia,
rhubarb, and dill- water was prescribed in 8 cases ;
5 at the first visit, 2 at the second, 1 at the third.
Ood-liver oil in emulsion with yolk of egg and dill-
water, was ordered in 6 cases ; 5 at the first, and 1
at the fourth visit. The syrup of the phosphate of
iron was ordered once ; and the calomel powder in
6 cases, once only at the first visit, twice at the
second, twice at the third, and once at the
sixth.
The benzoated oxide of zinc ointment was pre-
scribed in all the cases but one ; the powder of zinc
with camphor, diluted with starch, eleven times ; the
diluted red precipitate ointment in cases of ekzema
capillitii, six times ; the diluted white precipitate
ointment, four times ; and the diluted citrine oint-
ment, once, for ekzema palpebrarum. The lotio
picis, lotio plumbi, and lotio boracis cum oleo, were
ordered for the relief of pruritus, the first-named
twice ; the others once.
With one exception (Case 18) all the cases re-
covered ; but the duration of treatment is a matter
difficult to determine in consulting practice. The
only numerical evidence that we can offer is, that
14 cases we saw only once ; 11 cases, twice ; 3 cases,
three times ; 3 cases, four times ; and 1, six times.
In some instances these visits were at the week's
end ; in others, two, three, or four weeks. If the
case went on satisfactorily, the child was not brought
back; and the treatment was continued by the
parent, sometimes solely, sometimes under the ob-
servation of the fiwnily medical attendant. K any
EKZEMA INFANTILE. 275
adverse change had occurred, there can be no doubt
that the patient would have been brought again. In
some instances the amendment and cure were re-
markable for rapidity ; now and then a single dress-
ing with the zinc ointment would almost remove the
eruption ; under favourable circumstances a cure
might be expected in three weeks, while at other
times it was prolonged to as many months. All
precautions taken, we should say of ekzema infantile
that its cure is both certain and brief, and without
any drawback.
Summary. — ^We may simplify our observations by
putting the chief points into an aphoristic form, and
appending to this summary, by way of conclusion,
an abstract of the cases on which our statements are
based.
1. The percentage of ekzema to other cutaneous
diseases is 33 per cent.
TUb percentage of ekzema infantile to other cuta-
neous diseases is 1^ per cent.
The percentage of ekzema infantile to ekzema of
the rest of life is as 1 to 16.
2. That ekzema infantile is more frequent in the
male than in the female.
3. That the most frequent period of the eruption
of ekzema infantile is that between the second and
third month inclusive.
4. That ekzema infantile left to the chances of the
vis medicatrix natures is apt to become chronic, and
identified with the system.
5. Ths^t early treatment of ekzema infantile is of
the utmost importance.
6. That ekzema infantile generally occurs in the
head and face ; and more frequently in the former
than in the latter.
7. That the neck and upper part of the trunk is
more frequently attacked than the lower part of the
trunk and the limbs.
8. That in successive attacks and in chronic
T 2
276 EEZEMA INFANTILE.
okzema the flexures of the joints and tlie ex-
tremities are more apt to suffer than the face and
head.
9. That the forms of ekzema infantile are four in
number, and occur, in frequency, in the following
order : — erythematous, ichorous, pustulous, papulous;
ekzema erythematosum being twice as frequent as
ekzema pustulosum.
10. That ekzema papulosum, the most rare in its
occurrence alone, is commonly associated with the
other forms.
11. That furunculosis is a common compUcation
of ekzematosis.
12. That enlarged occipital and auricular lym-
phatic glands are commonly associated with ekzema
of the scalp.
13. That superficial cutaneous abscesses are not
iinfrequently associated with ekzema in cachectic
children.
14. That the predominant causes of ekzema
are five in number, and hold the following rela-
tion to each other in point of importance;
namely, food, temperature, diathesis, dentition, vac-
cination.
15. The most common predisposing cause of ek-
zema infantile is deficient or improper food.
16. Cold is an occasional cause of ekzema infan-
tile; sometimes predisposing, but more frequently
exciting.
1 7. Ekzema infantile is most frequent in December
and in the colder months of the year.
18. Hereditary diathesis is an occasional predis-
posing cause of ekzema infantile.
19. Dentition is a common exciting cause of ek-
zema infantile ; sometimes a predisposing cause.
20. Vaccination is an occasional exciting cause of
ekzema infantile; but is less influential than food,
cold, diathesis, and dentition.
21. Local or traumatic causes may be exciters of
BKZBMA INFANTILE. 277
ekzema, but are inoperative unless they be preceded
by a predisposing cause.
22. Debility is the proximate cause of ekzema.
23. The treatment of ekzema infantile calls for the
most careful observation to discover a diet congenial
to the patient.
24. The combination of iron and arsenic, with
attention to the secretions, if necessary, and the
local use of the benzoated ointment of zinc, and a
diluted zinc powder with starch, is an efficient method
of cure, if not the very best that is known.
Absteaot op Cases :—
1. Male cluld, »t 13 montliB ; ekzema frontis ; began when five
months old; foUowed vaocination; the eruption almost entirely
confined to forehead.
2. Male child, »t 5 months ; ekzema began at 2} months ;
vaccinated at 3 months; eruption increased after vaccination;
weaned at 3^ months, in consequence of insufficiency of mother's
milk. Two out of six children have suffered from ekzema ; the
parents have never had any eruptive complaint
3. Male child, set. 4 months; ekzema capitis; b^;an on the
18th day. The mother received a shock when the infant was two
weeks old, and her milk failed.
4. Female child, »t 7^ months ; ekzema began at the end of
the second month.
5. A female chUd, set 15 months ; has ekzema pustulosum of
the neck, arms, legs, and bends of the knees ; the eruption began
when she was two months old ; since the age of three months
she has been brought up by hand ; she has not been vaccinated.
6. A male child, set 6 months ; ekzema of the head and face ;
began at three months ; brought up by hand from the age of three
week&
7. Male child, set 4 months ; has ekzema of the cheeks,
shoulders, and chest; began at three months; the child was
brought up by hand fit)m two months.
8. Male child, set 3 months ; had two or three boils during the
first fortnight ; ekzema papulosum of the face and chest at the
sixth week. He is the ninth child; four out of the nine had
ekzema in infancy ; the mother is out of health.
9. Male child, set 17 months ; ekzema pustulosum, face and
shoulders, two months ; the eruption was preceded by consti-
pation ; during the last fortnight the bowels have acted three
times daily.
278 EKZEMA INFANTILE.
10. Male child, »t 7 months ; ekzema oommenoed at the age
of two months.
11. Female child, »t 2^ years; has had ekzema since the age
of eight months, with occasional attacks of congestion of the
longs ; she is anemic, and has a large head.
13. Male child, et 4 years ; has ekzema on the 1^ ; the
eruption made its first appearance in the fiace at the ege of six
months.
13. A male child, sat. 18 months; has ekzema pnstulosom of
the head, with patches on the back and upon one knee ; the emp-
tion has been in existence three months.
14. Male child, et 6^ months; ekzema capitis began at the
age of two months ; the in£Eknt was taken to Sunderland in very
cold weather, at the age of seyen weeks, and the eruption first
appeared a few days later.
15. Male child, et 15 months; has ekzema capitis, which
began at the sixth month, immediately after weaning.
16. Male child, set one year ; ekzema papulosum of the head,
fiu;e, shoulders, and chest ; began at the eighth month.
17. Female child, et. 5 months; ekzema broke out at the age
of ^ree months.
18. Female child, et 7 months; ekzema pustulosum capitis;
began third month. This infant died from mismanagement. We
saw it only once in consultation.
19. Female child, et 6 months ; ekzema of the face and head ;
broke out at the age of three months, shortly after vaccination.
The exciting cause was the use of camphor liniment to the cheeks
for a cold. The child has had two boils. The mother is subject
to boils in the axilla, but not to ekzema. She had an attack of
boils when the child was four months old.
ao. Male child, et. 2 years ; ekzema broke out at the age of
three months, after vaccination.
31. Male child, et. 8 months ; ekzema made its appearance at
the third month ; brought up by baud.
33. Female child, set. 4^ years ; has suffered from ekzema since
the age of one month.
33. Male child, set. 4^ yeSrs ; has ekzema of the head, chest,
and neck. The eruption fint broke out at the sixth week.
34. Female child, set. 6 months ; has ekzema of the scalp, fisu»,
and flexures of the joints of the limbs, together with furunculL
The eruption began at the age of two months, having followed a
bilious attack at the sixth week. The mother is delicate. In the
course of treatment it became necessary to open two abscesses.
35. Female child, set 2| months ; has ekzema erythematosum on
the inner side of both thighs ; began at the age of two months ;
the child's wet-nurse lost her milk ; the eruption commenced a
week after a new and healthy nurse had been procured. The first
child of the same mother had ekzema when a few weeks old.
EEZEMA INFANTILE. 279
26. A female child, »t. 2 years ; has ekzema fiusiale, which
began at the sixth month. The mother at the time had abscesses
in both axiUn.
27. Male child, »t. 4 years ; has ekzema capitis since the age of
six months. Several exacerbations have occurred from time to
time ; at present there is roughness of the flexures of the joints ;
he has also been subject to furunculL His mother reports of him
that he was a large child at birth and as yellow as an orange^ and
that he was covered with hair until the sixth week.
28. Male child, »t. 5 months ; has an outbreak of ekzema, which
commenced a month previously. A former child also had ekzema.
29. Male child, set. 8 months ; has ekzema ichorosum, which
broke out at the age of two months, from which period the child
has been brought up by hand ; the child always sickly.
30. Male child, »t 3 years; ekzema capitis et palpebrarum;
be^m at the seventh month.
31. Female child, sBt. 5 months ; ekzema of the face and trunk ;
commenced at the second month.
32. Male child, »t 1 year and 8 months ; ekzema faciei ; came
on at the fifth month, excited by vaccination ; the arm was much
inflamed, and abscesses followed. He was nursed up to the fourth
month.
33. Male child, »t 3 years ; ekzema aurium ; began as ekzema
capitis at the ninth month, and was associated with teething. He
has had three attacks of the eruption since the firsts each one
being apparently due to teething.
34. Female child, set 4 months; ekzema pustulosum; com-
menced at the end of the first month.
( 28o )
m.
Natubb, Varieties, and Tbeatment of Ekzeha.'
The great prevalence of ekzema, its manifold
varieties, and its undoubted increase of late years
among the population, will, I hope, be received as
reasons sufficient for bringing the subject of ekzema
under the notice of the British Medical Association.
The prevalence of ekzema is so considerable, that
its name has taken root among the population, even
as a " household word," There is scarcely a medical
practitioner in Great Britain who has not, at this
moment, a case of ekzema under treatment ; or who,
within a hmited period of time, has not had such a
case brought withm his observation. Ekzema is
common to all classes of society ; is restricted neither
by age nor sex ; is equally frequent in the male and
in the female ; and is met with in the infant of a few
weeks old, as commonly as in those who have reached
the more protracted term of human existence. In
one thousand cases of cutaneous disease of every
denomination, there occur 298 instances of ekzema ;
very nearly one in every three, or, in other words,
thirty per cent.t
The varieties of ekzema are so strongly defined
that the ancient writers, very naturally, assigned to
* Read at the annual meeting of the British Medical Association,
in 1864 ; and reprinted from &e Bbitish Medical Journax, for
November 19, 1864.
t Subsequent observations on 10,000 cases of cutaneous disease
of every kind, occurring in the w^thier classes of society, have
confirmed this estimate ; the number of cases of ekzema in 10^000
being 3,352 ; that is, somewhat over 33 per cent. ; or one in every
three patients afiUcted with cutaneous disease.
NATURE AND VABIETIES OF EKZEMA. 28 1
them different names ; and these varieties, possessing
separate names, came to be considered, in the course
of time, as distinct diseases. The Greeks, who, in
great probability, adopted the popular names of these
affections, called them psora, psoriasis, leichenes,
and pityriasis ; all of which terms represent forms of
ekzema.
In like manner, and with the same intent, the
Romans made use of the words — scabies, impetigo,
papulaB, and porrigo ; terms which may be regarded
as agreeing with the Greek appellations already men-
tioned; for example: psora comprehends scabies
and impetigo ; psoriasis and leichenes * correspond
with papulae ; and pityriasis with porrigo.
To us, it seems, that a greater source of difficulty
in the way of scientific investigation, can hardly be
conceived, than the appropriation of separate names
to simple varieties of one and the same disease; yet,
such was the case with regard to ekzema ; and to
this cause we may trace much of the confusion into
which cutaneous pathology had fallen at the time of
the revival of learning, and on the clearing away of
the mists of the dark ages, when learned physicians
were called upon to extricate from the ruins of the
Greek and the Roman literature, aided chiefly by
the translations of the Arabian physicians, the de-
scriptions of diseases of which, perchance, the exact
paraUel had ceased to exist among them, or had
ceased to be as common as they were in earlier
times ; and the difficulties were increased by the
absence of that art which has contributed so much
to the enlightenment of modern times — the art of
printing.
In the sixteenth century, Mercurialis and Riolanus
* A Greek patient^ who ia at present under mj care, suffering
from ekzema papulosum of the back of the hands and wrists, the
leichen agrius of Willan, calls the disease ** Xero-leichenes," the
popular name for the disease in her own countiy, and the equivA-
lent of " dry leichen."
282 NATURE AND VAEIETIES OF EKZEMA.
did good service to cutaneous medicine by their
study of the older authors ; and by their personal
investigation of these diseases. Plenck and Willan
advanced our information still more considerably in
the eighteenth century, and laid the foundation of
the greater part of the knowledge which we possess
at the present time. The descriptions left by the
ancients, taken by themselves, were far from being
clear ; the element of diagnosis by which a stranger
could determine their identity was wanting; that
element was supplied by Plenck and Willan. These
authors noticed the redness, the vesiculation, the
papulation, the pustulation, the desquamation, the
discoloration, of cutaneous diseases ; and upon these
characters they formed their arrangement or classifi-
cation. The student was no longer at a loss to
decide upon the diagnosis, upon the identification of
a disease ; he discovered the disease with certainty,
and he made it his study, so that he soon became
independent of the scheme which had supplied him
with this important faculty. By degrees, he arrived
at a position which enabled him to see beyond the
limit which his masters had attained, and to discover
that, however much he might owe to their assist-
ance in giving him the power to scale the ladder of
learning, there were faults in their plan*; and, it
must be adaiitted, faults of a very serious kind : —
that ekzema, for example, was capable of presenting
all those appearances which constituted the majority
of the classes and orders of these authors ; that it
might be represented only by redness, or by papu-
lation ; or by vesiculation ; or by pustulation ; or
by desquamation ; and consequently, that a simple
case of ekzema as it occurs upon different parts
of the body of the same individual was liable
to be taken to represent, at the same moment,
all the different classes or orders established by our
authors.
Therefore, while in the hands of the ancients
NATURE AND VARIETIES OP EKZEMA. 283
ekzema was designated, according to the diversity
of its formSi by a variety of names ; the classification
of Plenck and Willan, at the same time that it gave
us hqlp in defining the disease, perpetuated and even
increased the same evil. In the classification of
these authors ekzema is one while an erythema;
another while a leichen ; anon, a vesicle ; then a
pustule; or even, a squamous affection. Such are
the sources of obscurity which more modem views
in respect of these diseases have in great measure
removed ; and for which medical science is greatly
indebted to the labours of Hebra. We no longer
divorce ekzema firom itself, because it is one while
erythematous; another while papulous; another
while vesiculous, pustulous, or squamous ; but we
speak of ekzema erythematosum ; ekzema papulo-
sum; ekzema vesiculosum; ekzema ichorosum;
ekzema pustulosum ; ekzema squamosum, &c. Those
designations, which were the distinguishing signs
of the classes and orders of Plenck and Willan, are
still retained ; but instead of being the heads of
classification, are made to fill the humble office of
exponents of forms or varieties of a given disease.
Let us now turn to the question : What is ekzema?
Ekzema is an inflammation of the skin, attended
with alteration of its structure, and derangement of
its functions. It is more vascular than in health, its
vessels being in a state of congestion ; its sensibility
is morbidly increased, sometimes taking on the cha-
racter of itching, tingling, or smarting, and some-
times that of pain ; it is thickened by infiltration of
serum into its tissues ; is sometimes fissured and
sometimes oedematous ; it exudes a serous lymph at
various times and in various quantity, sometimes in
excessive abundance ; the epidermis is sometimes
raised into vesicles, sometimes wholly removed ; and
is reproduced unhealthily, so as to form muco-puru-
lent secretions and squamaB of various size; and
sometimes is replaced by a crust of greater or less
284 NATUBE AND VARIETIES OF EKZEMA.
thickness, resulting from desiccation of the morbid
secretions.
But ekzema rarely presents all these characteristic
symptoms in an equal degree ; and the diversity of
tne symptoms; and the modification which these
symptoms undergo in different parts of the skin, in
difierent constitutions, and in different temperaments,
are the foundation of its varieties. As the varieties
of ekzema are founded on the prominence of one or
other of the symptoms of the disease, they may be
easily designated and as easily recognised. For
example : when the prevailing sign is redness, the
eruption is an ekzema erythematosnm ; when the
pores of the skin are erected into the form of papulae,
the disease is an ekzema papulosum ; where there are
vesicles, the variety is ekzema vesiculosum ; where
excessive exudation of a serous or colourless lymph
is the leading sign, the case is one of ekzema ichoro*
sum; where there are pustules mingled with the
other signs, it is an ekzema pustulosum ; and, where,
as in the chronic forms of the aff'ection, the epidermis
is scabrous and scaly, the disease is an ekzema squa-
mosum. These terms comprehend the principal
forms of ekzema dependent on symptoms; but
additional terms suggest themselves naturally for
different conditions ; for example : the skin is some-
times cracked and fissured — ekzema fissum. Some-
times the thickening and condensation of the diseased
tissues, in a chronic stage of the affection, suggest
the terms ekzema sklerosum and ekzema verrucosum.
Sometimes the state of the part is aptly expressed
by the term ekzema oedematosum ; sometimes, from
the nature of the secretion, ekzema mucosum. And,
more than once, we have met with a case to which,
on account of the severe pain by which it was accom-
panied, the term ekzema neurosum was correctly
applicable.
It is rare to find an ekzema perfectly simple in its
eruption, and capable of being represented singly by
NATUEB AND VAEIETIBS OF EKZEMA. 285
any one of the terms already mentioned. More fre-
quently two, or indeed several of the forms, may be
present at the same time, and sometimes even the
whole. For example : in one case we may have an
erythematous ekzema combined with papulsB, which
we should then distinguish by the name of ekzema
erythematosum et papulosum (ekzema leichenodes) ;
or, it might be an ekzema erythematosum et ichoro-
sum ; or, if the exudation of fluid from the inflamed
surface were the most striking feature, we should
name it an ekzema ichorosum, which might be, but
in a less degree, erythematosum et papulosum ; or
even pustulosum. Or, the case might be one of
ekzema vesiculosum et erythematosum ; or, an ek-
zema squamosum (ekzema chronicum), which is, at
the same time, in part, fissum ; and in part, ichoro-
sum. These terms have the advantage of being
simple, expressive, and clear ; they rise to the mind
as freely as the terms : red, pimply, oozy, mattery,
or scaly ; and they render the narrator intelligible
to every one conversant with medicine and medical
language ; while the commoner appellations ekzema
simplex and ekzema rubrum, convey to the unin-
structed in cutaneous pathology, either an erroneous
idea or absolutely nothing at all.
Varieties of ekzema are also derived from situa-
tion ; from the part of the body attacked with the
eruption. For example, we have ekzema capitis ;
ekzema faciei; ekzema aurium; ekzema palpebra-
rum ; ekzema oris et labiorum ; ekzema axillarum ;
ekzema mamillarum; ekzema umbilicale; ekzema
inguinum; ekzema pudendi ; ekzema perinsBi; ekzema
ani; ekzema articulorum; ekzema manuum et pedum ;
ekzema dorsi mantis ; ekzema palmare et plantare ;
ekzema digitorum ; ekzema unguium, &c. Moreover,
we are taught by experience that in certain situations
we shall be most likely to meet with one or other of
the established varieties of the disease. For example :
ekzema capitis et aurium are commonly ichorosum in
286 NATUEE AND VAEIETIES OP EKZEMA.
a recent attack, and Bquamosum at a later period ;
ekzema articulorum, ekzema axUlaram, ekzema in-
guinum, and ekzema pudendi, are also very fre-
quently ichorosum, and sometimes mucosum. Ekzema
of the fleshy parts of the forearms and legs is not
unfrequently vesiculosum ; as is also ekzema digito-
rum. Ekzema dorsi mantis is usually papulosum ;
while ekzema palmare is squamosum et ssepe fissum.
The extent of the eruption is also to be considered il
in designating its varieties. It may be general or it
may be partial. When partial, the patches of the
disease may be single or multiple; they may be
defined (figuratum), or difiused (difiusum). Some-
times they suggest the idea of the dimensions and
figure of a piece of money, nummulare ; and some-
times they are bounded by a prominent ridge (mar-
ginatum) and spread by the circumference, while the
inflammation subsides within the included area ; this
is especially the case in a curious form of ekzema
marginatum common in India, where it is known as
the Burmese ringworm.
Willan and Bateman include all the varieties of
ekzema under the three heads : solare, impetiginodes,
and rubrum, corresponding with the ekzema vesiculo-
sum, ekzema pustulosum, and ekzema ichorosum of
our improved nomenclature. Hardy proposes four
varieties ; namely, simplex, rubrum, fissum (fendill6),
and impetigo. Hebra employs the suggestive terms
squamosum, papulosum (leichenodes), vesiculare (so-
lare), madidans (rubrum), and impetiginosum.
It will be perceived that Hebra makes ekzema
squamosum the first of his forms of ekzema ; whereas
I take it to be the last. Let me explain. Ekzema
erythematosum is commonly accompanied with de-
squamation ; and when the eruption is general, this
is remarkably the case. Now, Hebra selects the
moment when it is coated over with scales as the
type of this form of the disease. But it must be
remembered that the scales may be disposed of in a
• NATURE AND VAEIETIBS OP EKZEMA. 287
variety of ways : there was a time before which they
were formed ; there is a time when they have ceased
to be produced ; there is an intermediate time when
they may be removed artificially by dressings, poul-
tices, or baths. What are we to call the disease
when the scales and desquamation are no longer
present? The answer is plain; the redness, the
erythema remains ; indeed, the erythema is always
there ; from the beginning before the scales existed,
at the end, after they exist no more : hence, the
term " erythematosum *' appears to me to be more
appropriate than " squamosum." Again, there are
forms of ekzema in which there is redness, but nothing
deserving to be called scales ; and to those cases,
which are numerous, the term " erythematosum*' is
especially applicable.
On the other hand, when ekzema reaches its latest
period, when it is chronic, there is still redness ; but
scaliness and desquamation are a more predominant
character than redness ; and it is to this period
that I prefer to attach the term " squamosum.'*
Ekzema squamosum I regard as the chronic stage
of ekzema ; whilst ekzema erythematosum, which
may also be chronic, applies with especial aptitude
to the earliest stage of the eruption. Ekzema squa-
mosum is, therefore, in my view of the pathological
indications of the disease, an ekzema chronicum squa-
mosum, and is the true representative of the much-
abused term psoriasis. Psora represents the more
active, and especially the exudative forms of ekzema;
and psoriasis, its chronic, its dry, and its desqua-
mating form.
The Romans, who designated ekzema by the name
of scabies, drew attention to a characteristic distinc-
tion between its moist and its dry form — scabies
humida and scabies sicca. The Greeks appear to
have had the same object in view in employing the
words psora and psoriasis ; the former term corre-
sponding with scabies humida, the latter with scabies
288 NATURE AND VARIETIES OP EKZEMA. *
sicca. The distinction is a radical one, and of the
first importance in the study of ekzema. Ekzema
siccum, which is represented by ekzema erythema-
tosumi ekzema papulosum, and ekzema squamosum,
is specially distinguished by an absence of exuda-
tion, or by its presence in a very slight degree ;
whereas ekzema humidum, represented by ekzema
vesiculosum, ekzema ichorosum, and ekzema pustu-
losum, is remarkable for the exudation of a serous
and sometimes a muco-purulent fluid, often in as-
tonishing quantity — a perfect flux. According to
our observation, the dry forms of ekzema more
than double in frequency those of the moist or
humid kind ; therefore a classification that assumes
for ekzema a definition dependent on exudation as
a pathognomonic sign, must, of a necessity, be in-
correct.
A well-marked example of ekzema is an open
page, upon which we may read, with the utmost
distinctness, the pathology of the disease; and
anything that may be wanting upon this page is
suppUed by the examination of a succession of
cases. Let us note what such an observation
teaches.
In the first place, there is redness : one while,
uniform ; another while, punctated. The cause of
the redness is, congestion of the capillaries and
smaller vessels of the skin. When the redness is
uniform, the congestion is uniform ; when the red-
ness is punctated, the vascular plexus of the follicles
is also congested. Sometimes the congestion of the
vascular rete of the horizontal surface is primarily
and chiefly apparent ; sometimes the vascular rete
of the vertical walls of the follicles is the first to
show congestion, and the latest to retain it. When
the latter is the case, our patients speak of an erup-
tion under the skin ; and we, ourselves, perceive a
resemblance to the punctiform congestion of the
exanthemata. Another phenomenon follows the con-
NATUBB AND VABIBTIBS OF EEZBMA. 289
gestion of the vessels of the follicles ; namely, the
erection of their apertures or pores : these latter
become raised above the level of the adjacent sur-
face, and constitute small pimples. This is the
mode of formation of ekzema papulosum.
Occasionally, we have the opportunity of observ-
ing another process by which an ekzema is developed.
There may exist a slight itching of a part of the
integument ; if the part be carefully examined, a
reddish punctum is apparent in the substance of the
skin ; the finger passed over this punctum discovers
a hard granule : this is a congested follicle. K, to •
relieve the itching, we scratch the part, a papule
arises ; the head of the papule is torn off ; a serous
exudation follows, and then a small crust, which
covers its summit. But, while the one original papule
runs its com*se, the follicles around participate in the
pathological process, and soon a small patch is
formed, which presents all the characters of an
ekzema : there is an erythematous redness ; there
is papulation ; there is slight exudation — papular
at first, but afterwards general ; there is incrusta-
tion, and there is desquamation.
Congestion, therefore, gives rise to redness ; it
gives rise, also, to papulation, and to a moderate
amount of swelling ; but there is another important
pathological change which results from congestion,
and that is effusion or transudation. The congested
vessels are relieved from their distension by the
exudation of the fluid portion of the blood, and this
exudation causes the thickening and condensation
of the substance of skin. Sometimes the tran-
sudation from the vessels occasions oedema (ekzema
oedematosum) ; sometimes it is effused beneath
the epidermis, at the apertures of the follicles, and
produces vesicles (ekzema vesiculosum) ; a continu-
ance of this process causes the separation of the
cuticle from the cutis ; and the discharge from the
latter of a serous lymph (ekzema ichorosum). In a
u
290 KATUEE AND VAfilETIES OF EEZEMA.
different constitution, or in another region of the
bodj, the distension of the tissues of the skin may
occasion cracks and fissures (ekzema fissum) ; from
which an ichorous discharge may be poured out in
greater or less quantity.
There is yet another pathological operation which
occurs in the morbid skini and that is, an alteration
in the formation of the epidermis. Where two folds
of integument have lain in contact for awhile, and
where, from the constant presence of heat and
moisture, the cuticle has no power of acquiring its
natural homy density, but remains soft and cellular,
the surface of the derma is red, is more or. less
denuded of epidermis, and secretes a copious muco*
purulent discharge, which is, in reality, an aborted
and morbid cuticular substance ; a cuticle arrested
at its cellular stage and partly transformed under
the influence of inflammatory action, and the low
vitality of the part, into a fluid which is principally
mucus, but is mingled with a small proportion of
pus. There is no lesion of continuity, or destruc*
tion of the epidermis, in this case ; the muco-
purulent matter is a simple secretion produced at
the expense of the epidermis, a morbid conversion
of that tissue into a fluid matter, which performs
the same office to the otherwise unprotected derma,
as that of the mucus to the mucous membrane.
This is intertrigo mucofluens ; or, more properly,
ekzema mucosum.
Now, in ordinary ekzema, a morbid alteration in
the formation of the cuticular tissue takes place,
similar to that just described. The copious exuda-
tion of ekzema ichorosum is not merely a serous
fluid expelled from the vessels in consequence of
the over-distension of their parietes ; it is a positive
secretion in which the cellular elements of the
cuticle take an active part, and bestow upon the
fluid its special properties — for example, its density
tmd frequent opalescent appearance. That same
NATURE AND VARIETIES OP EKZBMA. 29 1
influence which causes the discharge of such im-
mense quantities of fluid from the mucous membrane
of the bowels in diarrhcea and cholera, is also active
in ekzema ichorosum. In the course of a few hours,
several pints of fluid may be poured out from the
denuded surface of the derma, partly, no doubt, by
way of excretion, but not less actively also by way
of secretion.
The pathological phenomena present and in ope-
ration in ekzema, therefore, are not simply those
of inflammation, but also involve a morbid aberra-
tion of secretion. The inflamed derma, which, at
an early period of the disease, exudes largely a
colourless lymph, at a later period may exude an
opalescent and even a yellowish fluid; the conse-
quence of the conversion of the mucous elements
of the cuticle into pus. And the continuance of
inflammation of the skin may so far lower the
vitality of the surrounding tissues, that pustules
may be developed around the circumference of the
patch of eruption, and add fresh purulent matter to
the morbid secretion ; the case is then one of ekzema
pustulosum, or ekzema impetiginodes.
In a disease of a secreting tissue, where inflam-
mation is apt to continue for a considerable period,
and where secretion is so greatly disturbed ; where
exudation takes place as the result of inflammatory
changes, and as the result also of modified secre-
tion, — we may expect to find crusts of various kinds
formed on the inflamed surface ; some resulting
from the desiccation of altered secretions, and some
from imperfect formation and altered structure of
the epidermis. It is in the power of the medical
man to prevent these crusts from appearing at all ;
but where the case has been left to itself, or where
the treatment has been misdirected, we may find
spongy crusts of a greyish, yellowish, greenish, or
brownish tint, or almost black ; we may find them
loose or adherent ; we may find scabs of various
u 2
292 XATUBE AKB VABIETIES OF EKZEKA.
degrees of density ; or we may find, where altera*'
tion of the epidermis is chiefly concerned, scales of
various thickness and magnitude — ^thicker, larger,
and rougher in more recent cases ; thinner and
smaller in more chronic forms ; and diminishing by
degrees to the fiirfuraceous and farinaceous desqua-
mation of psoriasis or pityriasis.
Ekzema is a chronic affection, and has no specific
course. Like other chronic inflammations, it has
its beginning and its end; or, in other words,
its rise and its decline, with an intervening period
of activity of greater or less duration. In a severe
case the rise may present redness, heat, swelling,
papulation, and sometimes vesiculation ; this may
be regarded as a first stage or first period of the
disease. Next, there may succeed exudation, in-
crustation, and sometimes suppuration; this is a
second stage, or second period — the stage of exal-
tation. Lastly, there will follow the third stage —
the stage or period of decline— comprising desqua-
mation, with redness and often thickening of the
skin. We may regard such an example as a typical
case of ekzema ; but the disease very rarely runs its
course so simply. The first stage may linger on, and
be lost eventually in the last, without the interme-
diate pathological phenomena ; or the whole course
of the eruption may be a successive repetition of
the intermediate stage, without any alteration of
the first. Even the last stage may exist in the
form of thickening and chapping, without any pre-
ceding first stage. It is this great diversity of
ekzema in pathological characters that is assumed
as the distinction of its varieties, and which contri-
butes so much to the obscurity of diagnosis of
the disease ; whilst its irregularity of course en-
hances the difficultv of treating it successfully. It
may be correct, therefore, to speak of a first, a
second,or a third period of ekzema, in relation to a
given attack of the disease ; but not so in relatioa
NATUBB AND VABIBTIBS OP EKZBMA. 293
to ekzema in general ; for, as we have endeayoured
to show, in the great majority of examples of this
affection, the regular succession of stages or periods
is wanting ; and it will be found more correct to
employ the terms previously suggested as the
proper designation of the forms of the disease.
Again, in reference to the pathological phenomena
presented by the disease during its three periods,
the first might be named the erythematous, the
papular, or the vesicular stage; the second, the
exudative and encrusted stage; and the last, the
squamous or desquamating stage.
Causes of Ekzema. — ^To conduct the treatment of
ekzema with success, it is necessary not only to
know the habits and phenomena of the disease — in
other words, its pathology — ^but also to be able to
form some judgment as to its cause. Carefiil ob-
servation has convinced me that the essential cause
of ekzema is debility — debility of constitution or
general debility ; and debility of tissue or local
debility. And further investigation has shown that
constitutional debility may present itself in three
forms ; namely, as an assimilative debility^ in which
the organs of digestion and secretion are principally
at fault ; as a nutritive debility^ where the powers of
nutrition are chiefly concerned ; and as a nervous
debility^ in which a morbid state of the nervous
system takes the lead. In 300 cases of ekzema,
278 were referable to general debility, and 22 to
local debility ; and of the 278 instances of general
debility, the examples of assimilative debility were
143, nutritive debility 103, and nervous debility 32.
Debility stands in the position of a predisposing
cause of ekzema ; but, as debility is itself due to
certain causes, these latter must be regarded as
bearing the relation of remote predisposing causes
of the eruptive disease. Of the 278 cases of general
debihty already referred to, the remote predis-
posing causes, taken in physiological order, admit
294 NATUBE AND YABIETIfiS OF EE2EMA.
of being arranged under twenty-four heads, as
follows : — 1. Hereditary diathesis ; 2. Strumous
diathesis ; 3. Weakly parentage ; 4. Errors of diet ;
5. Errors of hygiene — ^namely, air, exercise, clean-
liness, and clothing ; 6. Vicissitudes of cold, heat^
and moisture; 7. Transitions of seasons; 8. Un-
genial climate; 9. Excessive labour, mental and
physical ; 10. Anxiety and affliction ; 11. Sexual
excess ; 12. Vaccination ; 13. Dentition ; 14. Ex-
cessive growth; 15. Deranged digestion; 16. De-
ranged menstruation; 17. Uterine, reproductive, and
puerperal derangements ; 18. Fevers, eruptive and
malarious ; 19. Gouty and rheumatic diathesis ;
20. Constitutional and organic disease; 21. Ner-
vous shock and fright; 22. General cachexia; 23.
Hsdmorrhage ; 24. Local injury or disorder.
If we consider them in the order of their nu-
merical importance, the arrangement in reference
to the leading remote predisposing causes would
stand as follows : — ^Deranged digestion, 51 ; errors
of diet, 33 ; weakly parentage, 21 ; vicissitudes of
cold, heat, and moisture, 21 ; anxiety and affliction,
16; hereditary diathesis, 16; ungenial climate, 14;
constitutional and organic disease, 14; excessive
labour, mental and physical, 11 ; uterine, reproduc-
tive, and puerperal derangements, 11 ; errors of
hygiene, 10 ; gouty and rheumatic diathesis, 8 ; de-
ranged menstruation, 7 ; fevers, eruptive and mala-
rious, 7 ; excessive growth, 7 ; vaccination, 7.
In reference to the three subdivisions of the
remote predisposing causes — ^namely, assimilative^
nutritive, and nervous — ^the most numerous remote
predisposing causes of assimilative debility are met
with under the heads of — deranged digestion, 49 ;
vicissitudes of cold, heat, and moisture, 13 ; con-
stitutional and organic disease, 12 ; and anxiety and
affliction, 11. The chief remote predisposing causes
of nutritive debility occur under the heads of —
errors of diet, 28 ; weakly parentage, X3 ; hereditary
NATUEB AND VABIETIES OF EKZBMA. 295
diathesifi) 12 ; vaccination, 7 ; excessive growth, 7 ;
and errors of hygiene, 6. The most numerous
remote predisposing causes of nervous debility are
met with under the heads of — anxiety and affiction,
5 ; excessive mental and physical labour, 4 ; ungenial
climate, 4 ; uterine, reproductive, and puerperal
derangements, 4 ; nervous shock and fright, 3 ;
weakly parentage, 3 ; and vicissitudes of cold, heat,
and moisture, 3.
After the remote predisposing and the predispos-
ing causes of ekzema, follow the exciting causes,
which are best illustrated by the group of local
causes. Of the twenty-two cases referable to local
debility, the exciting causes admit of being as-
sembled under the following heads, — namely, cold ;
heat ; moisture, with cold or heat ; clothing, bed-
ding, etc. ; friction ; local irritants ; local injury ;
varicose veins. The most important groups in
numerical value were, cold ; local injury ; heat ; local
irritants ; and varicose veins.
Treatment op Ekzema. — J£ the foregone premises
with regard to the causes of ekzema be correct, the
treatment of ekzema resolves itself into a treatment
of debility — a treatment of constitutional debility,
* and a treatment of local debility ; and the influence
which we are called upon to exercise over our
patients is one which shall have for its object to
restore power, and thereby to regulate fimction and
to confirm health ; for health is nothing more than
correct function united with normal power.
In general terms, our constitutional treatment
must be directed to the regulation of the Amotions ;
and, concurrently with regulation of functions, to
the restoration of the tone, the vigour, the vitality
of the general system. In the most numerous
group of cases, those which depend upon debility of
assimilation, our attention is principally directed to
the digestive organs and the secretions. In the
next most numerous group, those which are due to
296 NATURE AND VARIETIES OF EEZEMA.
nutritive debility, the digestive and secreting organs
must also be carefully examined, althougli they are
less likely to be faulty than in the preceding group ;
and we are enabled sooner than in the former case
to resort to our strengthening remedies. The same
remarks apply to the third group, originating in
nervous debility, while, in these latter, we have to
deal with the special indication of weakened power
of the nervous system.
A more particular direction is given to our treat-
ment by the recognition of the remote predisposing
cause. The commonest of the remote predisposing
causes of ekzema we have seen to be derangement
of digestion and errors of diet ; we have but to
include the consideration of these causes in our
general treatment for regulating the digestive
organs and secretions and restoring tone, and our
treatment will be complete.
Next to the preceding comes a group of causes in
which the laws of hygiene have been infringed : for
example, vicissitudes of cold, heat, and moisture ;
errors of air, exercise, cleanliness, and clothing;
climate, and seasons. These various causes are too
suggestive to call for special comment. The same
may be said of another group of remote predispos-
ing causes ; namely weakly parentage, hereditary
diathesis, and strumous diathesis. Then comes a
group, of which labour in excess, both mental and
physical, together with anxiety, aflBiction, nervous
shock and fright, and mental distress of every kind,
are the leading features. Next we have debility
proceeding from the morbid operation of functions
natural to the body : for example, dentition ; exces-
sive growth ; and sexual excess. After these, there
are the disorders of female functions ; deranged
menstruation ; together with uterine, reproductive,
and puerperal derangement. And, lastly, there is
the debility which is due to the existence of other
diseases: for example, vaccination ; general cachexia;
NATURE AND VARIETIES OP EKZEMA. 297
eruptive and malarious fevers ; gout and rheumatism ;
hsemorrhage ; and visceral disorder.
The question, therefore, How shall we treat a case
of ekzema P is not so simple in one sense as might
be imagined, inasmuch as it demands a lengthened
inquiry into constitution and cause ; but simple
enough in another sense, because it involves no
more, but quite as much, as the treatment of any
other disease to which the human constitution is
liable. To treat an ekzema judiciously and correctly,
we must know the sex and age of the patient,
together with the predisposing cause, the remote
predisposing causes, and the exciting cause of the
disease. It may be that our treatment must be
directed to the restoration of digestion and secretion ;
or to the strengthening of an exhausted vitality;
or to combating an inherent and inherited weak-
ness; or to the improvement and sustainment of
defective power ; or to the regulation of disorders of
the female system ; or to the cure of visceral or of
organic disease. In a word, the highest and best
qualities of medical art and science must be put in
practice, with foresight and discretion, for the treat-
ment of an ekzema ; the universal must submit to
become the handmaiden of the special.
The agents of the constitutional treatment of this
disease, our remedies, belong chiefly to the class of
aperients and tonics ; while, as adjuvants, we have
recourse to sedatives, alteratives, and stimulants.
Our best aperients are : sulphate of magnesia ; and
the purgative extracts, either alone, or when specially
indicated, imited with blue-pill or calomel. These
remedies clear away accumulated ingesta and secre-
tions fipom the alimentary canal ; they restore a torpid
and lethargic function, in this sense performing the
part of derivatives from the inflamed tissues ; and they
E remote healthy secretion. But aperients require to
e used with great judgment ; they must neither be
carried too far, nor continued too long ; our object
298 NATUBE AND VAEIETIES OF EEZEMA.
should be to imitate nature as closely as possible ;
and above all, to avoid lowering the powers of the
constitution. !N'othing reanimates the energies of
the organism so much as the healthy operation of
the natural functions of the body : this should be
our aim ; and, when so applied and skilfully used, an
aperient, instead of producing exhaustion, becomes
a powerful tonic to the entire frame. The sulphate
of magnesia in small doses possesses all these good
qualities ; it restores the Ainction of the alimentanr
and urinary mucous membrane, and agrees with
most constitutions. Some there are, to whom the
warmer aperients or the mineral purgatives are more
suitable ; but this is a matter that can be determined
only by observation. Again, we are influenced in
our selection of an aperient, often by the season, and
often by some collateral object, such as derivation ;
in the spring and summer, saline aperients and
neutral salts may be indicated, whereas, in a colder
season we should prefer the warmer remedies, and,
in seeking for a derivative, we should possibly prefer
aloes to Epsom salts.
Besides their direct effects of removing obstacles
and promoting normal secretion from the mucous
membrane, aperients have the property of rendering
absoi*ption and nutrition more active. How usefully
on many occasions do we put this property of
aperients to a purpose in removing efnisions from
the tissues, in carrying off waste humours, and
stimulating nature to be more eager in the assump-
tion of fresh material. It is marvellous, how much
may be accomplished by the judicious use of reme-
dies, and with what certainty the results which we
seek to obtain may be secured. If we run the eye
down our list of remote predisposing causes, other
remedies suggest themselves which may be combined
with our aperients to adapt them to a particular
purpose ; let us instance rheumatism, which draws
our thoughts towards the iodide of potassium, gout
NATUHE AND VARIETIES OF EKZEMA. 299
towards colchicum, and uterine diseases towards
alkalies with bromine and iodine.
If we turn our attention in the next place to the
tonics which may be found suitable for the treatment
of ekzema, we find : simple vegetable bitters, cin-
chona and quinine, chalybeates, the mineral acids —
hydrochloric, nitric, sulphuric, and phosphoric, and,
above aU, arsenic. Among simple vegetable bitters
with what respect must we speak of gentian,
calumba, orange-peel, quassia, chirayta, chamomile,
and hop ; in infusion or decoction ; in extract or in
tincture ; in combination with the mineral acids or
with ammonia, soda, or potash. How admirably
cinchona and quinine perform their part ; cinchona
in decoction or tincture, or liquor, with sulphuric
acid or with ammonia ; and quinine in solution, with
an excess of sulphuric acid. How perfect a remedy
is one grain of quinine, with one drachm of sulphate
of magnesia, seven minims of dilute nitric acid, and
an ounce and a half of infiision of roses, both as a
gentle aperient, a corrector of acidity, a promoter
of mucous secretion, and as a tonic. Then the
ohalybeates, iron and its salts, the sulphate, the
tincture of the hydrochlorate, the citrate, the super-
phosphate, the iodide, and the citrate of iron and
quinine. Next, the mineral acids combined with
the bitter tonics, and especially the nitro-muriatic
and the phosphoric. Again, as a nutritive tonic we
have the cod-liver oil ; and our list of remote pre-
disposing causes will discover several sections in
which that remedy is peculiarly applicable ; for
example : strumous diathesis, excessive growth, and
sexual excess.
All that precedes applies to any disease of the
human frame, whether it be of the lungs, the heart,
the liver, the brain, the kidneys, or the womb ; the
treatment now under consideration is catholic and
not special ; its aim, to bring back normal function,
and so to restore health ; it is the routine of the
300 NATUBE AND VARIETIES OF EKZEMA.
physician's art ; but there is a remedy which pos-
sesses a special influence on the skin, and has long
been held sacred in cutaneous medicine, namely,
arsenic. When all has been effected that can be
accomplished by aperients, alteratives, derivatives,
and tonics, then comes the reign of arsenic, and at
that moment arsenic is triumphant. But arsenic
must be regarded, not as our common weapon, but
as our reserve ; to be administered when it can do no
harm, and when there is every probability of its
doing good. Arsenic is a tonic, a tonic which
influences chiefly the nerve-substance, and not only
gives force to, but improves the nutrition of the
nervous matter ; in this way it operates upon the
trophic system of nerves throughout the economy ;
and in cutaneous medicine we have evidence of its
remarkable powers upon the skin. Arsenic accele-
rates those actions of the skin which tend to its
nutrition and renovation, and therein it becomes a
healer of its eruptions, and a valuable aid to the
cure of ekzema. But arsenic, above all medicines,
must be handled with judgment and care ; it must
be jealously watched, lest it give rise to any un-
favourable symptoms, and its use must be suspended
at once if there exist even a doubt of its healthful
operation. Above all, it is to be borne in mind that
only at the right moment is arsenic applicable, and
that right moment can only be determined by watch-
ful care, or by long experience.
Our Pharmacopoeia is rich in preparations of
arsenic, but the most valuable are, the liquor potassaa
arsenitis, and the liquor arsenici chloridi ; the dose
of the former applicable to an adult suffering with
ekzema, is two to four minims ; and of the latter,
double that quantity.* Some years ago, in a paper
on ekzema infantile, I laid before the British Medical
* The British Pharmaoopodia has equalized the strength of
ihese preparations, so that the dose, now, is the same for both.
NATUBE AND VARIETIES OP EKZEMA. 30I
Association a formula for the administration of
Fowler's solution ; and experience has assured me
that no better form can be employed for its adminis-
tration.* Arsenic should always be administered in
small bulk, and the formula in question gives one
drachm of fluid as the dose, and always on a full
stomach, or, if possible, in the midst of a meal. The
object of these precautions is obvious ; arsenic is
intended especially as an improver of nutrition, and
therefore should be made to enter the stream of
blood with the chyle ; in its nature it is an irritant
to the mucous membrane, and, therefore, it should
be administered at a time when the lining membrane
of the stomach is coated with mucous secretion, and
at the same time when, by mixing with the mass of
the meal, the remedy is largely diluted.
All the processes of renovation which depend upon
Nutrition are slow ; hence, as we look for the good
efiects of arsenic in the improvement of nutrition,
we must be prepared to continue its use for a con-
siderable time. This is another reason for adminis-
tering arsenic in small doses, independently of the
suggestions to the same elBfect gathered from ex-
perience. Indeed, by employing it in larger doses.
We naturally frustrate the objects which we ourselves
have in view ; we set up the irritant action of the
medicine ; we excite nausea, sickness, pain in the
stomachjor alimentary canal, prostration of nervous
power, or cough, and then we are compelled to sus-
pend it. WhUe, on the other hand, administered
with judgment and discretion, there is no safer
medicine in the Pharmacopoeia ; and, at the sa me
time, in my opinion, there is none to equal it in
' excellence and usefulness.
To be a successfril practitioner in the treatment of
* R Yini ferri, Jiss ; syrnpi simplicis, 5iij ; liquoris potassse
anenitifl, Jj ; aqnn purse, Jij. Misce. Fiat mistura ; Jj pro
dosL
302 NATURE AND VABIETIES OF EKZEMA.
ekzema, a medical man must be an accomplished
physician ; to manage the local treatment with suc-
cess, he must also be an able surgeon. The local
treatment of ekzema must be conducted according
to the general principles of surgery. The inflamed
part must be soothed in the acute stages of the
disease, it must be supported and stimulated during
the chronic stages, and it must be excited to a new
action in the most chronic stage of all. To soothe,
we must employ water-dressing, unguents, cerates,
well-adjusted bandages, and rest. To give local tone,
we must have recourse to stimulant applications of
various kinds.
The water-dressing is useful where there is heat,
pain, itching, or tension, but should not be con-
tinued beyond the period during which those symp-
toms exist ; for, when prolonged for too great a time,
it lowers the tone of the tissues and perpetuates the
eruption. In our list of remote predisposing causes,
it will be seen that one amongst them is " moisture
with heat," the exact condition which at one moment
of the disease we emplo y w ith advantage in the use
of the water-dressing. Whereas, we could hardly
adopt any more certain means of producing ekzema
artificially, than by the application for a long time
of water-dressing to a healthy part of the skin. This
operation is often seen in practice, in the eruptions
which follow the lengthened use of poultices.
When the local inflammation partakes of the sub->
acute character rather than the acute, and when the
water-dressing has effected the purpose for which
it was applied, we may have recourse to cerates or
ointments. As a preliminary to both these appli-
ances, all crusts and sordes should be carefully wiped
or washed away from the inflamed part ; if they be
dry and hard, the water-dressing, or the ointment-
dressing may be applied with a view to soften them,
and then they should be removed, and the dressing
with the ointment nicely adjusted, and, wherever
NATURE AND 7AEIETIB8 OP EKZEMA. 303
•
practicable, secured in position by a bandage ; where
this cannot be done, then we must have recourse to
adhesive straps. In selecting an ointment, the best
with which I am acquainted is the benzoated oint*
ment of oxide of zinc. It should be spread thickly
on the lint ; the dressings should be shaped so as
not to overreach the sound skin, and the roller of
elastic cotton bandage should be put on smoothly,
and with a view to produce equable pressure on the
eruption, and support to the vessels of the limb.
On a part of any extent it is more convenient, and
we avoid wrinkles thereby, to apply the dressing in
slips, and dispose them in the manner of a many*
tailed bandage; and when a limb affected with
ekzema is carefully packed up in the manner de»
scribed, it may be left for twenty-four hours, and in
more chronic cases for forty-eight hours, without
disturbance ; then it should be unpacked, re-dressed,
wiped with a soft napkin to remove sordes, and
packed up again for a similar period. While packed
up in this way, the itching of an ekzema commonly
ceases, and the patient is saved from the annoyance
and suffering of that disagreeable symptom, while
the skin returns gradually to its healthy condition.
If there should be heat and burning of the limb
when packed, the bandage may be sopped with
water, and then we get the advantage of the water-
dressing superadded to the tonic treatment.
Where great irritability prevails in the constitu-
tion of the patient, we require to have recourse to
sedatives ; and where irritability is present in the
part, we may find it difficult to contrive a dressing
which will perfectly suit the eruption. Sometimes
grease of all kinds acts as an irritant, and then we
are driven for a while to the use of lotions or
powders. Sometimes a sedative, such as the acetas
plumbi, added to the ointment, reUeves the irrita-
bility ; sometimes a more stimulating appUcation,
such as the unguentum resinse flavas, or the ointment
304 NATURE AND YABIETIES OF EEZEMA.
of juniper tar. At other times we may put an end
to the irritability by pencilling the surface with a
weak solution of the nitrate of silver in nitrous ether.
Again, we rarely fail to relieve the irritability by un-
dressing the part, washing it thoroughly with the
juniper tar soap, drying it, and dressing and packing
it up again as before. The successful treatment of
ekzema needs many resources ; but only such as may
be explained on the recognized principles of phy-
siology and surgery.
The erythematous form of ekzema yields very
kindly to the benzoated ointment of oxide of zinc ;
so also do the moist forms of the eruption, the
dressing being aided by moderate compression with
a bandage. Ekzema ichorosum must be followed up
patiently with this plan of local treatment until the
ichorous secretion ceases to be formed, and the
eruption heals. But the chronic forms of the disease
represented by ekzema squamosum, require a stimu-
lant treatment. Washing with the juniper tar soap,
dressing with the unguentum resinas flavae, pencil-
ling with a solution of nitrate of silver, or a strong
lixivium of potash. Whenever these stronger loccd
remedies are used, the eruption should be subse-
quently dressed, ynore dicto, with the benzoated
ointment of oxide of zinc, and then carefully packed
up.
In the moist forms of ekzema there is always a
considerable quantity of serous lymph present in
the tissues of the skin ; and, until that serous fluid
is removed, either by absorption from within or by
excretion from the part, the skin cannot return to
its normal state. It is to the presence of this fluid
infiltrated in the substance of the skin, that the
chronic forms of ekzema owe their thickening, their
induration, and their rupture ; the latter giving oc-
casion to fissures and cracks, and being most con-
spicuous where the skin is naturally thick and
wrinkled, as on the hands and fingers, or the feet,
PATHOLOGICAL PHENOMENA OP ERZEMA. 305
behind the ears, along the borders of the mouth, and
in the cleft of the podex. For this state of the
skin in an aggravated form there is no remedy to
compare with a solution of caustic potash. That
application seems to purge the skin of its abnormal
fluids, to promote absorption, and to give energy to
nutrition ; and it is amazing with what rapidity the
cracks will heal, and the most chronic state of disease
get well under this treatment.
IV.
Pathological Phenomena of Eezema.
Correlations of Ekzema with other Diseases and
with Constitutional Disorder.
As we assume it to be better to do little, than to
do nothing at all; and that more cannot be ex-
pected of a man than he is capable of performing ;
we subjoin a few brief notes from our case-book in
illustration of the phenomena of ekzema as they
are presented to the medical man in daily practice ;
and with the view of contributing to a fuller know-
ledge of the natural history of one of the most un-
pleasant and troublesome, if not the most important,
of the diseases which afSict mankind. On the present
occasion our selection relates to the correlations of
ekzema, for example, with furunculosis, pityriasis,
scabies, chronic bronchitis and asthma, pruritus and
neuralgia, erysipelas, and sykosis ; with certain nu-
tritive diseases, embracing dermatoxerasia, phytosis,
scrofulosis, and lupus erythematosus ; with certain
constitutional disorders, as dyspepsia, haemorrhoids,
menstruation, parturition, lactation, uterine disease,
and gout and rheumatism; with some affections
X
306 FATHOLOOK^AL PHENOMENA OF EEZEMA.
of childhood, namely, dentition and rubeola ; and
with varicose disease of the veins of the lower
extremity.
Eezema with Pueunculosis.
The first of these cases is an instance of con-
genital ekzema ; the remainder belong to the group
of accidental ekzemata ; the attack of herpes zoster
was an accidental occurrence, but the long duration
of the neuralgia herpetis may, very possibly, have
had a corresponding relation -with the existing cu-
taneous diathesis.
6293. A married lady, aged 47, has ekzema pu-
dendi with furunculosis of the axillse. She has
been ekzematous from childhood. At the age of 30
she had herpes zoster lumbalis, followed by neu-
ralgia ; and she still feels a numbness in the hip,
and experiences occasional neuralgic pains, as a
sequel of the herpes.
6359. A gentleman, aged 28, has suffered from
ekzema squamosum of the legs for three years ; the
eruption being consequent on an attack of fever
followed by great depression of the vital powers.
For the last six months he has also been tormented
with fiirunculosis.
7245. A maiden lady, aged 57, has ekzema squa-
mosum of the feet; she has been troubled with
ekzema fissum of the feet and hands for ten years.
During the last five years she has also been teased
with fiiiruncles.
7346. A gentleman, aged 43, has ekzema squa-
mosum, which has existed for eleven years; and
during the last two years he has been much
troubled with furunculus. He has resided for
twenty-six years in India and China, and is now
CORRELATIONS OP EKZEMA. 307
suffering from dyspepsia, acidity, pale motions, and
headache. -
7537. A young gentleman, aged 18, has ekzema
squamosum capitis, which has lasted two months ;
and for the last month he has been much troubled
with boils.
7586. A lady, aged 65, has ekzema of the nostrils,
which has teased her for four months ; during the
last week she has had a boil ; she is suffering also
from weakness of the eyes and lumbago.
7645. A gentleman, aged 26, has ekzema of the
lower hp, and furunculi on the nape of the neck and
back of the hands. Both affections have existed
together for six months.
7653. A gentleman, aged 46, is suffering from
ekzema of the arms, which has existed a few weeks ;
four years ago he was troubled with boils, which
lasted for several months ; and three years back he
had ekzema of the nape and sides of the neck. He
is a dyspeptic subject.
7665. A gentleman, aged 45, has intercrural
ekzema and ekzema ani, which have existed for five
months. For ten years he has been suffering
from time to^ time with ekzema squamosum of
the toes : this sometimes produces swelling and
erythema, which is termed ** erysipelas." For the
last five years he has also been troubled with boils,
which, he says, alternate with the ekzema.
7697. A gentleman, aged 48, has ekzema capitis,
which has existed for four months; he has also
intercrural ekzema and ekzema in the folds of the
abdomen. During the same period he has been
suffering from furunculi.
Ekzema with Pityriasis.
6479. A young gentleman, aged 18, of dclicato
x2
308 PATHOLOGICAL PHENOMENA OP EKZEMA.
constitution and leuksBmic, is suiffering from pity-
riasis, the sequela of ekzema capitis, which made its
appearance two years. before.
6790. A young lady, aged 10, has pityriasis
capitis (ekzema furfuraceum capitis), which has
existed for two years ; she has, at the same time,
ekzema papulosum of the legs.
7058. A Sussex farmer, aged 59, after an un-
usual degree of exposure to the sun in the month
of July, and subsequent shampooing of his head,
was attacked with pityriasis capitis (ekzema fur-
ftiraceum). Three years ago he presented himself
with scabies, caught, as there was reason to believe,
from the handling of money received by him at
market. The scabies presented an ekzematous
character, and was unusually irritable; and, con-
jointly with the present attack, denotes the existence
of an ekzematous diathesis.
7 1 79. An unmarried lady, aged 60, has ekzema
squamosum digitorum, of five weeks' standing, in-
duced by exhaustion caused by hot weather. Two
years ago she was suffering from pityriasis capitis.
7231. A physician, aged 64, is suffering imder
pityriasis capitis; he has been ekzematous since
the age of twenty-one.
7360. A gentleman, aged 24, has ekzema squa->
mosum of the meatus of one ear ; the disease has
existed for four months. He has had pityriasis
capitis from his childhood, and four years back was
under treatment for that affection. He looks
weakly ; and his complexion is pallid.
7527. A maiden lady, aged 55, has pityriasis
capitis, which has existed for several years ; she has
been ekzematous since childhood ; and twenty years
ago had an issue opened for the relief of ekzema
ichorosum.
CORRELATIONS OF EKZEMA. 309
7553- ^ gentleman, aged 31, recently returned
from Australia, lias ekzema squamosum capitis,
which has existed for four months. He also suffers
from pityriasis capitis, which has troubled him for
twelve years.
7659. A lady, aged 31, has pityriasis capitis
(ekzema furfuraceum), which has teased her for
three months ; she has had slight attacks of
ekzema on two or three occasions after her con-
finements.
7685. A young lady, aged 23, has pityriasis
capitis, the sequela of ekzema capitis. When an
infant she was hydrocephalic, and at present ex-
hibits much nervous irritability ; she is apt to faint
on rising in the morning; has morning nausea,
irregular menstruation, and poor appetite. She is
tall and slender in figure.
Ekzema and Scabies.
6334. A medical man, aged 46, is suffering from
ekzema papulosum, which has teased him for three
years, having taken its origin in the irritation
caused by scabies. The acarus was, doubtless,
allowed to remain undisturbed for a considerable
period, but after its disappearance the .nerve irrita-
tion remained and has been perpetuated.
7271. A voung man, aged 21, is suffering from
ekzema of the hands, the flexures of the elbows, the
axillas, and hips : this eruption has existed for five
months, and is consequent on scabies.
7392. A gentleman, aged 24, has ekzema with
ekthyma, which have existed for some months, and
originated in an uncured scabies, which began a
year ago.
Ekzema with Cheonio Bronchitis.
In severe cases of congenital ekzema, the mucous
3IO PATHOLOQIOAL PHENOMENA OF EKZEMA.
membrane of the air-passages very commonly par-
ticipates in the surface inflammation, thereby making
manifest the known relation of the skin with the
mucous membrane. This ekzematous inflammation
gives rise at a later period to thickening of the
mucous lining of the bronchial tubes, and a kind of
bronchial asthma. The four following cases illus-
trate this part of the pathology of ekzema.
6559. A young lady, aged 9, has ekzema squa-
mosum of the hands ; her skin is dry, wrinkled,
and ill-nourished, and has been so from her birth ;
ekzema showed itself at the sixth month, and she is
at the same time a sufierer from asthma, consequent
on chronic bronchitis,
7041. A little boy, aged 4, has ekzema of the
popliteal hollow on each leg, with a small circum-
scribed patch on the forehead. This attack followed
a severe catarrh and whooping cough.
7262. A man-servant, aged 40, has ekzema of
the hands and front of the wrists ; and some little
in the popliteal hollows. He had ekzema in his
infancy, and has occasional fits of asthma from
chronic bronchitis.
7325. A young lady, aged 8, has ekzema of the
joints, and of the pudendo-crural grooves ; the
ekzema commenced when she was three years old,
and was accompanied for four years with a night
cough, described as a "croupy cough." During
the last twelve months the cough has improved,
and the ekzema has grown worse. At the upper
part of the thighs it presents the appearance of
ekzema marginatum.
Ekzema with Pruritus, Neuralgia, and Leiohen
tropicus.
7352. A gentleman, aged 58, has ekzema squa-
mosum of the occipitaJ region of the head, attended
COBBELATIONS OF EKZEMA. 31I
with sudden and violent fits of itching. The erup-
tion has existed for three months, but he has
suffered from occasional fits of pruritus for a year
past. On being put upon a treatment which relieved
the ekzema, he was seized with pruritus of the root
of the penis and perineum.
7540. A gentleman, aged 57, is suffering from
ekzema verrucosum, a very itchy form of the erup-
tion ; the disease being dispersed over the limbs,
particularly the lower extremities, in small patches,
little bigger than large prominent warts. He had
been suffering from Colonial fever for five years ; to
this succeeded a troublesome pruritus of the skin,
and the ekzema followed the pruritus.
7078. A married lady, aged 49, has had ekzema
behind the ears, in the head, and the grooves of the
folds of the skin of the trunk of the body, for three
years. For twenty-two years she has suffered from
neuralgia, which commenced six months after her
marriage ; and for ten years she hss had a patch of
area, which is still bare.
6520. A gentleman, aged 46, was attacked with
prickly heat, leichen tropicus, shortly after embarking
at La Plata for England ; the prickly heat subsided
into ekzema squamosum, with which he was affected
in April, 1867. At this time he was seized with
bronchitis, for which a saline treatment was pre-
scribed. In June the bronchitis had ceased, and
he was attacked with a pityriasis of the scalp and
face. And in September the pityriasis had disap-
peared, and had given place to an irritable state of
the urinary mucous membrane, accompanied with
pains in the spermatic cords and in the loins.
Ekzema with Eeysipelas and Sykosis.
7184. A ladv, aged upwards of 60, has ekzema
of the groove behind the ears, extending upwards,
312 PATHOLOGICAL PHENOMENA OF EKZEMA.
for a short distance, on the sides of the head. She
has no ekzema anywhere else, and the present affec-
tion has lasted eight months. Five years ago she
had erysipelas of the scalp after a fall ; and two
years ago a similar attack, which came on sponta-
neously. The latter may have been ekzema.
7088. A gentleman, aged 65, has ekzema squa-
mosum capitis, which has existed for thirteen
months. Six years back he came under our treat-
ment for sykosis labialis.
7632. A medical man, aged 65, has ekzema ery-
thematosum of the face, which has lasted three
months. Twenty years ago he suffered from
sykosis.
Ekzema with the Nutritive Affections: — Deb-
matoxebasia; Phytosis; Lupus erythematosus;
scbofulosis, and adenosis.
7389. An unmarried lady, aged 47, has ekzema in
a passive form, covering the whole surface of the
body, but worst on the face, the hands, and the neck.
She has suffered from ekzema from infancy ; on the
legs, the knees, and the shoulders, the ekzema has
assumed the appearance and has all the characters
of xeroderma.
7065. A gentleman, aged 49, has been suffering
with ekzema figuratum on the back of the hands, for
six weeks, and for this he was brought to us by
his medical attendant. On further inquiry, we
found that the whole of the trunk of his body
was covered with phytosis versicolor, which he had
had, he said, for twenty years. On the abdomen
were several broad spots of myrmehia, or flat warts ;
there were also here and there some small pouches
of tegwmentary molluscum ; while on the limbs were
^evetsU furunculi. We had thus under our eye, on
COBBELATIONS OP EKZEMA. 313
the same person, five different affections of the skin ;
some inflammatory, others simply disorders of nutri-
tion : of the first kind were the ekzema and furun-
culus ; of the second, the phytosis, myrmekia, and
moUuscum. One other disease was discovered when
we requested him to put out his tongue, namely,
syphilitic aphthsB and rhagades.
7050. An unmarried lady, aged 37, has ekzema
squamosum in small patches in the flexures of the
hands and fingers. She has suffered from this dis-
ease for two years without any change. Her sister
is the subject of lupus erythematosus.
7310. A little boy, aged 3, has ekzema of the head
and neck, which began at the age of four months,
after vaccination. For two years he has suffered
from scrofulous abscesses ; he was nursed by his
mother for the usual period.
6549. An unmarried lady, aged 44, has ekzema
behind the ears and in the axillaB. She has suffered
from ekzema for three years, but was cured in six
weeks. Some months later, in the month of No-
vember, the eruption broke out upon the back of
the head, and she suffered at the same time from
severe itching of the nape of the neck. This latter
attack was accompanied with enlargement of the
cervical lymphatic glands, an unusual complication
of ekzema.
Ekzema with Dyspepsia,
6509. A gentleman, aged 63, has suffered under
ekzema of the eyelids and flexure of the elbow-joints
for eleven months. The affection began in the eye-
lids ; in the month of May it was attended with
extreme redness and tumefaction and was taken for
erysipelas, and has lingered in a squamous form
until the present time. He is habitually dyspeptic.
314 PATHOLOGICAL PHENOMENA OF EKZEMA.
labouring under what he terms " derangement of the
liver.'*
6734. A physician, aged 65, has ekzema dorsi
man (is, with patches of the eruption on the face, and
dispersed over the body and limbs. He has suffered
from the eruption for four years, but it lias been
worse during the latter half of that period, He is
also much troubled with dyspepsia and constipation.
6948. An unmarried lady, aged 45, has ekzema
papulosum pretty generally dispersed over the body
and limbs, accompanied with hot flushes and some
degree of swelling of the affected parts of the skin.
The eruption has been in existence a week, and was
preceded by headache and nausea. The headache is
relieved, but the nausea still continues, and is not
benefited by the eruption,
7248. A married lady, aged 63, has ekzema of the
hands and feet, the eruption being vesiculous in the
palms of the hands. It has been in existence for
three weeks, and is associated with flatulent dys-
pepsia and constipation.
7312. A lady, aged 68, has numerous small patches
of ekzema papulosum dispersed over the thighs, lips,
and arms; they have existed for five months, and
followed an attack of dyspepsia excited by the sea-
air. She enjoys average health, but is nervous and
subject to dyspepsia. On her cheek, under the
right eyelid, is a small patch of sebaceous concretion
closely incorporated with the cuticle, and fissured on
the surface so as to form polygonal plates ; a form
of facial sauroderma consequent on imperfect nutri-
tion of the skin.
7373. A lady, aged 65, has ekzema papulosum in
small patches sprinkled over her arms and legs. The
eruption has existed for three months, and is attri-
butable to dyspepsia and torpid liver.
(
CORRELATIONS OF EKZEMA. 315
7382. A military officer, aged 35, has ekzema
squamosum, dispersed in patches over the arms and
legs ; the eruption has been in existence for four
years, and is attributable to service in India and the
Crimea, producing exhaustion and dyspepsia.
7431. A wine-merchant, aged 36, has ekzema
capitis of six months* duration; and for the last
T^eek is suffering from erythema tumescens of the
upper lip. Two years ago he had ekzema of the
face ; he is troubled with dyspepsia, which he attri-
butes to a necessity of his business, wine-tasting.
7669. A gentleman, aged 26, has ekzema squa-
mosum labiorum, which has existed for six weeks ;
for four or five months he has had ekzema papulo-
sum of the legs ; and for three months has been much
troubled with dyspepsia.
7695 . A married lady, aged 39, has ekzema aurium,
which has lasted for six weeks. Previously to the
appearance of the ekzema she was feeUng very un-
well, and thinks herself relieved by the eruption.
Four months back she suffered much mental anxiety,
which destroyed her appetite ; then she became weak
and listless, and has still a wearied expression in
her countenance. She mentions a series of small
illnesses which had attacked her in succession: —
1. Dyspepsia; 2. Urticaria; 3. a tubercle in the
rectum ; 4. Ekzema aurium.
7699. A medical man, aged 52, has ekzema of the
back of the hands, arms, and ears; the eruption
began in the hands twenty-six years ago ; he had
congenital ekzema as an infant, and has also suffered
considerably from rheumatism. He mentions *a
curious fact, namely, that some years back he took
a sea voyage, and was very sick ; the eruption ceased
during the continuance of the sickness, and did not
reappear for several years.
( 3i6 )
Ekzema with Rheumatism and Gout.
6132. A clergyman, aged 40, has ekzema papulo-
sum of the back of the hands, which has lasted for
eighteen months. This affection is associated with
the mal-assimilation of rheumatism; he is sub-
ject to slight attacks of ekzema and rheumatism in
hot weather.
7719. A cook, aged 33, has ekzema squamosum
of the hands and fingers ; it followed rheumatic fever
thirteen years back, but has been worse during the
last four years, subsequently to a second attack of
rheumatism.
7767. A gentleman, aged 37, has ekzema pudendi
et articulorum, which has existed for twelve months.
He is an engineer, very hard-worked, has much
mental pressure, to which has been added affliction ;
and he has much night travelling. The ekzema
broke out after a fatiguing night journey, and was
followed by an attack of rheumatic gout, and subse-
quently by a severe bilious seizure, the eruption
maintaining its ground throughout.
6680. A maiden lady, aged 30, is sufTering from
ekzema squamosum figuratum of the arms ; her usual
illness assumes the character of rheumatic gout, from
which she has been free for some months. The
ekzema has continued for three weeks.
7128. A gentleman, aged 69, has ekzema squa-
mosum of the neck and face ; it has lasted a year,
having been excited by the heat of summer ; and, at
present (July), is very troublesome. He is of gouty
diathesis ; and, three days after his visit to us, he
was attacked with gout in the wrist, to the great
relief of the ekzema.
CORRELATIONS OP EKZEMA. 317
Eezema mTu Menstrual, Parturient, and Uterine
Disorder.
7030. A lady, aged 36, has a circumscribed patch of
ekzema squamosum on the side of the neck ; she has
ekzema ichorosum behind the ears, and, on the scalp
just above the ears, ekzema squamosum. This attack
has lasted for six months. For some months she
has been subject to attacks of gravel, which recur
every fourteen days. She states that, at the age
of 15, she had a violent attack of ekzema consequent
upon checked menstruation ; and that the ekzema
was repeated three times, at intervals of eighteen
months apart.
7546. A young married lady, aged 24, has ekzema
ichorosum of the left thigh and hip ; the eruption has
lasted for three months. Seven years back she had
a similar attack, between the thighs at the upper
part. Of late she has been suffering from excessive
menstruation, is debiUtated, and has a soft, pale
tongue. She has lost her parents ; and a brother is
suffering from scrofulous caries of the tibia.
6 II 9. A young married lady, aged 19, has ekzema
vesiculosum et squamosum of the fingers, which has
existed for eighteen months. She has been two years
married, and this eruption commenced during her
pregnancy. She has since nursed her child, and has
ceased nursing him only two weeks.
7361. A lady, aged 32, has ekzema of the face,
neck, and hands, which has lasted for two weeks.
Two years back she experienced ekzema for the first
time while nursing ; it was repeated imder the same
circumstances a second time. This is her third
attack : she is sensitive and delicate of constitution.
3l8 PATHOLOGICAL PHENOMENA OP EKZEMA,
7770. A lady, aged 29, has ekzema vesiculosum in
the palm of the hands and in the groins, of one week's
duration. She has been subject to occasional attacks
of ekzema for seven years ; the first attack took place
shortly after her confinement with her first child.
At present she has an infant one year old.
7320. A married lady, aged 39, has ekzema of
one labium with pruritus vuIvab; the ekzema has
been in existence for six months, and is associated
with morbus uteri.
Ekzema with Infantile Disobdebs: Dentition and
Rubeola.
6384. A child, aged nine months, has a severe at-
tack of ekzema; it has been in existence for ten
weeks, and was excited by the cutting of his teeth.
He was brought up by hand from the fifth month.
6385. In another case, presented on the same day,
the mother remarked that several of her children
" had cut their teeth with ekzema.''
643 1 . A little girl, aged 7, sujffered fi'om ekzema
during her first dentition, and got well. With the
second dentition the eruption has returned, and has
lasted for two months. The seat of the disease at
present is her hands.
6775. A little boy, aged 4, has ekzema pretty
extensively dispersed over the whole body ; it began
when he was eighteen months old, and is attributable
to dentition.
6160. A delicate boy, aged between 6 and 7,
had rubeola in the autumn ; during the winter he
sufi*ered from chilblains ; and at present (January
24th) he has a catarrhal discharge from the nose,
and his skin is sprinkled over with ekzema papu-
losum in separate papules and in blotches. Herein
we have presented to us a series of causes of nerve-
COEBELATIONS OP EKZEMA. 319
exhaustion which favour the development of a disease
of debility, namely ekzema.
6658. A lad, aged 8, has a patch of ekzema on
the chin, which has existed for ten days ; he is just
recovering from a slight attack of measles which he
had a month ago.
7606. A little girl, aged 15, has had ekzema pus-
tulosum et ichorosum of the head for twelve years ;
the ekzematous disease followed rubeola.
7789. A little girl, aged 9, has ekzema capitis,
ekzema of the borders of the eyelids, and of the
meatuses of the ears ; the latter has caused partial
deafiiess. The ekzema followed upon the debihty
caused by an attack of measles.
Ekzema with Varicose Veins, including H^mobehoids.
6156. A lady, aged 58, has a small patch of
ekzema squamosum, situated upon the curve of a
dilated vein of the leg ; the eruption has existed for
six months, and is troublesome, chiefly in the
evening.
6786. An unmarried lady, over 60 years of age,
has ekzema squamosum of the right leg, attended
with some degree of oedema ; its predisposing cause
is, obviously, varicose disease of the saphenous veins.
6787. A gentleman, aged 44, has ekzema squa-
mosum of the popliteal space ; it has existed for two
years, and is due to varicose disease of the saphenous
veins.
6899. A lady, aged 53, has ekzema erythematosum
of one leg, attended with considerable pruritus.
The eruption is evidently due to a varicose state of
the veins ; it has been eighteen months in existence,
and is only sUght, but has been aggravated of late
by the necessity of being much on her legs in nursing
an invalid. It commenced with a sensation of itch-
320 PATHOLOOIGAL PHENOMENA OF EEZEMA.
ing ; she was tempted to scratch the itching part ;
some papules then made their appearance with an
increase of pruritus, and subsequently an erythe-
matous redness spread to the size of the hand.
7073. A married lady, aged 56, has ekzema cruris
from varicose veins.
7185. A gentleman, aged 60, has ekzema of the
legs, which has existed for thirty years, and was
preceded by varicose veins for ten years. The erup-
tion covers the whole of the legs below the knee,
and the greater part of both thighs, while there are
patches on the back of the hands, but the rest of his
body is free. He states that the varicose disease of
the veins of the legs was a sequela of typhus fever,
which " settled in his legs."
6363. A lady, aged 50, has been teased for twelve
months with ekzema ani ; the itching is sometimes
intolerable ; she also suffers from haemorrhoids with
occasional haemorrhage. The ekzematous tendency
of her constitution is at the same time manifested
by the presence of ekzema squamosum and ekzema
fissum of the hands and fingers.
Reguekent Ekzema.
6244. A gentleman, aged 37, has ekzema in the
groove behind the ears ; nine years previously he had
ekzema capitis.
6382. A gentleman, aged 44, is suffering from an
attack of ekzema perinei, which has just made its
appearance ; seven years back he was for a long time
teased with ekzema of the popliteal spaces.
6386. A lady, aged 55, has a somewhat severe
ekzema capitis, ichorous and squamous : it has lasted
a year ; and has recurred from time to time for a
period of fourteen years.
6414. A gentleman, aged 40, has had ekzema of
GOBBELATIONS OF EEZEMA. 32 1
the perineum extending around the anus, for ten
weeks. Seven years back he suffered from general
ekzema.
6429. A gentleman, aged 36, is suiBTering from
ekzema capitis, which came on in the winter time,
and has lasted for three months. Five years back
he had an attack of general ekzema, which continued
for fifteen months, and since that time the ekzema
capitis has returned annually.
6659. A maiden lady, aged 54, has ekzema papu-
losum et ichorosum of the back of one hand ; the
eruption has lasted four months. When 26 years
of age she had an attack of general ekzema, conse-
quent on nursing a sick relative. Her sister, aged
56, has had gutta rosea papulosa around the mouth
for nine years.
6653. A gentleman, aged 46, has ekzema of the
scrotum, penis, and perineum ; the eruption has been
a month in existence. He has also a patch of ekzema
squamosum on the arm, which has occupied its
present position for five years.
6551. A married lady, aged 37, has sufiered from
ekzema squamosum of the face and cheeks for five
years ; three months later the ekzema attacked the
perineum and anus. At the age of 20 she had a
previous attack of ekzema. Although married ten
years, she has had no family,
7043 a. A lady, aged 54, has a small patch of
ekzema on the side of the nose ; last year she had
ekzema inguinum, and fifteen years back pityriasis
capitis, otherwise she has enjoyed good health. At
present she is suffering with headache and noises in
the head, which have lasted a year ; indeed, since the
cessation of menstruation, which only took place a
year ago.
7076. A married lady, aged 63, is suffering from
ekzema pudendi et ing^num. The present attack
Y
322 PATHOLOOIOAL PHENOMENA OF EKZEMA.
has lasted one week, having been induced by the
heat of the weather (July). Seven years bact she
had a similar outbreak, at the same season of the
year.
7226. A gentleman, aged 51, has ekzema capitis
and ekzema manuum, of six weeks' duration. The
present eruption broke out in July, and he had a
similar attack a year ago.
7268. A gentleman, aged 60, has ekzema of the
hands, and of the hands only. The first attack took
Elace thirty-five years ago, the present three months
ack, and he has had one intermediate attack. In
the first he lost his nails, in the second and present
attack the nails are rough and uneven firom defective
nutrition. Eighteen months ago he suffered much
affliction from the loss of his wife, and latterly he
has been dyspeptic.
7358. A lady, aged 67, has ekzema axillare : it
has now been in existence for a few weeks. Four
years ago she had a similar attack, which lasted for
two months; and again one year back, when it
remained for three months.
7403. A gentleman, aged 70, has ekzema papu-
losum of the legs, which has lasted for seven weeks ;
several years back he had a similar attack.
7577. A gentleman, aged 23, has ekzema capitis,
which has lasted for three months : a year back he
had a similar attack.
7512. An unmarried lady, aged 31, has a patch
of ekzema, about an inch in diameter, on the point
of the chin : it has recurred from time to time for
two years.
7598. A gentleman, aged 35, has ekzema capitis,
which has existed four months. He was first at-
tacked with ekzema sixteen years ago, when it affected
his ears ; and two years back his head, in a similar
manner to the present.
SUBSTITUTIVE BKZBMA. 323
7593. A married lady, aged 58, has a circum-
scribed patch of ekzema squamosum on the knee :
it has lasted two years. Some time previously she
suffered from intercrural ekzema.
7647. A gentleman, aged 52, has ekzema papu-
losum of the trunk of the body, which has been in
existence for four months. He has been subject to
a similar eruption for thirty years ; it recurs an-
nually, in the middle of the summer, and breaks out
on a sudden. At present he has, in addition, a boil
on one arm.
7792. A clergyman, aged 48, has two patches of
encrusted ekzema ichorosum on the legs : the erup-
tion has existed for six months. Fifteen years back
he suffered an attack of ekzema.
7630. A gentleman, aged 67, has ekzema papu-
losun> of the thighs with troublesome pruritus : it
has existed for three weeks ; three years back he
had a similar attack.
Substitutive Ekzema.
9047. A gentleman, aged 69, a hale, healthy man,
has ekzema of the head and face, arms and hands,
as also on the lower limbs. The eruption began on
the scalp three months back, and within the last six
weeks has spread to the already mentioned parts.
It is his first attack, and the eruption presents the
usual variety of character in the different regions
affected. It began on the scalp as a mere scurfi-
ness, as an accumulation of fine scales, in dermato-
logical language, a pityriasis; at present it is a
psoriasis or ekzema squamosum. The ears are red
and swollen, and somewhat roughened by desqua-
mation, ekzema erythematosum ; behind they are
squamous and ichorous ; the eyelids, face, and neck
present the erythematous form of the affection, as
also do the arms, hands, and legs. The pruritus
Y 2
324 PATHOLOGICAL PHENOMENA OP EKZEHA.
on the face and neck is troublesome, but most so
behind the ears, where exudation is taking place.
This gentleman enjoys excellent health, with the
exception of occasional temporary disorder of the
digestive organs, which takes on the character of
slight diarrhoea. He was a little exhausted by the
hot summer of 1868 ; he then suffered some anxiety
on account of the illness of his wife; for his wife's
health he exchanged the bracing climate of Thanet,
his ordinary residence, for the relaxing climate of
Hastings, and it was while he was at Hastings that
the first external manifestation of exhausted nerve-
force took place, showing itself in the form of
ekzema erythematosum capitis. On his return home
he had one of his usual bilious attacks, and as this
subsided the eruption became general over his body.
As is commonly the case, under the influence of a
substitutive disorder, when the latter creates no con-
stitutional irritation, he is feeling remarkably well,
his digestive organs are performing their functions
properly, his tongue is clean, and he is, in fact,
better than usual.
5476. A married lady, aged 56, suffered from
disorder of digestion, her " bilious attacks " recur-
ring pretty regularly every three or four weeks. For
three months she missed her gastric disorder, and
was then seized with ekzema, which app>eared in
patches on various parts of her body and limbs.
Five years later she was exposed to considerable
anxiety, loss of rest, and fatigue, in consequence of
the illness of a daughter whom she nursed. On this
occasion the ekzema returned, attacking the puden-
dum and axillaB, and lasted for eight months. The
eruption was accompanied with abscesses in the
axillae and boils on the lower part of the trunk and
thighs. The boils were small ; they began as itch-
ing pimples, and were fourteen days before they
reached their full size ; they then threw up a
ETIOLOGY OF EKZEMA. 325
phlyktaenous vesicle, and afterwards slowly sub-
sided.
Two months after getting well of the ekzema,
this lady had a smart attack of neuralgia of the nape
of the neck and back of the trunk. She compared
the pain in her back to the sensation of opening and
shutting of the spine.
5355. A gentleman, aged 55, the very picture of
health, has ekzema capitis, which has continued for
one month. For twelve years in succession he was
a sufferer from gout, the attacks being frequent but
slight. The gout then left him for nine years, and
during the last three years ekzema has taken the
place of gout. Ekzema and gout are not unfre-
quently interchangeable.
7094. A married lady, aged 36, has ekzema papu-
losum.of the chest and abdomen : the eruption has
existed for a fortnight, and followed exertion (July)
under which she became overheated. She had been
disordered in health for some weeks previously to
the attack of ekzema ; in the first place, she had a
sore and bUstered tongue ; subsequently, an attack
of haemorrhoids : both these disorders are now well.
7289. An unmarried lady, aged 32, has ekzema
palmare et digitorum, which has existed for two
years; during the same period she has also been
troubled with furunculosis. In the preceding winter
she suffered from bronchitis, and at that time the
ekzema was relieved.
V.
Etiology of Ekzema.
Our friend Professor Laycock, writing to us under
date December 18th, 1867, makes the following
observation in reference to the " contagious furuncu-
326 ETIOLOGY OF EEZEMA.
loid" :♦ — " Although the cause, whatever it be, is
asthenic or cachectic in its influence, it is often only
so locallj. That is to say, a man or woman may
have boUs or ekthyma, and yet be in good health
generally.'' Herem is a suggestion for a theme of
much importance, and one which we had already in-
tended to illustrate at some future period. It no doubt
represents the opinion of a considerable number of
medical men, and possibly of more in foreign coun-
tries than at home. We do not take upon ourselves
to express a judgment on the matter until we have
investigated it by the aid of numerous cases,
but we may state in Ivmne that we have always
entertained a diametrically opposite view of the
question ; and that our belief is that, almost without
exception, a constitutional cause is the mainspring of
every local affection.^ We would not for a moment
wish to detract from the special jurisdiction of the
tissues, but we believe that they are incompetent to
evil in the absence of a failure of power in the con-
stitutional government.
The detection of a causa morbi by medical
examination of the appearance of the skin, the
functions of the body, and the history of the
patient, often undoubtedly presents considerable
difficulties. The patient declares himself to be
well ; the physician can detect nothing wrong.
But are we therefore to conclude that there is
really nothing wrong ? We think not ; it may be
that all that is wrong is, so to speak, occupied with
the local affection, and, therefore, does not manifest
itself in the central organs of the body, or in the
functions. Or, it may be, that the oidy apparent
sign of deranged health is a defect of cheerfulness
* JouBNAL OF CuTAVBOUS MsDioiNB, ToL i page 411.
t We must not be supposed to refer to local affections produced
hj external causes; but to local affections originating without
apparent external cause.
ETIOLOGY OF BKZBMA. 327
or activity, conditions of which the physician has
no means of judging correctly ; or it may be some
tint of the complexion, some defect of brightness or
colour of the eye, or of freshness of the features or
lips. But we have promised to abstain from specu-
lation in the abstract, and we will only say that with
the conviction of a general disorder, a general
principle of treatment is usually so successful in
our hands that we could not conscientiously abstain
from the practice.
Within a few minutes of the receipt of Dr.
Laycock's letter, a patient presented himself, who
gave the following account of his health : — ^He was
aged 31, a Sussex farmer; he had ekzema with
swelling of the lips, chiefly the upper; redness,
with some degree of swelling of the mucous lining
of the mouth and gums ; ekzema, with slight thick-
ening of the eyelids ; and sUght ekzema of the peri-
neum. The eruption had been in existence for
three months, sometimes was watery, and some-
times itchy. For three years previously he had
been teased with boils, which appeared usually in
the spring season of the year ; but he had had no
boils since the eruption had made its appearance.
He had had no previous illness since he suffered
from scarlatina m childhood. As regards his
present health, he reports himself as thoroughly
well, without pain or ache; his appetite good,
digestion easy, bowels regular ; no derangement of
function of the kidneys; good rest at night, no
lassitude or deficiency of activity, spirits good.
Here, then, is an example such as Dr. Lavcock
refers to local disease without constitutional dis-
order, with what would pass as a thoroughly good
state of health.
Let us apply the test of special medical tact : he
is paler than comports with our idea of the standard
of health, particulaily the conjunctivsa ; he is some-
what sallow ; his tongue is a trifle too red, there is
%
328 ETIOLOGY OF EKZEMA.
a brownish slime near its root ; and he confesses
to a bitter taste in the mouth occasionally, on
waking. In a word, there is evidence of imper-
fection of digestion, and this we accept as our
indication for treatment. Probably if it were not
for the derivative operation of the ekzema, the
dyspepsia would have been even more decided.
We look upon it that in this case there was a causa
morbi, originating probably in deficient power of
the digestive function ; that the furunculi were the
first expression of the existing debility ; the ekzema
its subsequent manifestation. Therapeutically we
conclude that a moderate increase of function of the
alimentary canal, producing waste, may give rise to
a greater demand for supply, and consequently in-
crease the energy of action of the nutritive functions ;
and we hope and do not doubt to secure this result
by a compound rhubarb pill at bedtime every night,
with ten minims of dilute nitro-hydrochloric acid
combined with a drachm and a half of compound
tincture of gentian twice in the day. Locally we
prescribed the benzoated ointment of oxide of zinc.
Our next patient, also aged 31, was in appearance
the very ideal of robust health ; ruddy and hearty ;
not too bulky ; and temperate in his habits. His
malady is a dry and scaly ekzema of the scalp ;
ichorous ekzema behind the ears, and a few circum-
scribed blotches of papular ekzema on his arms.
In him the eruption is diathetic and hereditary ;
his mother suffered from ekzema behind the ears,
and as a boy he had ekzema furfuraceum of the
scalp, otherwise pityriasis. During the past sum-
mer he was annoyed for six weeks with boils in one
axilla, and down the inside of the arm.
The eruption in this patient is a degree more
severe than that of the former ; the symptoms of
disorder of the general health were also a degree
more intense ; nevertheless, he would pass with
many as being, with the exception of the eruption.
ETIOLOGY OV EKZEMA. 329
in excellent health. He has suffered from slight
dyspepsia for three years ; considers himself bilious ;
is occasionally fickle in appetite ; sometimes a little
depressed in spirits ; and in the evening, when he
occupies a warm room, or a warm bed, there is
some itching of his skin. Nevertheless, his tongue
is clean, bowels regular, and other functions regu-
larly and well performed. How different might
have been the report were it not for the derivative
operation of the ekzema! Our treatment in this
was the same as in the preceding case, with the
addition of a pomade for the head, consisting of one
part of the nitric oxide of mercury ointment to three
of benzoated lard.
We may note in connection with these cases that
the association of furunculus and ekzema, and we
may add dyspepsia, is among the commonest of
dermatopathic phenomena ; and, in no less degree,
the derivative relationship that seems to subsist be-
tween the three affections.
Succession of Disease.
Our Clinicle Circle was visited in March, 1868
(12th), hj a citizen of London, a clothier, aged 44,
having his house of business in the City, and his
country house at Stamford Hill. His special com-
plaint was a diffused annulus of ekzema squamosum
seated on the side of the neck, which he thought
might have been " caught" from two of his boys
who had had ringworm ; and the more so as a ring
had existed on the arm of his wife. There pre-
vailed in his mind the usual unreasoning confusion
of cause and effect, of idiopathic and contagious,
which we commonly meet with in the world in asso-
ciation with these events.
On examination, we found ekzema squamosum
of the scalp of three months' duration ; and on
expressing some surprise that he had not applied for
330 £TIOLOQT OF EEZEKA.
treatment for the greater evil in preference to the
lesser, we were met by the remark that he had
" never felt better in his life than since the breaking
out of the ekzema on his head/' and that it was
the apprehension of ringworm alone which had in-
duced him to seek our assistance.
His medical history, which is that of a great
number of similar patients, was as fullows : — ^To-
wards the latter end of !N'oy ember he had suffered
from a large boil on the nape of the neck ; the boil
was poulticed, and the depressing action of the
poultice on the skin had set up an ekzema, which
soon spread to his head and had now assumed a
chronic character.
It needed some reasoning to prove to him that
close appUcation to business in an unwholesome
atmosphere had lowered his vital power.
He attributed to increasing age that which was
the simple consequence of these causes; he had
been less vigorous than formerly ; listless and some-
what irritable ; and upon these symptoms, so im-
portant to the medical observer, although frequently,
as in this case, overlooked by the patient, the boil
had succeeded. The catisa morbi was developed
primarily in the shape of a boil; the boil was
followed by ekzema ; and then the patient became
aware that his inward feelings of health were
improved.
This was just one of those cases in which an
unobservant practitioner might have been led to
believe that the constitutional health was perfect,
and that the affection was simply local. But
the evidence was before him that the ekzema
had exerted a derivative action on the general
economy ; and that now it became his business to
charm away the ekzema, without bringing down a
contrecoup on the general health. His appliances
must be derivative, tonic, and if necessary neuro-
tonic.
ETIOLOGY OF EKZBMA. 331
Cutaneous Sympathies.
6570. A delicate lad, aged 11, has ekzema of the
edges of the eyelids, psorophthalmia, attended with a
constant exudation of ichorous and puriform matter.
This has lasted for four months, and has occasioned
the loss of the eyelashes. A year back he had an ulcer
of the leg ; the ulcer was followed by a septic abscess
in the thigh of the same leg, and later on by impetigo
phlyktadnodes around the mouth.
Propagated Ibbitation.
A married woman, aged 32, has an ekthymatous
eruption on the back of the neck and on the fingers
of the right hand, and a phlegmon of the first joint
of the forefinger. She has been married eleven years
and has two children ; the youngest nearly four
years old. She has always been healthy ; but was
very much exhausted by her confinements, taking a
year to recover her strength in each instance. More-
over, she has worked hard, has had her share of
anxieties, and has lived somewhat too abstemiously ;
but has never before suffered from a cutaneous com-
plaint of any kind.
A month back, a heavy piece of meat fell on her
right hand, the bone tore the skin just over the me-
tacarpo-phalangeal joint of the index finger. She
applied the universal cure of the ignorant, tincture
of arnica. As a result of the operation of the two-
fold irritant, the wound and the arnica together, the
part became inflamed, remained painful and swollen
for a long time, and has only recently healed, leaving
a red and somewhat infiltrated cicatrix.
About a week after the occurrence of the wound,
some half-dozen ekthymatous papules, subsequently
maturating into pustules, made their appearance
around the nape of her neck ; one of the ekthymata,
332 ETIOLOGY OP EEZEHA. .
of larger dimensions than the rest, assuming an
anthrakoid character. And more recently, and
within the last few days, a deep-seated phlegmon
has taken possession of the soft parts upon the radial
side of the first phalanx of the index finger at a short
distance from the original wound, and has produced
swelling and tension of that finger, of the neighbour-
ing part of the hand, and, in a less degree, of the
rest of the fingers. On the dorsum of the first
phalanx of the three remaining fingers, there is an
angry ekthymatous pustule upon each, and on the
palmar side of the same phalanx of the ring finger a
bulla filled with serous fluid as big as the hemisphere
of a large pea. There are besides, an ekthymatous
pustule on the right upper arm, another on the lefb
upper arm, and a few red papulas on the upper part
of the chest, more particularly at the right side.
Now, the interest attaching to this case centres
in the relations subsisting between the wound of the
hand and the subsequent development of an ekthy-
matous and anthrakoid eruption, together with a
deep-seated phlegmon. It may be asked — First, why
did not the trifling wound heal at once ? Secondly,
what proof have we of the dependence of the erup-
tion and phlegmon upon the original wound ? and.
Thirdly, admitting this dependence, how is it to be
explained ? The case is a trivial one, but the issues
are important, and all the more important because
the case is a homely one, and therefore one that is
common and of frequent occurrence. And the issue
is important because the reasoning applicable to the
explanation of this simple case is applicable also to the
most complex and most severe that can be brought
before us ; and we are consequently led by a paral-
leUsm of reasoning from the most simple upwards to
the most difficult and obscure.
Let us endeavour to answer these questions in
succession. The original wound did not heal kindly
and at once, for two reasons ; in the first place, in
ETIOLOGY OF EKZEMA. 333
consequence of exhaustion of constitutional nerve-
power from insuflBcient diet, prolonged labour, and
mental anxiety ; and, secondly, from the immediate
and injudicious application of a recognized irritant of
the skin, namely, tincture of arnica. It might be
supposed that we should accuse the bone or the meat
of poisonous qualities, and suspect the presence of
some septic principle ; but we see no reason for such a
line of argument. We believe the local irritation alone
to have been perfectly equal to the causation of the irri-
tability and of the sluggish reparation of the wound.
Secondly, we infer that the remote cutaneous
affection, namely, the ekthyma, the anthrakoid ma-
nifestation, and the bulla, as also the deep-seated
phlegmon, were the secondary effects of the original
wound, because such consequences have been fre-
quently observed ; because they occupied the same
side of the body as the traumatic lesion ; and because,
in the instance of the hand, they may be said to have
been in almost direct communication with it. Not
that this latter fact is of much value, because we
know the nerves to possess the power of the electric
wire of bridging over space, and bringing the most
distant regions into communication. In this way
we explain the production of the ekthymata upon the
back of the neck, and also the occurrence of one pus-
tule on the upper arm of the opposite side of the body.
As to the third proposition, namely, the explana-
tion of the dependence of the secondary phenomena
upon the primary injury, we are not prepared to
adopt a popular idea that the wound may have been
poisoned — poisoned by the meat or poisoned by the
bone ; in fact, inoculated with a septic poison ; and
that the poison was conveyed by the blood into the
system. But, on the contrary, we would suggest an
explanation which we fully believe, and one which
is founded on the recent researches of Andrew Clark,
of Burdon Sanderson, and Wilson Fox, namely, the
propagation of an abnormal cell-nutrition from the
334 ETIOLOGY OF EKZEMA.
wounded part to the seat of the secondary pheno-
mena. In the experiments of these observers the
nosogenetic process was propagated from the seat of
injury to the central organs of the body. In the
instance before us the secondary processes on the
wounded hand were effected in a similar manner ;
and we think it not improbable that the local nervous
system may also have taken part in the propagation,
in the instance of the eruption developed on the
back of the neck. The idea of a morbidly active ceU-
nutrition in no way, in my opinion, invalidates the
supposition that the nerves may also be the means of
diffusion of the morbid process by the propagation of
a sympathetic impulse. It may, in fact, be a reflex
operation, developing in a distant organ a function
identical with that existing in the part from which
the nerve influence springs. . , . ,
We are aware that the question may be asked, has
not pyaamia a share in the process P And to this
question we should unhesitatingly answer in the
negative. We will not deny pyaemia, by which we
mean the transport of pus elements from the morbid
to the distant part, entirely; but we believe that
many phenomena are ascribed to pyaemia and to
septic influence, which are in reality nothing more
than the propagation of an irritation, to use an old
form of expression ; or, to speak more in consonance
with modem views, the propagation of an exagge
rated cell-nutrition and ceU-proliferation. Two caset>
of death, apparently from disease of the lungs, after
the simple operation for the removal of the whole or
of a part of a diseased breast, have lately come before
us, in which the secondary disorder was explained
upon the hypothesis of pyaemia ; but in both of these
instances we were led to doubt the fact, and for
many reasons are much more willing to credit th*
theory of a direct propagation of a morbid process
from the seat of injury to the neighbouring deeply-
seated organs.
ETIOLOGY OP EKZBMA. 335
On Local Ibbitation as a Cause of Cutaneous and
Glandulab Disease.
In the presence of the modem theory of cell-
pathology, the following case may prove interesting
to our readers, and probably conduce to further in-
vestigation. A delicate boy, aged 6, of weakly
nutritive power, and endowed with an unusually
sensitive skin, was bitten on the cheek by a young
dog. The bite was not severe, and drew blood at
one point only, where the canine tooth abraded the
skin. The boy was teasing the dog while the latter
was feeding ; the dog was healthy, and the bite a
mere admonition to the little tyrant to " be quiet.**
The wound was sucked by the child's father, and
afterwards touched with some caustic application,
and now remains an angry papule.
A week or ten days after the accident, six small
patches of impetigo made their appearance on the
cheek around the bite, and within the radius of an
inch. By impetigo, in this instance, is meant small
oblong patches of red and infiltrated skin, sur-
mounted by vesico-pustules, slowly spreading by
their circumference. The largest of these patches
measured half an inch long by a quarter of an inch
ia breadth ; and five weeks aft)er the bite, when we
first saw the boy, some of the patches were red and
smooth, some still bore evidence of their previous
vesico-pustulous condition, and others were coated
with the brown crust of a desiccated secretion.
Moreover, he had similar impetiginous blotches of
more recent development on the buttocks and
thighs.
Concurrently with the appearance of the impetigo,
or very shortly aft^er, the cervical lymphatic glands
at the angle of the jaw began to enlarge, and a sub-
maxillary gland became prominent beneath the chin.
Here the mischief appeared to end ; we could dis-
336 ETIOLOGY OP EEZEMA.
cover no swelling of the concatenate glands lower
in the neck, and believe that they will escape.
One word more in reference to the medical history
of our little patient. A year ago he was brought to
us suffering under ekzema of the flexures of the
elbows and hams. The eruption first appeared at
the age of sixteen months, and therefore may be
ascribed to dentition as its exciting cause. It got
well quickly under the use of Fowler's solution and
zinc-ointment, and has not shown itself since, and
he has been well up to the period of the accident
above referred to. It may be mentioned, also, that
his skin is unusually sensitive — a flea will produce
considerable irritation of the integument — ^and his
mother is prohibited from using, in his case, lini-
ments and applications that she would employ
for the other children. We therefore find illustrated,
in this little fellow, that which we should call an
ekzematoiLS diathesis^ but what our Parisian colleagues
Bazin and Hardy would possibly denominate a
herpetic diathesis.
It can hardly be questioned that in this case there
is evidence of the impetigo being a consequence of
the bite, and that the same irritating cause gave rise
to the enlargement of the lymphatic glands. The
hypertrophy of the glands has now continued for a
month, and there is reason to hope that it will sub-
side by degrees. Should such be the fact, the case
will* resolve itself into one of simple enlargement of
lymphatic glands in association with a traumatic
irritation of the skin, a not unfrequent combination.
But let us suppose that the glands, instead of
diminishing in size, should increase, and that others
should take up a similar morbid action, the case will
then become one of scrofula ; and the predisposing
elements of scrofula are not far distant : the boy is
slightly anaBmic, his nervous system is susceptible —
even irritable — and his nutritive powers are weak.
Should such a consummation occur, — and there are
ETIOLOGY OP EKZBMA, 337
many more unKkely, we should have before us a
case of scrofula induced by the bite of a dog.
Can we doubt that, if the opportunity were given
us of dissecting the tissues involved in the morbid
process in this case, we should meet with the granu-
lations, the bands, the retrograde regeneration of
tissues, so clearly described in the late investigations
into the phenomena of the inoculation of foreign
matter by the skin or the insertion of foreign sub-
stances beneath the integument. And the question
arises, may not the irritation caused by the bite of
the dog in this instance, instead of being arrested in
the lymphatic glands, run on in the course of the
lymphatic vessels, and so reach the bronchial glands
and the lungs ? — ^in a word, set up the process of
altered nutritive function that constitutes tubercle
and issues in consumption P
These are reflections that force themselves into
our thoughts in the consideration of this kind of
affection, that, although local in its origin, has a
tendency to spread and to diffuse morbid action in
every direction, and they suggest the suspicion that
the distinctions between scrofulosis and tuberculosis
are not so strongly defined as we are taught to
believe, and that a scrofula may, in certain cases, be
in reality a localized and aborted tuberculosis.
Traumatic Eezema. — A gentleman, aged 22, a fine
robust man, a rifle volunteer, was engaged at the
shooting match at Wimbledon, on Thursday, July
2nd, 1863. His gun, which was a ** kicker," recoiled
with some violence after each discharge, and the
result was a bruise of the integument and soft parts
in front of the right shoulder, and of the lower part
of the forearm on the same side. His captain pre-
scribed for him the use of tincture of arnica, and in
the evening he rubbed the bruised skin vigorously
with this tincture. The remedy, and its somewhat
rough application, caused erythema of the skin, fol-
lowed five days after by an acute attack of ekzema,
z
338 £TIOLOaT OF EKZEMA.
ekzema vesiculosum et ichorosum. On the seventh
day from the application of the arnica and the
second from the invasion of the ekzema, he com-
menced treating the eruption with water- dressing.
On the ninth day of the eruption he presented him-
self before us ; the whole of the front of the shoulder
was of a deep red colour, and a streak down the side
showed the direction of a stream of th'e tincture
that had flowed beyond the limit intended for its
use. The tint of redness was dull, the skin looked
sodden, and the softened cuticle gave a greyish
colour to the surface. The limit of the ekzema was
abrupt, but beyond this, and extending over the
whole of the right side of the chest, was a mode-
rately abundant crop of pimples of ekzema papu-
losum seu leichenodes, the pimples being large and
of a dull red colour, and more numerous near the
ekzema than at a distance from the focus of the
disease. The same description applied to the erup-
tion on the forearm. His chief complaint was as to
the abundance of the discharge, and to the bad odour
which it emitted ; and he further complained that
the eruption was breaking out over all parts of his
skin ; that he had a patch on the scrotum ; a papular
eruption on both thighs ; even on the head and face
and hands pimples had appeared. The new eruption,
he said, was preceded by itching, and that wherever
he scratched an eruption seemed to follow.
There was no disturbance of his general health ;
the weather had been extremely hot on the day of
shooting, but he had not suffered from it ; and as
far as health was concerned, he felt no inconvenience
at the time of consulting us. And, indeed, with the
exception of a little whiteness of the tongue, and
muddiness of the complexion, we could discover no
signs of sympathetic disorder in the economy.
This case is interesting, and unusually free from
complication. The subject, a young man in robust
health ; the primary injury, a bruise of the soft partSj
ETIOLOGY OP EKZEMA. 339
of a very simple and obvious kind ; the result of
this injury, as a matter of course, a lowered tone and
vitality of the tissues. Next we have an irritant,
the tincture of arnica, used irritatingly to the in-
jured part ; and then the revulsion, a well-developed
eruption of ekzema vesiculosum et ichorosum ; on
the less injured circumference, its papular variety,
ekzema papulosum.
But a still more interesting series of pathological
actions begins from this point ; the irritation excited
in the injured part is propagated by the injured
nerves to other cutaneous nerves at a distance ; the
mechanism of reflex nervous function is set in
motion ; and papular and vesicular eruption, with
pruritus, are developed on parts of the body at a
considerable distance from the original focus of
irritation.
Our patient, who was clearly deeply imbued vrith
humoural pathology, remarked, "The arnica has
evidently poisoned the blood, and the poisoned blood
is producing breakings-out over the whole skin."
We made no remark, for we remembered that the time
had been, and that not so very far distant, when we
should have reasoned in the same manner ourselves ;
the hot weather, the heated blood, then disturbed
nutrition, mal-assimilation, and elimination of the
mal-assimilated products.
The irritant effects of tincture of arnica have been
noticed by Professor Galassi, of Rome, who reports
in the Qiornale Medico di Roma, three cases out of
many of a similar kind observed by himself, and five
cases communicated by Dr. Mozzoni. The principal
symptoms of the eruption are, slightly elevated red
puncta, which are quickly converted into very minute,
middle-sized vesicles, similar to those produced by
croton-oil, swelling and burning heat, and the spread-
ing to surrounding parts. We should have no hesi-
tation in calling this eruption an ekzema ; but it is
termed by Galassi, erysipelas vesiculare.
z2
340 ETIOLOaY OF EEZEMA.
Ekzema TEAUMATICUM.
A tradesman, aged 66^ residing in the country and
enjoying good average health, bruised the outer
ankle of his right leg sixteen years back. The bruise
got well with the use of a poultice, but as some ekze-
matous irritation appeared in the circumference of
the bruise, he appMed a water-dressing. . By degrees
the irritation spread onwards, and ascended the leg
to above its middle; and has continued, with in-
tervals of cure of a few months' duration, from that
time imtil this. He has no ekzema on any other
part of his body, and none on the opposite leg. His
only other complaint is haemorrhoids, which, he says,
alternate with his ekzema. For the last few weeks
he has been treating the ekzematous leg with water-
dressing, and with the usual mischievous result. It
is intensely red and tumid; the cuticle thin and
shining, abraded here and there; there is watery
exudation at a few points ; the central part of the
inflamed skin is somewhat indurated; below, it is
dry and squamous ; above, at its upper border, is a
raised and papular margin, and above this margin a
few scattered papulae, highly irritable ; and some with
summits torn off by the nails.
Ekzematous Asthma.
The association of bronchial ekzema with cutaneous
ekzema, as in the instance of ekzema infantile, is one
of the commonest phenomena of that disease ; the
causa Tnorbi is one and the same for both, the patho-
logical manifestations only differ in the differences
which naturally appertain to the mucous membrane
in comparison with the skin ; and just as in the ordi-
nary process of cure of ekzema, one part of the sur-
face recovers its normal state sooner than another,
or, having recovered, is liable to relapse, so in its
BTIOLOOy OF BKZBMA. 34 1
relation to the mucous membrane, the morbid state
of the latter may alternate with the former; the
affection of the mucous membrane may for the time
being become the most serious feature of the disease ;
or, the skin being well, the ekzematous irritation of
the bronchial membrane may still be kept up and
give rise to that impediment of respiration which is
termed asthma. This is no case of transference from
the exterior to the interior ; no case of " driving in,*'
although the interior may be at its worst whfle the
exterior is better ; but a simple pathogenetic action
of one or more parts of that surface which is nor-
mally exposed to the action of the atmosphere,
whether internal or external. And the unity of the
disease is further shown by the yielding of the
symptoms in both instances to the same principle of
treatment.
Every one who is at all conversant with the mode
of manifestation of cutaneous disease must have seen
this combination of endermic with exodermic ekzema
over and over again, while every consideration of
structure and physiology predicates the possibility of
such an occurrence. In a paper on ekzema infantile,
read before the British Medical Association, in July,
1856, we remarked, "Not unfrequently in ekzema
infantile, the mucous membrane of the mouth and
nose, of the air-tubes and lungs, and of the alimen-
tary canal, participates in the disease, and is either
affected simultaneously with the skin or takes a
vicarious part. The affection of the alimentary canal
gives rise to diarrhoea and the production of mucus
in large quantities and sometimes of coagulated
lymph. The affection of the mucous membrane of
the mouth and i^ose is shown by redness, sometimes
aphthaa and augmented secretion ; and the ekzema-
tous congestion of the mucous membrane of the air-
tubes produces bronchitis in various degrees, accom-
panied with hoarseness, from thickening of the
mucous lining of the larynx, and an excessive accu-
342 ETIOLOGY OP EKZBMA.
mulation of phlegm throughout the lungs. This
latter symptom is one which is calculated to give us
some anxiety, and requires dexterous management ;
but it is less severe than common bronchitis, and is
often as sudden in getting well, as in its attack.
When the mucous membrane of the mouth and air-
passages is affected, hoarseness is a conspicuous and
striking feature of the complaint ; the hoarse cry is
unmistakable, and is sometimes the first and oply
sign of the congestion of the mucous membrane. It
is a sign as diagnostic of congestion of the respiratory
mucous membrane, as is whiteness of the eye of
general anaemia."
Ekzema we believe to be always curable ; but when
neglected it is apt to grow into a chronic and some-
times an inveterate state. It is a disease that should
always be cured as quickly as practicable, for its con-
tinuance merges by degrees into a habit, and lays
the foundation of a diathesis ; the dread of curing
ekzema is one of the follies of a past age, and cannot
be too strongly reprehended ; and the fiddle-faddle
of the pill-box literature that warns us against its
cure, is simply contemptible. But when ekzema does
become chronic, it produces two remarkable changes
in the economy, namely, a chronic thickening of the
mucous membrane of the air-tubes, manifested by
obstructed respiration or asthma, and a chronic in-
duration, dryness, and roughness of the skin, amount-
ing in some instances to xeroderma. Sometimes
both these states are present at the same time, some-
times one only ; but it is rare that one or other exists
without a corresponding affection of the other, either
permanently or separately. Under these circum-
stances, the terms ekzematous asthma and ekzema-
tous xeroderma are strictly applicable and practically
expressive. Ekzematous asthma has two periods,—
that of the active stage of the disease, and that of
the chronic stage of the disease ; and these stages
must be borne in mind in treating it pathologically
and therapeutically.
ETIOLOGY OP EKZBMA. 343
Ekzema with Fueunoulosis.
Dermopathists wiU doubtless agree with us that
there exists no more frequent complication of ekzema
than furunculus. We will, nevertheless, throw a few
observations together, in order to illustrate the fact,
and probably serve as a text for future consideration.
A medical man in Devonshire writes to us as follows :
— '* I am forty-nine years of age, always temperate,
my usual stimulant not exceeding two glasses of
sherry a day, and I work hard. About a month
since I had a boil over my right eyebrow, and within
a few days ekzema appeared in my left groin, and
thence extended to the scrotum and penis ; the itch-
ing and smarting are most distressing. I have since
had another boil on the scrotum, and one is now
coming on the right clavicle." Our friend proves
himself to be no disciple of ours, although ready to
call for help when in need, for he says : " I took a
five-grain calomel pill, mistura sennas, and salines
for about a week ; I then began liquor arsenicalis,
five minims, three times a day, and continued it
until my stomach rebelled and my tongue became
coated and disagreeable, &c. I have taken no spirit,
wine, beer, or coffee." To all of which our reply
was, — " Ekzema is a disease of debility, and so also
is furunculus. Live well ; take beer or wine, as
you prefer, and five grains of citrate of iron and
quinine twice a day." While we were penning the
above case, a mother took a seat before us with a child
on her lap, suffering from ekzema figuratum of the
cheeks and dispersed over the trunk. The child was
six months old ; at three months she was vaccinated,
and the vaccination took well ; the child then had a
cold, and camphorated oil was rubbed into its chest ;
the friction and oil proved an irritant, and ekzema
became developed. She had likewise several small
boils on various parts of the body, generally one at
344 ETIOLOGY .OF EKZBHA.
a time. The mother had been subject to boils oc-
cmring chiefly in the axilla ; she had one when the
infant was four months old, and has had one or two
since.
Illustrations of Causation.
7550. A gentleman, aged 64, has ekzema of the
pudendum and thighs, which has lasted for four
months ; it was excited by a chill after getting hot
with exercise in the month of August.
7597. A married lady, aged 40, has had ekzema
squamosum for six years ; it was attributed by her
medical adviser to drinking unwholesome water.
7601. A lady, aged 45, has ekzema squamosum
between the fingers ; the disease has lasted three
months, and arose from the heat and fatigue con-
sequent on a hunt after a lost dog.
7619. A gentleman, aged 35, has ekzema of one
leg, which has lasted for nine months. Seven years
ago he had a compound comminuted fracture of the
tibia, and the leg has been weak ever since.
Shortly before the appearance of the ekzema the
leg was chilled, erythema with swelling resulted
from the chill, then an elastic stocking was had
recourse to, which heated the leg and produced
first a scurfy condition of the cuticle and then
ekzema.
A gentleman, aged 30, of somewhat sensitive
temperament, has an attack of ekzema erythe-
matosum of the front of the chest whenever he
eats ricp. A friend of his sufibrs in a similar
manner. Urticaria after eating rice is not un-
common, but we have never before met with an
instance in which ekzema was produced by that
means.
7357. A gentleman, aged 27, has a patch of
KTIOLOGY OP EKZEMA. 345
ekzema squamosum on the ball of the thumb, which
followed a blow with a cricket-ball five years ago.
The present eruption has lasted three months (Sep-
tember), and it has recurred in the hot weather
ever since the accident.
7314. A captain in the army, aged 38, has
ekzema of the legs and back of the hands, which
has existed one month, and was brought out by a
course of hydropathic treatment.
7277. A married lady, aged 64, has ekzema of
the leg, extending from the knee to the ankle : it
has existed for six weeks, and was occasioned by a
bruise. Nine years back she had ekzema of the
forehead ; and three months since ekzema of the
great toe. She complains of lassitude and weari-
ness, and her tongue is soft and pale.
7096. A gentleman, aged 67, has ekzema of the
right leg below the knee : the eruption has existed
for two years. Seven years ago he ruptured some
of the muscles of this limb, and the leg has re-
mained weak and swollen ever since. The injury
to the limb we regard as the predisposing cause of
the ekzema.
7830. A maiden lady, aged 48, has ekzema squa-
mosum nuchaB, a patch of moderate extent, which
has existed for four years. She has had similar
attacks previously. She attributes the eruption to
affliction and mental anxiety, aud also sufiers from
headaches.
7167. A gentleman, aged 51, has ekzema of the
hands, chin, and in the groove of the nates, from
which he has suffered for four years. He is a man
of nervous temperament, an engineer by profession,
and has been much overworked.
7155. A merchant, aged 33, has ekzema digitorum,
which has existed for two years : at present he has
ekzema behind the ears, and in small circumscribed
346 ETIOLOGY OF EKZEMA.
spots dispersed over various parts of the body. His
feet swell in winter. This state of disorder of his
health would seem to be attributable to change from
an outdoor life, with anxious occupation. He states
that he is never free from mental pressure.
7257. A clergyman, aged 54, has ekzema of the
hands. The disease has existed for eleven years,
but was latKsly very much aggravated by fright and
a severe run, on an occasion when he was attacked
by highwaymen. He has worked laboriously both
mentally and physically for thirty years, having had
under his charge an important congregation.
7175. A gentleman, aged 21, has ekzema perinei
and three annulate patches on the right thigh.
The eruption has existed for one week, and suc-
ceeded an extremely heated state of the body,
followed by a chill. He was playing cricket on a
Thursday in July, and the ekzema made its appear-
ance on the Saturday.
7235. An elderly lady, aged 72, has ekzema of
the hands, which has been more than usually trou-
blesome for the last month (August). She has
suffered for a long period from ekzema, which
usually makes its attack at the spring and < fall of
the year. She is besides somewhat gouty.
7229. A gentleman, aged 68, has ekzema of the
thighs, hands, face, and behind the ears. The
attack broke out in the month of June.
7087. A young lady, aged 16, has ekzema in
small circumscribed patches on the hands and fore-
head, and vestiges of the same affection in the
flexures of the joints. The disease began in the
joints at the age of seven, and has recurred in the
summer season ever since. She has pale conjunc-
tivae, and is delicate in constitution.
6782. A little boy, aged 10, has ekzema erythe-
matosumj which has broken out as a spring erup-
ETIOLOGY OF BKZEMA. 347
tion chiefly on the legs, and has already existed for
a few weeks. His digestive functions are deranged,
his appetite variable, and he has copious perspira-
tions at night.
7023. A married lady, aged 23, has a patch of
ekzema squamosum on the side of the neck. She
has no other manifestation of the eruption. She is
delicate, dyspeptic, and has given birth to five
children.
7372. A lady, aged 41, has ekzema of the hands
and feet, with oedema. She is much debilitated,
and owes her exhaustion to prolonged nursing and
anxiety.
7375. A lady, aged 26, has had ekzema squa-
mosum capitis for some weeks. Nine months back
she had abscess of the breast afler her confinement,
and to the debility resulting from these causes the
ekzema is to be attributed.
7378. A young man, aged 27, has ekzema squa-
mosum of the head and front of the chest : it has
existed for four years, and is worse in the winter
season. He is a druggist's assistant, and much
confined by his duties.
6330. A male infant, aged three months, was
attacked with ekzema at the end of the first month.
The eruption covers the whole body. It is ichorous
on the head and face, erythematous and papulous
on the body and limbs. The mother received a
fnght when she was six months pregnant; and our
presumption is, that in consequence of this shock
to the nervous system, caused by the fright, the
nutritive quality of her milk has suffered, and the
defective nutrition of the infant has become the
predisposing cause of ekzema ; cold possibly being
the exciting cause.
61 14. A lad, aged 16, has ekzema pustulosum or
impetigo of the scalp and ears, which has been in
348 ETIOLOGY OF EKZEMA.
existence two months. He is a weakly, languid
boy, pallid and overgrown, and has just left school
to enter upon the duties of a merchant's office.
These are conditions in the highest degree favour-
able to the development of a pyogenic ekzema.
6555. A young lady, aged 6, has ekzema pustu-
losum of the scalp (impetigo capitis) : it ensued
upon the debility occasioned by a succession of ex-
hausting causes : namely, insufficient diet, low fever,
and whooping cough.
6495. A clergyman, aged 58, is suflfering from
ekzema of the forehead, chin, fingers, and perineum.
He has been subject to this affection for twelve
years ; it recurs in spring and autumn, and on the
present occasion (April 4th) has lasted for three
months, having been preceded by lumbago. He is
an habitual dyspeptic, and certain simple articles of
food, such as bacon and oranges, produce vertigo.
6222. A gentleman, aged 52, has ekzema erythe-
matosum in moderate-sized patches (figuratum) dis-
persed over the front of the forearms. He is not
liable to eruptions, and the present attack is attri-
butable to the cold weather, and has existed for three
weeks. As this is not a case of diathesis or of
inveterate character, arsenic is not indicated, and
we have prescribed nitromuriatic acid with gentian,
a mild aperient pill, and the benzoated ointment of
oxide of zinc.
6403. A lady, aged 31, has suffered from ekzema
of the hands for twenty years : it is worst in the
summer season. Her tongue and mucous membrane
are pale and soft.
6404. An unmarried lady, aged 28, has suffered
from ekzema squamosum of the knuckles of the
fingers for ten years : it is most troublesome in the
winter season.
6411. A gentleman aged, 28, has been troubled
ETIOLOGY OF EEZEMA. 349
with ekzema papulosum of the lower extremities for
eighteen years : it is worst in cold weather. He is
a nervous, sensitive man, and during his treatment
was attacked with severe pain in his side, which was
relieved by haemorrhage from the bowel.
7796. A lady, aged 55, has been the subject of
ekzema for ten years : it occurs on the back of the
hands, ekzema papulosum (leichen agrius of Willan),
and comes on usually in hot weather . The present
attack made its appearance in the winter.
6474. A gentleman, aged 43, has ekzema of the
left leg, and gives the following account of its
origin. Three years ago he was troubled with
varicose veins of the leg : a cluster of these veins
still remains, as well as a mottled melasmic patch
resulting from the congestion caused by the obstruc-
tion of circulation in the veins. A year later the
leg was attacked by boils, for which a poultice was
applied, and consequent upon the irritation caused
by the poultice, ekzema was developed, which still
continues.
6737. An unmarried lady, aged 43, has ekzema
squamosum ani : it began as pruritus ani, consequent
on haBmorrhoids, and has lasted for five years.
6701. A young lady, aged 22, has ekzema erythe-
matosum of the face, which has existed for two
years : it originated from exposure to the sun. She
has been subject to neuralgia for eight years, and is
at present suffering from ascarides, which invade the
vulva as well as the rectum.
6669. A military officer, aged 42, is suffering
under ekzema ani, excited by sitting on a damp
seat in a railway carriage. He possesses an ekze-
matous diathesis, and is subject to frequent attacks
of that disease, the attacks alternating with furun-
culosis.
6694. A young lady, aged 10, has ekzema of the
350 ETIOLOGY OF EEZEMA.
lobe of one ear, excited by piercing the ear for ear-
rings.
6556. A gentleman, aged 64, is suffering from
ekzema pustulosum of one leg : it followed phleg-
monous erysipelas, and its treatment, which he had
experienced four months before.
6563. A gentleman, aged 68, has ekzema squa-
mosum of the left leg extending from the toes to
the knee : it has been in existence six months, and
was excited by poulticing the leg for six weeks after
the bite of a dog.
6099. A young lady, aged 1 5, has ekzema erythe-
matosum of the palm of the hands, with fission in
the lines of motion, the borders of the latter being
red and the cuticle in a state of desquamation.
Flexion and extension of the hands is extremely
painful. The hands have been in this state for three
weeks ; and first became inflamed from the use of a
solution of soda intended to bleach her hair.
This case reminds us of its analogue the dermatitis
toxica occasioned by the aniline dyes.
6277. A general, aged 63, has ekzema squamosum
of one leg, which has existed for nine years. The
eruption followed an accident to the leg and its
treatment. With proper management we anticipate
that the disease, although of such lengthened dura-
tion, will get well in a few weeks.
7714. A lady, aged 41 , has ekzema of the knuckles
and back of the hands : it has existed for eighteen
months ; it began in the summer, and is more active
in the summer than in the winter season.
7720. A nursemaid, aged 19, has ekzema pustu-
losum of the arm in the neighbourhood of the
elbow. She had some shght annular eruption on the
elbow, for which a poultice was applied, and the
ekzema followed. She is weakly and delicate, and
has been underfed.
ETIOLOGY OP EKZBMA. 35 I
7727. A gentleman, aged 22, has ekzema on the
right hand : it has lasted for three months, and came
out suddenly, together with a similar eruption in
the face, in consequence of sleeping in a damp bed.
He is congenitally ekzematous.
7748. A gentleman, aged 59, has a patch of
ekzema papulosum on the front of the shin ; the
eruption followed a bruise caused by a blow.
7706. A gentleman, aged 31, has ekzema papu-
losum of the head, whiskers, shoulders, and chest ;
it has existed for four months, and broke out in the
autumn after some days of confinement in a hot
room.
7673. A gentleman, aged 56, has ekzema labiorum,
which has teased him for two years : he is depressed
in spirits and under the pressure of anxiety.
7639. A married lady, aged 40, has ekzema vesi-
culosum of the back of one hand, which is spreading
upwards to her wrist. The eruption is only three
days old, and was excited by the use of tincture of
arnica applied for the relief of a sprained thumb.
She made the application on a Sunday evening and
kept it on all night ; on Monday night the ekzema
made its appearance. Her skin is very sensitive,
and she was unable to bear the oxide of zinc oint-
ment; but the eruption gave way to the use of
starch powder.
CoNGENrrAL Ekzema.
6752. A young lady, aged 18, has been the sub-
ject of ekzema since the age of six weeks. The
eruption makes its attack in the winter season, and
at present occupies the head, the eyelids, and the
ears. She was brought up by hand.
6753. A young gentleman, aged 16, is troubled
with ekzema vesiculosum and squamosum of his
352 ETIOLOGY OF EKZEMA.
fingers. He was attacked with ekzema at the third
month, and has suffered from it more or less ever
since. A state of constitutional debility is fiirther
indicated by enlarged tonsils.
6560. A little boy, aged 3 years, has suffered from
ekzema since he was two weeks old. At present the
disease lingers in the flexures of his popUteal and
elbow joints, and also in his right hand. He has a
habit of sucking his thumb, and the saUva dribbles
from his mouth and runs down to his chin. This
constant moisture has acted as an irritant to the
skin, and along its course ekzema is developed, but
the thumb has escaped.
6667. A male infant, aged 3 months, has a mild
attack of ekzema, the eruption being situated on one
side of the head and face, on the shoulders, the
sides of the trunk, and in the popliteal space. The
chief point of interest in the case is that vaccination
has failed on two occasions.
6793. A gentleman, aged 72, is suffering from
ekzema, which is dispersed on various parts of the
body ; it presents the squamous type, and he has
suffered, he says, from ekzema from his infancy.
6513. A lady, aged 50, is at present suffering from
ekzema of the head and of the fissures of the ears.
She has been ekzematous from childhood.
6525. A medical man, aged 48, has suffered from
hereditary ekzema since his infancy. At the present
time (April) his head and face are covered with
ekzema squamosum, and he is teased with intense
itching arising from ekzema ani.
6202. A gentleman, aged 42, had ekzema in his
infancy, and has been troubled with it from time to
time ever since. At present (February), and brought
on by the cold weather, he has ekzema squamosum
fissum et ichorosum of the hands, and several other
parts of the body, particularly the popliteal cavity.
KTIOLOGY OF EKZEMA. 353
This is a case in which the alternate use of local
stimulation and soothing applications is of value, and
the internal administration of the arsenical solution,
four minims three times a day.
6272. A gentleman, aged 46, is suflfering from
ekzema squamosum of the head and behind the ears.
In the latter situation, as is usual, the eruption is
accompanied with a little ichorous exudation and
considerable pruritus. He is a hale, strong man,
but has been ekzematous from childhood.
4
6280. A married lady, aged 32, has ekzema squa-
mosum of the head and upper half of the body.
Menstruation is deficient, and she has no family, but
is otherwise in good health. Ekzema first made
its appearance a week after her birth. Her mother
was a delicate woman, but of seven children our
patient is the only one afflicted with this disease.
6401. A physician, aged 32, has ekzema capitis,
also of the fissursB aurium, axillaB, and groins. He
has suffered from the disease since childhood, but
has been worse during the last three years. His head
is the region chiefly affected, and it is only during
the last three months that the disease has extended
to the groove behind the ears.
7224. A young gentleman, aged 13, has ekzema
palmare of one hand, the remains of ekzema
infantile.
7239. A young medical man, aged 24, has ekzema
squamosum of the forehead and ekzema papulosum
on the limbs ; he also suffers from asthma. The
eruption made its appearance first immediately after
vaccination.
7241. An unmarried lady, aged 66, has ekzema
of the ears, pudendum, and joints. The disease
began immediately after inoculation for small-pox ;
and her father, who entertained a prejudice against
vaccination, common in those days, accused the
2 a
354 ETIOLOGY OF EKZEMA.
medical man of using vaccine lymph. A few weeks
after her first visit, in the month of December, she
suffered from profuse discharge of mucus from her
nose. On her neck she has a crop of akrochordones
—a common accompaniment of age.
7243. A young lady, aged 18, has ekzema frontis,
which has troubled her for two years ; formerly she
used to suflFer with ekzema articulorum. In her in-
fancy she had congenital ekzema.
7276. An unmarried lady, aged 36, has ekzema
squamosum of the scalp. She has been ekzematous
from infancy, had scarlatina at the age of eleven, and
a severe attack of ekzema ichorosum at twenty-one.
7368. A gentleman, aged 32, has ekzema poplitei
of the right leg ; it has troubled him for six months.
He was the subject of congenital ekzema in infancy.
Hereditaby SIezema.
7591. A married lady, aged 37, has had ekzema of
the palm of the hands and fingers, with rhagades at
the tips of the latter, for three months. She has
suffered from ekzema for fourteen years, and inherits
the diathesis fi:*om her mother.
7589. A gentleman, aged 35, has ekzema pudendi,
which has lasted two weeks ; he has been troubled
with circumscribed patches on the fingers and arms
for two years. The disease is hereditary, his father
having suffered similarly^ and also a brother.
6747. A child, aged 6 months, is suffering from
ekzema pustulosum, which began at the fifth week.
The father of the child is ekzematous, the mother
healthy ; of eight children, the fruit of the marriage,
one has ekzema capitis and another is the subject of
fiirunculosis.
6158. A clergyman, aged 40, has been a suflbrer
from ekzema for six years, and from spring-asthma
ETIOLOGY OP EKZEMA. 355
or hay-asthma, since the age of eight years. His
present attack occupies the hands, and was excited
by having his gloves wetted through with snow.
He is a man of weakly constitution, is leukaemic,
and subject to rheumatism; but all his ailments
cease when residing at Brighton, his present dwell-
ing being situated in a low and damp locality. His
mother is ekzematous, and his sister has occasional
attacks of ekzema of the face.
6163. A young lady, aged 16, has been troubled
with ekzema since the age of three years ; she now
presents herself with the remains of the aflfection
lingering around her mouth, particularly at the com-
missures, where there are several rhagades.
Her mother, aged 40, consults us at the same time
for ekzema ani, and pruritus of the mucous surface
of the labia pudendi.
6383. A male child, 4 months old, is afiUcted with
ekzema ; the child has been partly brought up by
hand. The mother has ekzema in the fissure behind
the ears, and is the subject of hysteria.
6434. A medical man, aged 42, has suffered from
ekzema pustulosum of the fingers for sixteen years ;
it makes its invasion in the spring, and is heredi-
tary ; his mother and a sister being also ekzematous.
The present attack has given rise to inflammation of
the lymphatics of one arm and enlargement of the
brachial gland.
7286. A lady, aged 30, has ekzema pustulosum of
the fingers ; she was confined nine months ago, and
since that event has remained languid and weak.
The present eruption has lasted one week (August),
but she has suffered for several months with e^ema
papulosum, also of the fingers. One of her children,
a boy, aged 6, has ekzema pustulosum of the ear,
cheek, and nostril of one side ; this has also lasted a
week.
2a2
356 ETIOLOGY OF EKZEMA.
6773. A lady, aged 45, has ekzema sklerosum of
the back of one hand ; the patch of eruption is thick
and dense, and has existed for ten years. Her
daughter, aged 27, has ekzema erythematosum,
which came on in December, and has last-ed for six
months.
7679. A gentleman, aged 39, has ekzema squa-
mosum of the palm of both hands, which has lasted
one month ; some blotches on the legs have existed
for six months ; his first attack occurred ten years
ago, and the eruption has shown itself, " spring and
fall," ever since. On the hands and legs the erup-
tion bears a close resemblance to the pityriasis rubra
of Devergie. The patient inherits ekzema from his
father.
VI.
Anomalous Cases of Ekzema and Eezematous
Affections.
Dermatitis exfoliativa seu Ekzema exfoliativum.*
General Dermatitis is sufficiently rare to excite
some attention and interest whenever a case of the
kind comes under notice. I have already published,
in my work " On Diseases of the Skin," two in-
stances of this disease and one of a local form, and
I now present to the profession the details of
another example of the same affection. Heretofore
I have followed the nomenclature of Devergie and
Hebra, and have called it "pityriasis rubra" ; but,
on the present occasion, I have ventured to employ
a term which, I believe will convey to the mind
a better idea of the nature of the complaint than
* Reprinted froro the Medical Times akd Gazette, of
January 29, 1870.
EKZEMA BXFOLIATIVUM. 357
the name given to it by my colleagues, and which,
at the same time, is calculated to escape contro-
versy. There may be some doubt as to the true
meaning of pityriasis and as to the appropriate-
ness of the application of the name to the disease
in question, but t^ere can be none as to the term
" dermatitis exfoliativa," — that is to say, inflamma-
tion of the skin accompanied with exfoliation of the
epidermis, the inflammation being of an unusually
intense kind, and the exfoliation of cuticle profuse,
amounting, in fact, to a state of positive flux.
The case which I am about to describe may be
briefly stated as follows : — ^A punctated exanthema,
following a shock to the nervous system occasioned
by chill, nausea, perspiration, and checked perspi-
ration ; the exanthema developed in a few hours,
and rapidly difl'used, until the whole body presents a
bright red colour ; excessive heat with soreness and
stiffness of surface; well-marked infiltration and
condensation of the skin; tendency to crack into
fissures on motion ; in six or seven days incipient
exfoliation of the epidermis in thin laminaB with
elongated base ; the line of fracture of the cuticle
corresponding with the grooves of motion of the
skin, and when the laminae are only partially sepa-
rated, projecting from the skin in narrow frills
sometimes several inches in length. Incessant ex-
foliation of cuticle, so as to fill the patient's bed with
thin laminae ; no pruritus ; no exudation ; no general
perspiration, and but slight partial perspiration from
the forehead and back of the hands ; tendency to
oedema about the ankles ; scanty urine loaded with
urates ; no albumen ; pulse quick and excitable ;
tongue clean ; appetite and digestive organs undis-
turbed, and strength but little affected.
The patient, a young man, aged 28, enjoying
average health, and engaged in a brewery, was
attacked with ekzema erythematosum, which was
developed in small circumscribed patches on his
358 ANOMALOUS CASES OF EKZEMA.
limbs, chiefly those of the lower extremity. This
occurred in the month of May, 1869, the eruption
desquamating and continuing without other change
until October. At the latter date he left home with
his wife for an afternoon's holiday. The day proved
to be wet, and his clothes were saturated with mois-
ture. He stood under an archway waiting for a
cab for nearly an hour, and on reaching his house
was seized with nausea. He then went into his
garden to relieve himself by vomiting, but was un-
able to do so, and became suffused with perspira-
tion. While in the garden he experienced a chill,
which he was unable to shake off the whole evening,
and he has remained abnormally sensitive to cold ever
since. On the following morning it was perceived
that his skin was covered with a bright red and
punctated exanthema, which in the course of the
two following days spread over the whole surface of
his body. Nevertheless, the rash was unattended
with fever, and did not therefore confine him to the
house. The inflammation of the skin, with great
redness and excessive heat, lasted without breach of
surface for about a week, but after this time the epi-
dermis began to crack and exfoliate, and has con-
tinued to do so up to the present time — namely,
about six weeks from the beginning of the attack.
On November 20 1 saw the patient with Dr. Locke.
His face presented the usual remarkable character of
this foliaoeous form of dermatitis — a deep red hue,
with tightening and contraction of the skin, and an
unusual expansion of the eyelids, which gave to the
countenance a staring expression, and, added to
this, the white edges of numerous partially separated
stripes of epidermis, which marked the forehead and
face all over as if it had been tatooed. The ears also
were deeply red, and looked parched, and there were
dark scabs at the root of the pinna and at several
points on the helix, produced by the oozing of blood
occasioned by his habit of picking at the scales.
BKZEMA EXFOLIATIVUM. 359
From the bead down to the feet the same cha-
racters prevailed, although in a heightened degree.
The skin everywhere exhibited the appearance of
tightening and contraction ; it was vividly red,
covered with loose frills and shreds of epidermis,
was hot and parched, and exhaled an unpleasant
valerianic smell, while the lower sheet was covered
with similar shreds and flakes. The exfoliation of
the epidermis was, however, most remarkable on the
back, which was covered with small gauze-like
shreds, ranged for the most part transversely, the
rows being situated at short distances apart. The
derma had the appearance of being thinner than
ordinary and the grooves of flexion were strongly
marked. The only parts of the skin which had
escaped the general dermatitis, but those only par-
tially, were the soles of the feet and palms of the
hands, the latter being moistened with perspiration.
But at a later period the cuticle of the palm was
raised by numerous pimples, was hard and stifi*, and
subsequently exfoliated, as did that of the soles of
the feet.
The symptoms accompanying this state were a
feeling of burning heat with occasional transient
chills, of soreness and stiffness ; he had difficulty in
opening his mouth when told to put out his tongue,
and he dreaded movement, from the fear of cracking
his skin. There was no itching, and he had had
none from the first.
Constitutionally, his appetite was good, and
digestive functions moderately healthfully per-
formed. His tongue was clean, bowels a little
confined, and urine normal in appearance and some-
what scanty. He remarked that he was thirsty,
and drank a good deal of water ; but he was at a
loss to understand what became of the fluid. This
difficulty is easily explained when the burning heat
of the surface of the skin is considered, and the
necessarily rapid evaporation of moisture. He slept
360 ANOMALOUS CASES OF EKZEUA.
well, and the only important symptom of disorder
of health that could be discovered was a nervous
pulse, ranging in frequency between 106 and 110.
To summarize the chief features concerned in the
origin of the disease, we may note the predisposition
to ekzema, the wetting through, the shock to the
nervous system evinced by nausea ; the outburst of
perspiration; the succeeding chill; and finally the
reaction declared by the exanthema and subsequent
dermatitis. That the eruption is allied with ekzema
seems proved by the presence of an existing ekzema ;
but it diflfered from ordinary ekzema in the total
absence of ichorous exudation, although the skin
was obviously condensed by infiltration, and espe-
cially in the absence of itching. Neither in ekzema
do we ever find the rapid growth and exfoliation
of epidermis which is so strikingly characteristic of
this form of disease.
At a subsequent visit to our patient nine weeks
from the commencement of the attack, I was
informed that he had remained at his work for five
weeks previously to taking to bed, and that this
latter event was brought about by a painful boil
situated near the anus. With the pain and irksome-
ness of the boil, the dermatitis had increased in
uneasiness, and he has now kept his bed for a
month, although the boil healed in a week. He
had been subject to boils as a boy of fifteen, and
had outgrown the tendency; but at the present
time he has several small boils on the occiput,
induced probably by the heat of the pillow. Since
my last visit his state had improved very materially ;
a few days before he had attempted to get up, but
he found his skin still stifi* and sore, with a tendency
to crack, especially in the joints, and the sense of
chill previously spoken of was very disagreeable.
His pulse is now 80 ; his tongue clean, but soft and
over moist; the appetite good; bowels regular
with the aid of a SeidUtz draught; and urine
BKZEMA BXFOLIATIVUM. 36 1
natural. The scales have disappeared from his
scalp, they have lost their linear arrangement on
the face, and they are thinner and less abundant on
the rest of the body. The armour-plate distribution
of the stripe-like laminae is, however, more striking ;
the patient speaks of his skin as being " ribbed '*
by the white streaks of exfoliating epidermis, and
these lamina3 are transverse upon the arms, and longi-
tudinal on the outer side of the thighs. In the
latter situation, the scales, or rather frills, are many
inches in length, about half an inch in breadth, and
situated pretty evenly at about an inch apart ; while
on the palms and soles the epidermis is desqua-
mating in broad laminae. The derma is paler, and
thrown into small wrinkles, and is evidently less
infiltrated, indurated, and hot 7 still there is no
exudation of moisture on any part of the body, and
no perspiration-
With these characters of this very singular and
interesting disease before us, we are in a position to
inquire, what name would be most suitable to
convey the idea of its nature ? That it is a derma-
titis is self-evident, but so also is ekzema. Dr.
Wilks, in describing a similar case, calls it a
" general inflammation of the skin or dermatitis."
I myself called it, in the first instance that came
under my notice, dermatitis squamosa rubra; l)ut
the word dermatitis itself expresses redness, and
" squamosa " hardly suflSces to give an idea of the
foliaceous and firilled character of the desquamation
— in fact, of a fi^agmentary exfoliation rather than
a desquamation. Hence my selection, as the heading
of the present case, of the term dermatitis exfoliativa.
Its decided alliance with ekzema, if not its positive
identity with ekzema, suggested another name which
occurred once to me as being particularly appropriate
— namely, ekzema foliaceum, and the further desig-
nation of psoriasis squamosa rubra ; while it would
seem to be this malady which has received from
362 ANOMALOUS CASES OF EKZEHA.
Devergie and Hebra the name of pityriasis rubra.
An objection to the term pityriasis is palpable —
namely, the large size of the laminad of epidermis,
which bear no proportion whatsoever to the small
bran-like scales of psoriasis and pityriasis. Indeed,
in the presence of the patient the latter term is
wholly inapplicable, and, if it were recognized,
pityriasis foliacea or pityriasis foUacea rubra would
be much more suggestive than pityriasis rubra
simply. The exfoUating laminsB have generally an
elongated figure corresponding with the grooves of
motion of the skin, and they are free only by the
border, which, in accordance with the motions of
the part, is one while directed upwards and another
while downwards; and these elongated laminaa,
sometimes many inches in length, are apt to be
broken into smaller fragments, which, when collected,
have the appearance of the bracts of the hop rather
than the smaller scales of bran,*
By actual measurement many of the exfoliated
laminae extended to 2 in. in length by ^in. and f in.
in breadth, while, in quantity, the scales amounted
in weight to somewhat more than two ounces, and
in bulk to upwards of a pint in the day.
In the case reported by Dr. Wilks in the " Guy's
Hospital Reports for 1861," the patient was a coal-
porter, aged 34, under the care of Pr, Bees. On his
admission into the hospital he was exceedingly ill,
with febrile symptoms, pulse full, tongue thickly
furred, and skin covered with a punctated rash, which
was thought to be incipient small-pox. In a few
days the whole skin manifested a general and intense
inflammation ; it was vividly red, and " slightly
swollen." On the sixth day the skin was beginning
to roughen with desquamation, and on the tenth
^ Specimens of these hop-like laminss may be seen in the
" dermatological collection" of the College of Surgeons, and also
those obtained in the present c^se.
EKZEMA EXFOLIATIVUM. 363
day large flakes of epidermis were peeling off. On
the palms and soles there was no redness at first,
bat in the desquamating stage the ends of the
fingers were raised in bladders, from which the fluid
became absorbed, and the cuticle subsided and
shrunk, while at a later period he lost the nails of his
fingers and toes. As the desquamation proceeded,
the tongue was less coated, but became superficially-
ulcerated, and it was ascertained that he had had a
suppui'ating bubo ten years before. The patient was
convalescent at the end of a month ; but, although
convalescent, he was still an out-patient at the end
of the ninth week, and at that time he was losing
the nails of his fingers and toes.
According to Devergie, pityriasis rubra is the only
affection, with one exception — namely, acute lepra —
that is capable of invading at once the whole surfece
of the body. It has been met with more frequently
in females than in males, and chiefly between the
age of 40 and 45. It makes its appearance on any
part of the body, most commonly the front of the
trunk or the inner side of the limbs. It presents
itself as in erythema, vividly red, deep and uniform
in tint, and terminating by an abrupt boundary. It
increases rapidly in extent and depth of colour, the
skin becomes thickened and moist, and throws off
thin epidermic scales that are easily detached. The
redness and moisture are augmented with the pro-
gress of the disease, and the epidermic lamellas
become larger and more abundant, the symptoms
which accompany the disease being heat, tingling,
and some degree of itching.
If the eruption be severe, a surface of skin of con-
siderable extent may be invaded in the course of a
few days, and not uncommonly the whole body may
become affected in from two to four weeks. When
this is the case, the subcutaneous tissue as well as
the skin is slightly swollen, and the sweat-like ex-
udation is SQ excessive thq,t the patient may require
364 ANOMALOUS CASES OF EKZEMA.
a change of linen twice or three times in the night.
As the cutaneous transpiration subSldes, the amount
of epidermic exfoliation increases to such an extent
that in the morning there may be collected from the
bed a quantity of scales suflScient to fill a measure of
from two to three quarts {deux et meme trois litres).
Contrasting pityriasis rubra with ekzema, Devergie
remarks that although, from the presence of inflam-
mation of the skin accompanied with exudation,
lieat, and itching, ekzema might be suspected, yet
that there really exist strongly marked differences
between the two : for example, in ekzema the red-
ness is less vivid, and blonds with the surrounding
skin; the pruritus is severe, the eruption never
occupies the totality of the skin ; there is no thick-
ening of the skin, and the scales only make their
appearance at the chronic period of the disease ;
they adhere very firmly, and can only be removed
with pain. Whereas, in pityriasis rubra the redness
is intense and abruptly circumscribed ; the skin is
thickened, the subcutaneous cellular tissue some-
what swollen. There is very little itching, but a
severe burning sensation; the exudation has the
character of sweat, scales appear from the first, are
abundant and easily detached, and there are no
red secreting puncta, the redness being perfectly
uniform.
Pityriasis rubra resembles ekzema in the firmness
of hold which it takes upon the system, and is often
more difficult to cure. When it has invaded the
whole of the skin, it is perpetuated for several
months, and continues during the entire period to
produce epidermic lamellae. This wasteful operation
results in debility ; the patient becomes emaciated,
his mental and digestive powers both suffer, and not
unfrequently diarrhoea is developed. Even when the
inflammation has the appearance of subsiding, it is
liable to relapse, and the disease rarely runs its course
without evincing a relapse.
EKZEMA EXFOUATIVUM. 365
Devergie indicates two periods of the eruption —
acute and subsiding. During the former the skin is
burning hot, so that the patient can scarcely bear
any covering, even in winter ; while in the subsiding
period the heat and exudation are diminished, but
the lamellated exfoliation continues. The prognosis
of the disease, he tells us, is not grave, unless it
occur in the debilitated or the aged ; but it is always
serious on account of its persistent character and
the tendency which it occasionally exhibits to merge
into pemphigus. Moreover, when neglected, it is
apt to become chronic, and to last for several years.
The treatment most suitable to the acute period
of the disease consists of daily baths, inunction
with lard several times a day, starch powder, cooling
drinks, sometimes the vapour bath, and, where the
condition of the patient is favourable, arsenic;
while in the subsiding stage the best remedies are —
applications of tar, baths of alum or perchloride of
mercury, and gentle ftictions with juniper tar every
three or four days.
The pityriasis rubra of Hebra corresponds suf-
ficiently closely with that of Devergie to make the
identity of the disease evident ; but he states that
the affection is extremely rare, that he had seen but
three cases, and that these three cases all terminated
fatally after a duration of a certain number of years.
Indeed, the fatal issue of the complaint, and its
resistence of remedies found useful in ekzema, he
regards as the main causes for a distinction between
pityriasis rubra universalis and ekzema squamosum.
The stage of ekzema squamosum which corresponds
with pityriasis is the stage of decline of the disease,
and is that consequently which the most readily
yields to treatment. ** I give the name of pityriasis
rubra," he observes, " to an affection in which,
throughout its whole course, the only symptom is
the persistent deep-red coloration of the skin. In
this disease there is no considerable infiltration of
';66 ANOMALOUS CASES OF EKZEMA.
O
the cutis ; no papules or vesicles are formed ; no
secretion is poured from the surface ; the itching is
slight, and does not lead to the formation of excoria-
tions ; no fissures make their appearance ; and,
lastly, particular regions of the body are rarely
affected, the whole surface of the skin being
generally attacked."
The patients seen by Hebra represented to him
that the eruption had made its appearance on the
whole body at once ; at first the redness was slight,
but it increased quickly in depth of colour. Their
health was undisturbed, they could pursue their
daily avocations, and they were reminded of the
disease, not by any unpleasant sensation, but simply
by the redness of the skin ; little by little they lost
appetite, then their strength gave way ; they became
emaciated, and finally succumbed to exhaustion.
Hebra pays no especial attention to that remarkable
feature of the disease, the thin exfoliating lamellad,
which are real lamellse and not scales^ but concludes
by recommending, with a view to therapeutic treat-
ment, prolonged tepid bathing and inunction with
oils and emollient ointments^ This, he says, tends
to render the skin more supple ; but " neither arsenic,
tincture of cantharides, sulphur, antimony, decoctum
lignorum, sarsaparilla, iodine, nor mercury, has suc-
ceeded in putting a stop to the disease."
Comparing the descriptions of the disease given
by Devergie and by Hebra, the chief point of dif-
ference between them relates to the prognosis of the
affection. The former states that it is not grave,
while the latter, certainly with the limited experience
afforded by three patients only, found it always
fatal. Devergie speaks of its commencement on a
limited portion of the skin, and spreading thence, in
the course of a few days, to the whole body ; while
the patients examined by Hebra declare that it
appeared on the whole body at once, and such was
the case in the example recorded by Dr. Wilks and
EKZEMA EXFOLIATIVUM. 367
that by myself. Another discrepancy is more ap-
parent than real. Devergie remarks upon the infil-
tration of the derma, and its exudation of a sweat-
like secretion ; and he also finds some degree of
swelling resulting from subcutaneous infiltration.
In my own experience the infiltration of the derma
is well defined, but there was no visible transudation
from the surface, and to the hand the skin gave the
sensation of dryness. And Hebra, in his definition
of the disease, while stating that there is " no con-
siderable infiltration," in other parts of his descrip-
tion observes, "There is no infiltration of the cutis";
and again, " no swelling or serous infiltration exists."
I think, therefore, that we shall only be doing justice
to Hebra to regard these latter expressions as rela-
tive, and not positive. For most certainly there does
exist a decided infiltration and condensation of the
derma.
In reference to the treatment adopted in the
present case, it consisted in the administration
mtemally of sulphate of magnesia and quinine, one
drachm and one grain, in infusion of roses, with a
few minims of dUute sulphuric acid, twice in the
day ; and in inunction into the skin of the benzoated
oxide of zinc ointment in combination with carbolic
acid, ten minims to the ounce ; and the Carron oil
also with the addition of carbolic acid. As t have
stated above, it was found necessary to give the
patient a Seidlitz draught occasionally to secure a
free action of the bowels ; and at the end of a fort-
night the medicine was changed to the citrate of
iron and quinine. At the present time there is every
reason for expecting that the case will end favour-
ably without further treatment ; but should the
dermatitis assume a chronic form, it may be neces-
sary to have recourse to arsenic.
On the 6th of January, 1870, three months fit)m
the commencement of the attack, the patient re-
ported that he had returned to his duties about
368 AXOMAi.OUS CASES OF EKZEMA.
three weeks previously ; that he had nearly regained
his usual strength ; and that he had lost the un-
pleasant feeling of chilliness already mentioned. On
examining his skin, I found that the exfoliation from
the general surface of the body had ceased, but that
a remnant of desquamation existed on the scalp and
around the apertures of the face, the eyes, nose,
and mouth ; and that in these situations there was
also an abnormal amount of redness. The scales
on the scalp were circular in figure and loose at the
circumference, the loose border being white in ap-
pearance. The skin of the palm of the hands had
exfoliated completely, and the nails of all the fingers
were detached at their roots, whitish in colour, and
in progress of separation.
Ekzema tuberosum.
If we were called upon to mention the most
constant symptom of ekzema, we should name
infiltration^ before redness, or desquamation, or
exudation. We have seen ekzema without redness,
but ekzema would cease to be ekzema without infil-
tration. As is manifest in many diseases, a given
symptom may present every possible degree of de-
velopment ; it may be a mere shadow, or it may be a
confirmed and grave reality. This observation is
strikingly applicable to many diseases of the skm,
and not least among them, to ekzema. Infiltration
may be present without thickening, giving rise to a
leathery state of the integument that is apt to break
into fissures and give origin to ekzema fissum ; or it
may swell up the tissues so as to produce promi-
nences having three-quarters of an inch and even an
entire inch, in elevation. When, as frequently hap-
pens, the portion of the skin so infiltrated is of small
extent, we may then have tumours of considerable
prominence, and with a base scarcely at all exceeding
their height. This peculiarity of manifestation of
EK2EMA TUBEBOSUM. 369
the disease is rare, but nevertheless we have seen it
several times, but never to so great a degree as in a
case which we shall presently describe. It will be
seen, that in using the word tuberosum, we have
no intention of indicating so much even as a variety
of the parent disease, but simply to mark a symptom
with which ekzema is sometimes liable to be com-
plicated.
A lady was delicate in her youth ; she then led a
life of gaiety and fashion, with its consequent ex-
citement; she married at thirty, had several mis-
carriages, and much exhaustion from sickness in her
family ; she is now fifty-five. Soon after the birth
of her last child, fifteen years ago, she was seized
with intense hemicrania. All kinds of remedies
were resorted to for the cure of this painful afflic-
tion, but in vain, and she was fairly worn out and
prostrated by its obstinate continuance. The attacks
recurred frequently ; they were attended with severe
retchings, violent pulsation in the head, and lasted
for several days. Among other forms of treatment
that were adopted was mercurialization to the extent
of salivation.
As a last resource she was advised, four years ago,
to wear a galvanic belt ; the belt excited ekzema,
and the ekzema gradually spread over the entire
skin. For a time the ekzema only added to her
sufferings, but within the last twelve months has
proved derivative ; nature is content with the sub-
stitution, and she no longer suffers from headaches.
The ekzema, which has now occupied the skin for
four years has remained stationary; it has been
treated without plan, without principle ; has been
sometimes benefited, sometimes aggravated by the
means employed, but has defied all alike. We
found her on a couch, unable to bear her dress;
her face reddened, eyebrows dry and corrugated,
scalp scurfy, neck red, wrinkled, and tuberculated ;
and her hands dry, parched, rough, and scaly ; the
2b
370 ANOMALOUS GASES OF EKZEMA.
skin was fissured in the lines of motion, and the
nails were discoloured and scabrous. The covered
parts of the body presented similar characters, the
skin being wrinkled and impoverished, red, squa-
mous, infiltrated, and in some parts oedematous.
Scattered numerously over the surface were the in-
filtrated tubera already mentioned, some single,
others in groups, and a few excoriated and moist
with exudation. In the earlier periods of the disease
she had suffered greatly firom pruritus ; she had
taken arsenic to excess, and without benefit ;
and six months ago had placed herself under the
management of a doctor of the feminine gender.
The good woman had scrubbed her severely with
tar ; this relieved the pruritus, but being car-
ried too far, had set up the renewed irritation,
which resulted in the tubercular infiltrations, so
remarkable in this case. At various times, and es-
pecially since the conclusion of the tar treatment,
there has been very copious exudation from the
inflamed surface, constituting ekzema ichorosum.
We found her tongue as red as her skin, and
glazed ; she had constant thirst, but her appetite was
good, and she could eat meat and drink beer with
enjoyment ; she had a little bronchitis ; her pulse
was firm, bowels somewhat confined, and nights sleep-
less. We prescribed for her an effervescent sahne
with ammonia, and directed that the whole surface
of her body should be carefiiUy anointed with the
benzoated zinc ointment, and afterwards dusted over
with oxide of zinc, diluted with starch-powder and
camphorated. We ordered a repetition of this pro-
cess night and morning ; oftener if agreeable, and
abstinence fi:»om ablution of every kind ; the surface
was to be gently wiped with a soft napkin previously
to the repetition of each inunction. Her diet was
to be that of health, irrespective of her invalid
condition. We expect, by thus allaying the con-
gestion of the mucous membrane and skin, and
EKZEMA SPAEGOSIFOEME. 37 1
conservating her vital powers, to allay the irritability
of her nervous system, and lead her by degrees to a
more nutritive and tonic method of treatment.
Eezebia spabgosifobme.
Gentle reader, tremble not at a new term, for
what is that term ? Why, truly, nothing more than
an expression in scholarly and familiar words for an
ekzema which, by infiltration and hypertrophy of
the derma and subcutaneous tissues, has become
developed into a bulk and appearance suggestive of
spargosis cruralis, the bouknemia tropica, the Bar-
badoes leg, the elephant leg of the Arabians. Such
a condition of the lower extremities must have been
seen often, but never more characteristically than in
a patient whom we have just visited in consultation
with Mr. Spencer, of Stoke Newington. Our patient
is a man of 62, a retired butcher. He had been
for a long time a sufierer in health ; his heart was
large and flabby ; the kidneys were diseased, as was
shown by the occasional presence of a considerable
quantity of albumen in the urine ; his liver was
large and inactive ; he suffered under asthma, and
not long since had an attack of apoplexy. Mr.
Spencer had treated him for some years wisely and
judiciously, and he looked well in the face, and had
a good appetite and fair digestion. Some part of
the immunity from the destructive consequences of
his disease was possibly due to the invasion of his
legs by a large share of the causa morbi present in his
system. From the instep to the middle of the calf,
and surrounding both limbs, was an ekzema of a
deep red colour, which exuded many ounces of
. serum in the course of the day. The ekzematous
portion of the limb was swollen and tense from
serous infiltration and hypertrophy; on the instep
it formed several prominent folds, and the surface
2b2
372 ANOMALOUS OASES OF EKZEMA.
was granulated, or, as Mr. Spencer observed, nodu-
lated by the hypertrophy of the papillae cutis. The
foot also was enlarged from oedema, but free from
ekzema, and the general aspect of the limbs, irre-
spective of the ekzema and excessive exudation, was
exactly that of the subjective character which we
have selected, namely, spargosis or bouknemia. It
was as much spargosis from cellular inflammation,
infiltration, and hypertrophy as spargosis itself; all
that was wanting in the latter being ekzema. (For a
definition of spargosis we may refer our readers to
vol. i. of the Cutaneous Journal, page 110 ; and for
the association of hypertrophic papillae cutis with
spargosis, to page 118 of the same volume.)
Scabies PHLYKTiENODBs.
6628. A gentleman from Lincolnshire, aged 28, has
had scabies for five months ; it began in the hands,
and has been under treatment for three months.
As the true nature of the disorder had been over-
looked, the eruption has spread to almost every part
of the body, it is especially confluent and severe
on the thighs, where it has been much aggravated
by scratching, and in this region are four large
bullaB resembling those of pemphigus, and numerous
large vesicles or phlyktaenae. Fresh bullae and
phlyktaenae appear each day, while the older ones
collapse and desiccate into thin scabs. Some of the
phlyktaenae are umbiHcated, and several of the bullae
have two or three umbilical indentations. In ten
days under appropriate treatment this gentleman
returned home cured.
6529. A gentleman, aged 88, and his daughter,
aged 11, are both suffering from scabies ; the,
daughter for three months, the father for two
months. The eruption in the father presents the
peculiarity of being accompanied with large bullae
EKZEMA lOHOEOSUM BT SQUAMOSUM. 373
resembling those of pemphigus. These are developed
chiefly on the thighs. At the end of a month of the
mildest possible treatment, unguentum staphisagriaa
diluted with three parts of unguentum zinci, ekzema
appeared on the extremities, upper and lower, of the
father ; and ekzema yesiculosum on the hands of the
child. From these facts we deduce the conclusion
that father and daughter possess the ekzematous
diathesis, which has been excited into activity by the
scabies and its treatment.
Leichen prubiginosus after Scabies.
6205. A lad, aged 9, had been teased for four
years with prurigiuous pimples, leichen pruriginosus ;
the pimples were discrete and dispersed over the
body, and were scarcely apparent until they had
been scratched ; they had, as is very commonly the
case, succeeded scabies, and appeared to be un-
eradicable. The boy's mother, also, suffered from
the same, and had become the victim of an itch-
monomania, a not unfrequent delusion. We pre-
scribed, for both, three-minim doses of liquor arse-
nicalis, spongings with a tar lotion, and ablutions
with the jimiper tar soap. The arsenic disagreed
with the boy, and was suspended at the end of ten
days, but the local treatment was continued, and he
was quite well at the end of three weeks. The
mother's progress was more tardy, and we had
occasion to change the ferro-arsenical drops for a
mixture of phosphoric acid, liquor strychni®, and
tincture of orange-peel ; but she also recovered in a
few weeks.
Ekzema ichorosum et squamosum.
In a paper read before the Medico-chirurgical
374 ANOMALOUS CASES OF EKZEMA.
Society in 1810, and entitled, " An Account of a
severe Case of Erythema, unconnected with mercurial
action," Dr. Marcet, its author, calls attention to
the papers on Erythema mercuriale and Hydrar-
gyria, from the pens of Dr. Spens and Dr. Alley,
and adduces the present case in proof of the possi-
bility of occurrence of a similar form of disease with-
out the interposition of mercury as a cause. " The
most characteristic symptoms of this disease are,"
he says, " a sudden desquamation of the cuticle all
over the surface of the body, with an ichorous dis-
charge and a general redness and tumefaction" ; and
we must admit that he could hardly have drawn a
clearer definition of ekzema.
His case is as follows : — A gentleman, aged 30,
of spare habit and pale complexion, had been subject
to eruptions of the skin since the age of sixteen, and
similar attacks are liable to recur, without regularity,
from time to time. The attack is preceded by an
uneasy sensation at the pit of the stomach, but
without nausea, fever, or loss of appetite. He
then begins to feel stifiness and heat in various
parts of the body ; the parts become red and swell
rapidly ; the hands, the feet, the ears, and the lips
are the regions principally affected ; but the disease
also appears frequently in the face, the eyes, and the
scalp ; and in its severest degree pervades the whole
body. On the second or third day the cuticle is
raised in innumerable small vesicles ; and when the
swelling abates on the third or fourth day, the epi-
dermis begins to crack and exfoliate, exposing an
inflamed and partially abraded surface, from which
a fluid possessing a strong disagreeable smeU exudes.
On the extremities and in the bend of the toes and
finger-joints, pretty deep fissures and excoriations
(ulcerations) are formed, which heal readily, and in
a day or two the cuticle falls off in large patches,
sometimes as large as the hand ; sometimes the nails
are also cast off. In the course of a fortnight or
EEZEMA ICHOBOSUM ET SQUAMOSUM. 375
three weeks the complaint is entirely removed, but
occasionallj, at the moment of convalescence, the
new cuticle becomes hard and dry, and cracks
again as in the first instance, producing a repetition
of the old symptoms.
Although there was no distinct pyrexia attending
these symptoms, there appeared to be a great degree
of irritability and a peculiar degree of susceptibility
or morbid sympathy of his stomach and nervous
system. Sometimes the eruption was confined to
one hand or one finger ; and on another occasion
the desquamation of the cuticle all over the body
was such that on raising the bedclothes the spot
where he lay was found literally strewed with scales.
This last attack was immediately preceded by and
connected with a severe wetting in a shower of rain.
" In giving a name to a disease," says Dr. Marcet,
who looks upon the case as one of great rarity as
well as obscurity, " there never can be any objection
to our avaihng ourselves of some of its most con-
stant symptoms. Thus, as the ichorous discharge
is a constant prominent feature of this affection,
I should think the term erythema iclioro»wm, well
adapted to distinguish it."
Dr. Marcet invited Willan to see this case during a
slight attack, who suggested that it must be referri-
ble to the genus impetigo^ and it appeared to him to
answer nearly to the impetigo rubra of Celsus ; " but
the disease presents itself in many different forms,
none of which, amongst those that he has met with,
have equalled in extent and severity that which has
just been described."
The impetigo rubra of Celsus we regard as an
ekzema, and his account of the affection is as
follows : —
Another kind is more severe, almost like a papula,
but more rough and red, and presenting a variety of
figure. It throws off superficial scales; there is
more erosion ; it spreads more quickly and exten-
376 HISTOLOGY OP BKZEMA.
sively ; and is more regular in its periods both of
recurrence and cure than the preceding species.
Dr. Marcet found the most successful treatment
to be mild aperients, the warm bath, and poultices
with liquor plumbi to the hands and feet ; and he
further remarks on the perfect similarity of Dr,
Rutter's case, published in the fifth volume of the
Edinburgh Medical Journal^ to his own.
In reflecting on this case, which is one of every-
day occurrence amongst ourselves at the present time,
we cannot but be struck by the presumed rarity of the
disease. Willan himself seemed to be undecided as to
its diagnosis, while the shrewdness of Dr. Marcet in
naming it erythema ichorosum brought him instantly
to the truth ; the man of classes, and orders, and
genera was foiled by the man of simple observation.
Ekzema must have been many times rarer in those
days than it is in ours.
VII.
Histology of Ekzema.
The researches of German pathologists, and es-
pecially those of Wertheim, Auspitz, Biesiadecki,
and Neumann, have recently thrown much light on
the histological pathology of disease of the skin.
They have shown that the tumefaction of exudative
affections is not alone due to infiltration of the
tissues with fluid, but that a hypertrophic and
hyperplasic process is also present, and in great
activity. Existing cells of the tissues become en-
larged or distended; their nuclei are increased in
size ; and there prevails an abundant formation and
rapid proliferation of new cells. This energetic
hyperplasic operation taking place in the substance
of the tissues, and especially around the circumfer-
ence of the minute arteries and capillary vessels.
HISTOLOGY OF EKZEMA. 377
tends to enlarge certain of the structures, such as
the pars papillaris and the rete mucosum, and to
disintegrate the stroma of the corium itself, intro-
ducing into its areoldd and spaces a new substance,
forcing asunder the existing tissues, and thus mate-
rially and solidly increasing the bulk of the skin.
Additional interest is given to these observations
by the discovery made by Biesiadecki of the presence
in the rete mucosum of the normal skin of cells of
connective tissue sometimes fusiform and sometimes
stellate, and of the proliferation of these cells in
the exudative affections, and the extension of their
ramifications between the cells of the rete mucosum,
including the latter in a retrform web. These con-
nective tissue cells are continuous with the connec-
tive tissue of the pars papillaris and papillas, and a
direct continuity is thereby established between the
corium and the rete mucosum, which exercises an
influence over its morbid phenomena.*
In illustration of these views we subjoin a para-
graph from the Journal op Cutaneous MEDiciNB,t
for which we are indebted to Dr. Tilbury Fox : —
" Biesiadecki has recently investigated the special
pathology of certain inflammatory affections of the
skin, especially in regard to the cell-changes that
take place in them. This observer starts with the
proposition that the demarcation between the epi-
dermis and the corium is not so distinctly defined
as is generally taught. In newly-born children, and
even to some extent in adults, the two structures
are continuous the one with the other. In infants
• In Max SchuUze's " Archives of Physiology,** Dr. Podcopaew
saya that nervous filaments have been traced in and through the
rete mucosum, and have been found to constitute a plexus be-
tween that layer and the horny epidermis. His observations
have been made on the skin of the rabbit, and with the aid of a
solution of the chloride of gold. The discovery is sufficiently
remarkable to need corroboration .
t Vol. iiL p. 326.
378 HISTOLOGI OF EKZEMA.
the uppermost layer of the corium is composed of
a homogeneous blastema and granules ; the rete
mucosum is made up of these same granules that
have developed and invested themselves with a
layer of protoplasm, and as they gradually come
nearer to the surface, they flatten out, and become
more distinctly homy, the nuclei meanwhile shrink-
ing, and causing the formation of vacuolar around
them. In addition, there are certain elongated cells
in the rete mucosum which are supposed to be de-
rived from the cells of the connective tissue. They
are described as small fusiform cells, sometimes
branched, containing one or several nuclei, more or
less flattened out and elongated (staff-shaped).
Now it is believed by Biesiadecki that these parti-
cular cells play an important part in the develop-
ment of skin diseases. In ekzema the papillary
layer of the skin is specially involved ; the first
stage is transmission from the vessels of the papillaa
of a clear serous fluid, by which the papillsB them-
selves are enlarged and, so to speak, distended.
The peculiar cells spoken of a moment since rapidly
enlarge in size and increase in numbers, whilst they
are pushed onward towards the free surface amongst
the cells of the rete mucosum. As they advance
or migrate from the papillsB, these same cells
branch, and form a network of fibres in the inter-
stices of which lie the ordinary cells of the rete
mucosum. Biesiadecki is of opinion that the
branches unite together in such a way as to form
* nutrient canals,' and a channel by which the
transmitted serum is conveyed to the surface.
When pus is formed, Biesiadecki is of opinion that
the connective tissue corpuscles increase at a specially
rapid rate, so as to form a sort of layer oftentimes
in the rete mucosum, and themselves give rise to
corpuscles, the cells of the rete mucosum being
flattened out and compressed into a semi-network
of fibres.**
( 379 )
vm.
Thebapbtjtios of Ekzema.
If any one were to inquire who was the inventor
of medicine, the answer must be, Nature ! Certainly
not man. Or, if we inquire whence our remedies
are derived, the answer would be, from the three
divisions or kingdoms of nature, — the animal king-
dom, the vegetable kingdom, and the tellurian king-
dom. We hear ignorant people not unfrequently
protesting against mineral medicines. But they are
unprepared for the answer, that minerals as well as
vegetables and animals are fashioned by the hand of
the Almighty for the natural food of man. Iron, as
we know full well, abounds in our drinking-water ;
and we have only to point to the village of Whit-
beck, in Cumberland, for an example of arsenic
destined to be the food of man. The river stream
that flows through Whitbeck contains a considerable
quantity of arsenic ; so much, in fact, that neither
ducks nor trout can live in its waters, and yet this
is the sole drink employed by the inhabitants from
the day of their birth to their last hour. And, then,
we often find these very protesters taking under their
patronage the vegetable remedies, the rapid jalap, or
the gentle colocvnth, the squirting elaterium, or,
perchance, the lethal aconite, the blinding bella-
donna, or the cramping nux vomica. No wonder
that the uninitiated should seek to inquire in what
manner these, and such as these, become the remedial
agents of man. We know that our older Phar-
macopoeias contain some strange and startling
remedies. Take one example, album ^rsecum, the
stercus canis ; and yet there is wisdom m the use of
380 THERAPEUTICS OF EKZEMA.
this substance, although its first mentiou excites only
disgust. The medicine of the album graecum or
album canis is phosphate of lime in a state of im-
palpable subdivision, a remedy, under appropriate
circumstances, of the highest possible therapeutical
value. But animals are physicians as well as man,
and the dog is not slow in retaliating upon his
master. The dog is sometimes costive, sometimes
bilious, and, upon homoeopathic principles, lie dis-
covers a remedy in the waste bile of man, which he
swallows greedily when his needs demand. Nay,
we ourselves have found in fel bovinum an elegant
as well as an excellent remedy ; but no better, set-
ting prejudice aside, than that which the dog finds
nearer home in the stercus domini. But we took
up our pen not to repeat that which is known to all
who have studied medicine, but to narrate an illus-
tration which has just been mentioned to us as a
common practice in Mexico. Major C„ our informant,
accompanied Fremont's American expedition to
Mexico in 1847, and while in the plains at the foot
of the Rocky Mountains, to the east of New Mexico,
and on the homeward march, one of the horses was
suddenly seized with intense colic, which bent the
poor animal almost double. The Mexican owner
immediately threw the animal on its back, while one
of the party, at the shortest notice, produced a
cylinder some eight or ten inches long of the well-
elaborated material so fascinating to the dog when
suffering under intestinal difl&culty. The stercus
hominis was gUbly thrust down the horse's gullet,
and he was allowed to rest. In a very short space
of time all his spasm ceased, the animal had a
copious relief from its bowels, and it was well and
able to pursue its journey. Who first, it may be
said, suggested this valuable remedy to the muleteer ?
Possibly, the dog ; we doubt very much if he derived
it from the tables of the Asklepiadas, or fi*om the
books of the learned. Sometimes, no doubt, neces-
THEBAPEUTICS OP EKZEMA. 38 1
sity may be the mother of invention. We can under-
stand that to the victim in the agonies of the intense
pruritus of a chronic ekzema, the chamber utensil
may be made to supply the i)lace of an experimental
bath, and, in fact, may prove salutary where other
means have failed. We know a learned professor of
medicine, who, suffering habitually from intertrigo
in the grooves of his prepuce, finds suffusion with
urine his best remedy ; and we have known of
instances in which chronic ekzema in the dog was
treated successfully by similar means. But we were
scarcely prepared for the statement of a patient who
applied to us the other day for the treatment of
chronic ekzema, and who informed us that for many
months she had drunk every morning a wineglassful
of her own urine ; but, alas I without any beneficial
result. The theme is suggestive and interesting, but
practically, unless in the instance of the horse and
the dog, of little real value.
( 383 )
INDEX.
Ac ABUS Bcabiei
.. 233
Classification, Hard/s
FA«a
... 128
Acid remedies
.. 113
— EEebra's
... 130
A liberies classificatioii
.. 126
— homoeopathological
... 130
Alkaline remedies ... .
.. 113
— Lorry's
... 135
Alterative remedies ...
.. 118
— physiological
... 132
Aperient remedies ... .
.. 118
— Plenck's
... 120
Arnica an irritant ...
.. 339
— Bayer's
... 123
Arsenical remedies ... .
.. 213
— systemo-pathological
... 130
Asthma, ekzematous
.. 340
— Willan's
... 121
Ajdle corpuscle
4
Clinical classification
... 133
CoBliaca
... 24
Basement membrane
Baum^ classification
Bazin's classification
1
.. 137
.. 138
Colour, pathological
Complexion of the skin
Constitutional remedies
/^ J. ♦
... 57
... 11
... 118
Benzoated ointments
Biett's classification
^jiKO ... ... ... .
Bulla
.. 112
.. 124
.. 15
15 47
Contagion
Copper colour
Corium •••
Corpusculum tactfis ...
... 102
... 17
... 1
... 4
JJUliO* > » ... ... ...
i.*/i ti
Crusta lactea
... 18L
Cutaneous sympathies
... 331
Caustic remedies ... .
.. 114
Cuticle
... 6
Gazenave and Schedel
.. 124
Outis • • .
... 1
Chaps
.. 71
Cutis anserina
... 3
Chill, nature of ... .
.. 18
Cicatrization
.. 73
MJKnnJk ... ... •••
... 1
Classification
.. 119
Dermatitis
... 16
— Aliberfs
.. 126
Dermatitis exfoliativa
... 356
— Baumds'
.. 137
Dermato-pathological classi-
— Bazin's
.. 138
fication
... 130
— Biett's
.. 124
Desquamation
... 63
— clinical
.. 133
Devergie's classification
... 124
— dermato-patbological .
.. 130
Diagnosis
... 93
— Devei^e's
.. 124
Diathetic classification
... 139
— diathetic
.. 139
Dietofekzema
... 263
— etiological
.. 133
Discoloration
... 79
— Gibert's
.. 124
Distribution of eruptions
... 80
84
IKDEX.
Ekzeha
rAOB
141
Ekzema scabidum
rxoB
... 155
— articulonim...
•
168
— sklerosum ...
... 167
— assimilative ...
183
— spargofiiforme
156, 371
— capillitii
268
— squamosum . . .
150, 373
— capitis
. 162
— statistics of ...
... 265
— causes of
344
— substitutive . . .
... 323
— circumscriptum
161
— successivum . . .
... 159
— congenital ...
351
— sulcorum
... 167
— constitutional relations .
. 175
— table of forms
146, 158
— coriaceum . . .
• • «
157
— traumatic ...
337, 340
— crustaceom ...
• • 4
155
— treatment of
... 195
— definition of
• • 1
141
— tuberosum . . .
156, 368
— diagnosis of
• • 4
176
— unguium
... 174
— diathesis
• ■ 1
. 181
— varicose
... 188
— diet of
■ • 1
. 263
— verrucoBum . . .
... 157
— diffusum
• • *
161
— vesiculoBum . . .
... 148
— erythematosum
m m t
. 147
Ekzema with adenosis
... 313
— etiology of ...
178
,325
— asthma
... 340
— exanthematosum . . .
• • 1
159
— bronchitis ...
... 309
— exciting causes
of
■ • «
187
— dentition
... 318
— exfoliativum
• * *
356
— dermato-xenuiia
... 312
— faciei
• m i
165
— dyspepsia . . .
... 313
— figuratum . . .
• • i
161
— erysipelas . . .
... 311
— fissum
• • fl
154
— furunculosis
306, 343
— foliaceum . . .
• • «
361
— gout
... 316
— hereditary ...
• ■ •
354
— bsBmorrhoids
... 319
— ichorosum ...
149
, 373
— leicben tropicus
... 310
— impetiginosum
• • m
150
— lupus eiythematosus ... 312
— infantUe
• • 1
247
— menstrual disorder
... 317
— madidans ...
• • 1
149
— neuralgia ...
... 310
•— mammae
• • 1
. 170
— parturition ...
... 317
— manuum
t ■ <
171
— phy toais
... 312
— marginatum...
■ • 1
153
— pityriasis
... 307
— mucosum
• • 1
155
— pruritus
... 310
— neurosum . . .
« • fl
157
— rheumatism . . .
... 316
— neurotic
• • «
184
— rubeola
... 318
— nummulare . . .
• • •
161
— scabies
... 309
— nutritive
• • ■
182
— scrofuloRis ...
... 312
— oedematosum
• « •
156
— sykosis
... 311
— papulosum . . .
• ■ •
147
— uterine disorder
... 317
— pathological phenomena
i 305
— varicose veins
... 319
— pedum
• « *
171
Ekzematoua affections
... 218
— perinsRl
* • •
169
Epidermis
...
5
— predisposing caoseB
of!!!
186
Erythema
...
... 15
— prognosis of
• ■ •
193
— ichorosum ...
...
... 375
— pudendi
• • •
169
Esthiomenon . . .
...
... 73
— pustuloBum ...
« • •
150
Etiological dasaification, 1 33, 1 35
— recurrent
• • •
320
Etiology
• . a
... 95
INDEX.
385
Exanthema
Excoriation
I • • • •
••t ••• •*•
TAom
15
67
Fattt remedies 112
Ferro-araenical mixture, 202, 262
Eission 71
Follicles of skin 2, 9
OiBEBT*s classification ... 1 24
Glycerine Ill
Goose skin 3
Hair-follicle
Hair, structure of
Hardy's classification
Hebra's classification
Hereditary
Hereditary ekzema
Histology of ekzema
Homoep-pathological
fication
Hyperplasia
Hypertrophy
Hysteria ...
ICHORRHCEA
Impetigo ...
— figurata
— rubra ...
— sparsa . . .
Incrustation
Induration
Iodine remedies
Irritation, local
— propagated .
Itch
. . . ...
. * . ...
... ...
Emidosis
Lead remedies . . .
Leichen
— annnlatus ...
— drcinatus . . .
— circumscriptum
— febrilis
— gyratus
— lividus
— marginattiB ...
• . ...
classi-
• • ■ • •
* • • • •
9
11
128
130
105
354
376
130
21
21
24
• • • ••
■ • • • •
• • • t •
... 149
27, 229
... 231
... 375
... 231
69
68
... 115
.. 331
... 337
... 232
98
... 116
... 2-20
... 224
... 224
... 223
... 222
... M^O
... 229
... 225
Leichen pilari<4...
— plaaus
— pruriginosus
— simplex
— strophulosus
— tropicus
— urticatus
Lesions of the skin
Limitary membrane
Lines of motion
Lorry's classification
I . . ...
Macula
Melitagra
Mercurial remedies
Milk crust
Milk rash
rAoi
... 229
... 227
225, 273
... 222
... 226
... 222
... 226
14,29
... 1
6
... 135
15,56
.. 71
.. 117
.. 272
.. 272
Nature's therapeutics
Nerves of rete mucosum
Nervous sympathies..
Nitrate of silver
OiLT remedies
Ouloid cicatrix ...
« • • • •
• * • • •
Pain of skin
PapillflB cutis
Papillary body
Papula
Pars papillaris
Pathological lesions..
Pathology of skin
Pemphix
Phagedena
Phlyzakion
Phyma
Physiological classification
Physiology of the skin
Pimple
PityriasiB ...
— rubra . . .
Plenck's classification
Pompholux
Pomphos ...
Pores of skin
Porrigo
Powders
2n
... ...
... ...
... . . I
••• ... ... ...
379
377
13
116
112
76
18,23
... 2
... 2
15,31
... 2
14,29
... 14
... 47
... 73
44, 230
55
132
11
15
164
356
120
47
47
2
155
110
386
INDEX.
Prickly heat
PriiDAiy leuona
Ph>pagated irritation
XOT>ra. . • • • •
Ftoriaris ...
— sqaamoaa
Psydrakion
Postola ...
Ratb&*8 classification
Red gom
Redness of akin
Remedies
Rete muoosam
Rhagades
Rubor
Scabies
»- phljktaenodes
Sebiparous glands
Sebum
Secondary lesions
Sensibility of skin . .
Silver remedies
OWilf ... .•• .«• ..
Soap-cure of scabies . .
Speedy cure of scabies
Squama
Statistics of ekzema . .
Strophulus confertns
— intertinctus
-» Tolaticus
Styrax cure of scabies
Succession of disease
Sudoriparous glands...
FA«S
... 222
29,61
... 331
... ^0
25, 164
... 361
44, 230
15,41
123
272
16
106
7
71
29
27, 232
. 372
5
. 9
9
29, 63
. 12
. 116
. Ill
. 245
. 245
15,49
265, S80
. 227
. 227
. 227
. 224
. 329
WAQM
Sulphur cure of scabies ... 244
Sulphur remedies 117
O WOnw ... ••• •.. ... V
Swelling of skin ... 17,21
Systemo-pathological classi-
fication 130
... • • •
• . • • • •
... • . •
• • • ...
. • . t . •
•• • • • •
Tab remedies
Temperature of skin . . .
Therapeutics
Tinea amieutaoea
— asbestina
Tonic remedies . . .
Tooth rash
Traumatic eksema
Tuber
Tubercle
Tuberculum
Tumour ...
Tumer^s cerate .. .
UljCERATIOlf ... .
Urticaria ,
Vegetable remedies
Vesicant remedies ..
Vesicula ...
• • • . . •
• . • • . •
... . . <
Wateb, as a remedy
Willan's classification
— definitions
Xebo-lbichenes
ZiKC remedies .. ..
... 115
18,23
106, 379
. 162
. 162
. 118
. 272
.. 337
.. 55
.. 15
15,52
.. 55
.. 197
.. 72
.. 98
.. 114
.. 113
15,36
... 10f»
... 121
... 16
.. 281
. . 116
!
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A CLASSIFIED INDEX
SO
\
AVATOirr.
Anatomleil Bemembnaeer .. 7
Flower oa Nerres 16
Heale'a Anatomj of the Longs 19
Heath's Praetieal Anatomj .. SO
Holden*s Hainan OsteoloiOr •• SO
Da onDlMectiona .. .. 80
Jones* and SloTeking's Patho-
logical Anatomy 83
MacDoqgal--Hlnichfeld on the
NeiTona System t
MacUae's Sorgleal Anatomy .. 86
St Bartholomew's Ho^tal
Catalogne 81
Sihaon's Medical Anatomy .. 88
Waters' Anatomy of Long .. 87
Wheeler^ Anatomy for Artiats 88
WUson's Anatomy 89
0HEMI8TBT.
Bemays' Notes for Stndenti .. 9
Blozam's Chemistry 10
Da Laboratonr Teaching 10
Bowman's Practical Ghemlatry 10
Do. Medical do. .. 10
Fownea'Mannal of Chemistry.. 16
Do. Actoniaa Prise .. .. 16
Da QoalltatlTe Analysis .. 16
Fresenltts* Chemical Analysis.. 17
QaUoway's First Step .. ..17
Da SecondStep .. .. 17
Do. Analysis 17
Do. Tables 17
Qrifflthsf Fonr Seasons .. .. 18
Horsley'sChem-Philoeophy .. 81
Mulder on theChemlstry of Wine87
Plattner & Mnspratt on BlowpipeSS
Shnttleworth'8ModeniChemiil^8a
Spoor's PathoL Chemlstiy .. 84
Sutton's Yolnmetrlc Analysis . 84
CXJMAXS.
Bennefs Winter in the South of 9
Europe •* .«
Cbsmbers on Italy 18
DataTmpIs on Enr* 14
Frands on Change of GUnate.. 16
Qrabbam on Madeira .. .. 18
HaU on TorquaT 19
HarUaad on donate 19
Horton on West Coasiof Africa 81
LeeonClimate 84
Do. Watering Places of England 84
McClelland on Bragal .. .. 86
McNlcoU on Sonthport .. ..86
Martin on Tropical Climates .. 86
Moore's Diseases of India .. 86
Fsttenon's Egypt and the Nile 88
Sooresby-Jackson's Climatology 88
Bhapter on Sooth Deron .. ..83
Slordet on Mentone 88
Taylor oa Pan and Pjrspecs .. 86
DSFOEMITIES, Aw.
Adams on Spinal Cunrature
Do. on Clohfoot . . . .
Bigg's Orthopraxy . . . .
Bishop on Deformities
Do. Articolate Sounds
Brodhurst on Spine .. ..
Da on Clubfoot
Hugman on Hip Joint
Salt on Lower Extremities
rA«a
6
6
9
10
10
11
11
81
81
OENEBATIVS OSOAlfS,
SifMiei of; and SYPHILIS.
Acton on BeproductiTe Organs 6
Coote on Syphilis 14
Coolson on Syphilis 14
Oant on Bladder 17
Hutchinson on Inherited Syphilis 88
Lee on Syphilis 38
Oppert on Syphilis 87
Parker on Syphilis 87
WQson on Syphilis 89
EYOIEHX.
Armstrong on Naval Hygiene 7
Beale's Laws of Health .. .. 8
Carter on Training 18
CharasBe'sAdTicetoaMother.. 18
Da Counsel to do 18
Da AdTioe to a WiilB .. 18
Dobell's Oerms and Vestiges of
Disease 16
Fife & Urqnhart on Turkish Bath 16
Oordonon Army HTgiene .. 17
Hartwig on Sea Bathing .. ..19
Hartwig on Physical Education 19
HufeUnd's Art of prolonging Lite 8 1
Hunter on Body and Mind . . 81
Lee's Baths of France,Qennany,
uid Switserland 34
Lowndes on the Maintenance
of Health 36
Moore's Health in Ttopios .. 86
Parkes on HTgiene 88
Parkin on Disease 88
Pearae's Notes on Health.. .. 88
Picklbrd on Hygiene .. .. 88
Robertson on Diet 81
Bonth on Inlknt Feeding.. .. 81
Wells' Seamen's Medicine Chest 88
Wilson on Healthy Skin .. .. 89
Do. on Mineral Waters .. 89
Da onTorUshBath .. ..89
KAXmiA XEDICA and
PEABXAOT.
Beasle^s Formulary 9
Da Receipt Book .. .. 9
Da Book of Presoiptloas 9
KATEBU XEBIOA and
Birch on Oxygen 9
Brunton on Digitalis 11
Flux on Sale of Poisons . . . . 16
Lescher's Elements of Pharmacy 84
NeTins' Analysis of Pharmacopi 87
Perelra's Selecto ^ PrMcriptis 88
Prescriber's PharmaoopoBia .. 89
Boyle's Materia Medica .. ..81
Squlre'sHospitalPharmacopKlas 84
Da Companion to the Iliar-
maoopssia . . 84
Steggall's First lines for Che-
mists and Druggists .. .. 34
Stowe's Toxlcolo^al Chart .. 84
Taylor on PolMms 86
Wahltuch'B Materia Medica .. 87
Waring's Therapeutics .. ..87
Wittstein's Phannaey .. .. 89
^^^^A^^A^
XEDIdNS.
Adams on Rheumatic Gout .. 6
Addison on Cell Therapeutics . . 6
Do. on Healthy and Dis-
eased Structure 6
Aldis's Hospital Pznctice .. .. 6
Anderson ^Andrew) on Fever . . 7
Austin on Paralysis 7
Barclay on Medical Diagnosis. . 8
Do. on Gout 8
Barlow's Practice of Medldne 8
Basham on Dropsy 6
Braidwood on Fyasmia
Brinton on Stcnnaeh
Do. on Intestinal Obstnetlon
Bndd on the Lirer
Budd on Stomach
Camplln on Diabetes
Catlow on JBstheUc Medidne . .
Chambers on the Indigestions
Da Lecturea
Cockle on Cancer
Dale's Practical Medldne . . . .
DaTey'sOanglionlcNenronsSyst
Day's Clinical Histories .. ..
Elam on Medldne, Disease, and
Death
Eyre on Stomach
Fenwickon the Stomach.. ..
Do. on Dlagnods
Fuller on Rheumatism . . . .
Galrdner on Gout
Gibbon Throat
Do. on Laryngoscope .. ..
Gully's Simple Treatment
Habershon on the Abdomen . .
Da on Mercury . .
Hall (Marshall) on Apnoea
Da Obserrations ..
Headland— Action of Medicines
Da Medical Handbook
Hooper's Physidan'a Vade-
Mecun •• •• t*
1
1
1
1
8
8
8
8
8
4
4
6
6
6
6
16
9
!
¥^^»^
TV
CLASSIFIED INDBX.
f
^
Inmas*s New Theory .. .. M
Do. MvalfcU 21
Jamea on Larynffoicope . . . . SS
Jencken on Cholen SS
Jone« (Bence) on Petholosy ead
Hicnpentics ti
MAcUcliUn on Advenred Life.. SA
Mac fiend on Acholic Dlteawe.. S5
Maeleod'sBenKhyddlng.. .. S5
llAenemare on Cholera .. .. SA
Marcet on Chronic AlcohoUim . 2A
If acphmon on Cholera .. .. 26
Merkham on Bleeding . . . . S6
Mertyn on Hoofrinc CoOKh . . 26
Morria on Germinal Matter . . 27
Mnryon on Paralysla . . . . 26
MnMiet on Apoplexy 27
Nlchnlton on Yellow Fever .. 27
Piirkin on Cholera 28
PaTy on Diaheice 28
Do. on Diircetinn 28
Roberts on ralcy 81
Robertion on GoQt 31
Sanson) on Cholera 82
Savorv's Domestic liedidne .. 82
Sempfe on Coni^h 32
Seymour on I>ropC7 8>i
$h«w*s Medical Rememhrancer 32
Shrimpton on Cholera . . . . 82
8mee *m Debility 83
Steggairs Medical Manual .. 84
Thomas' Practice of Phytic .. 8A
Thndlchum on Gall Stones . . 8A
Tndil** Clinical Lectures . . ..36
Tweedle on Continned Ferers 86
Walker on Diphtheria .. ..87
WliMt to Obeerre at the Bedside 2.)
Williams' Principles 38
Wright on Headaches .. ..89
KICBOSCOFE.
Beale on Microscope In Medldne 8
Carpenter on Microscope . . .. 12
Schachtou do 82
^^^^%^^^^
mSCELLANEOTJS.
Acton on Prostitution . . . . 6
Barclay's Medical Krrors .. .. 8
Ba.«cnme on Epidemics . . . . 8
Buckle's Hospital Statistics ..II
Coolcy's Cyclopsedla . . .. ..13
Edwards' I'hntORmphs .. .. lA
Gordon on China 17.
Graves* Physlolofry and Medicine 17
Guy's Hospital Reports . . . . 17
Harrison on Lead in Water ..19
H ln(reston*s Topics of the Day . . 20
Howe on Epidemics 21
Lane's H}'dropathy 23
Lee on Homoeop. and Hydrop 24
London Hos?iltal Reports. .. 24
Maync'a Medical Vocabulary . . 26
Oppert on Hnspitali 27
Part's Case Book 28
Redwood's Supplement to Phar-
macopoeia 80
Ryan on Infanticide 31
St. George's Hospital Reports . . 31
Slmms' Winter in Paris .. ..83
Snow on Chloroform 83
Wnrinff's Tropical Resident at
Home 87
Wlillehrad on Transmission . . 88
Wise's Med. amongst Asiatics.. 88
VEBV0U8 DI80BDEB8
AHD nrDiossnoK.
AlthansonBpllepey,Hyiteria,Ac. 7
Birdi on Constipation .. .. 9
Carter on Hysteria 12
f)ownlng on NeuTalgla .. ..15
Hunt on Heartburn 21
Jonea(HMndffeld) on Ftmctknud
Nervous Disorders 22
Lmred on Imperfect Digestion 28
t«obb on Nervous Affsctioos . . 24
Morris on Irritability 26
Reade on Syphilltle Afltetions
of the Nervous System .. ..80
Reyn^ds on the Brain . . . . 80
Do. on Epilepsy .. ..80
Rowe on Nervous Diseases ..81
Slevcking on Epilepsy . . . . S3
Tombull <MDi Stomach .. .. S6
OBSTETRICS.
Barnes on Obstetric Operations 8
Hodges on l*uerpera1Convulslons20
Lee's Clinical Midwifery .. ..24
Do. ConKUltat'ons 24
Leishman's Mechaniam of Par-
turition 24
Pretty's Aids during Labour .. 29
Priewtley on Gravid Uterus . . 80
RMmsbotham's Obstetrics . . .. 80
Sinclair & .TnhnKton'R Midwifery 83
Smellle'H Obstetric Plates . . . . 33
Smith's Manual of Obstetrics . . 33
Swaync's AphnriNms 34
Waller's Midwifery 87
^^^^JW^^**
OPHTHAIMOLOOT.
Cooper on fnJnries of Eye .. 13
Do. on Near Sight .. ..13
Dalrymple on Rye 14
Dison on the Eye IS
Hogg on Ophthalmoscope . . 20
Hulke on the Ophthalmoscope 21
Jago on Entoptics 22
Jones* Ophthalmic Medicine .. 23
Do. Defects of Sight .. ..23
Da Eye and Fat 23
Macnamara on the Rye . . . . 2-^
Nunnelcy on tiie Organsof Vision 27
Power's Illustrations of Dis-
eases of the Eye 29
Solomon on Glaucoma . . . . S3
Waltrm on the Eye 87
Wells Treatise on the Eye . . 88
Do. on Spectaclea 38
Wolfe on Cataract 89
^»WS»W»»M»
PHTSIOLOOT.
Beale on Protoplasm 8
Carpenter's Human 12
Do. Manual 12
Heale on Vital Causes .. ..19
Richardson on Cosgnlatlon . . 30
Shea's Animal Physiology .... 82
Vlrchow's (cd. by Chance) Cel-
lular Pathology 12
P8TGH0L00T.
Arlidge on the State of Lunacy 7
Bncknill and Tuke's PqrclKdo-
glcal Medicine 11
Davey on Nature of Insanity . . 1 4
Hood on Criminal Lunatics . . 2t
Murray on Erootidiial Diseaaea 27
Noble on Mind 97
Sankey on Mental I>tsea8es . . SI
Van der Kolk on Mental Diaeaae 37
Winalow'e Obscure Dia of Bxain 19
PUIKOHABT tnd CHEST
DISEASES, te.
Alison on Pulmonary Gonsnmp-
tion
Bright on the Chest
Cotton on Stethoscope . . . .
Davles on Lungs and Heart . .
Dobell on the Chest
Da on Tnlwcnlosto .. ..
Da on Winter Cough . . . .
Do. First Stage of Conaump-
tion
Fuller on the Lungs
I)a on Heart
Jones (Jas.) on Consomptioa . .
Laennec on Auscnltatioo . . . .
Markham on Heart
Peacock on the Heart .. ..
IMrrio on Hay Asthma .. ..
Salter on Asthma
Skoda on Auscnitstlon . . . .
Ttiompson on Consumption . .
Thnrowgood on Asthma . . . .
Tlmms on Consumption . . . .
Tumbull on ConsnmptlOB
Waters on the Chest
Da on Emphysema .. ..
6
10
14
14
15
16
IS
18
16
JO «.
16 A
23 T
23
26
28
29
31
26
88
88
86
86
37
S7
i
M^^tf^^W
BEVAL uid URDTABT
DISEASES.
Acton on Urinary Organs . . 6
Beale on Kidney Diseaaes . . 6
Bird's Urinary Deposits .. ..10
Coulson on Bladder 14
Haasall on Urine 19
Parkcs on Urine 28
Tlindichum on Urine . . . . 86
Todd on Urinary Organs .. ..86
SCIEirCB.
Baxter on Oiganic Polarity .. 8
Bentley's Manual of Botany .. 9
Brooke's Natural Philosopby ..II
Hardwich's Photography.. .. 19
Hinds' Harmonies 20
Howard on the Clouds .. ..21
Huxley on ClaasUieatioii of
Anlmsls t2
Jones (Bence) on Matter and
Force 22
Jonea (Wharton) on Vision . . 23
Da on Body, Sense, and Mind 23
Mayne's Lexicon of Terms . . 26
Moad on the Induotorinm .. 27
f
!
CIiASSIFIED INDEX.
8GISHCE— «MlMaf«f.
Prmtt*iG«neftlog7 0fCrBttlon.. 99
Da Soeentric* Centric Foroa 99
Do. on Orbital Motion .. ..99
Do. AMtronomicallnTattifatlou 99
Do. OniclMofQod 99
Price*! Phntogrtplij SO
Ralney on Shells 30
Roymond't Animal Elaetridtj 80
Tajlor't Medical JnrispnideDca 35
Veatlgw of Creation 86
^»^^^^^»
8T7BOEBT.
Adaina on Reparation ofTendona 6
Da Subcutaneous Surgery 6
Anderson on the Slcin . . . . 7
Ashton on Rectum 7
Brodliarst on Anchylosis . . . .
Bryant on Diseases of Joints . .
Do. Clinical Snrgery ..
Odlender on Rupture .. ..
Cliapman on Ulcers
Do.. Varicoas Veins.. ..
Clark on Visceral Leiions
Da Outlines of Surgery .. ..
Collia on Cancer
Cooper (Sir A.) on Testis . . . .
Da (S.) Surg. Dictionary
Coolson on Stone in Bladder . .
Curling on Rectum
Do. on Testis
Dmitt's Suriceon*s Vsde-Mecnm
Fayier's Clinical Surgery
FergusMm's Surgery
Da Progre<iS of Surgery
Oamgee'sAmputationat Uip-|olnt
8T7BOEBT— «Mi/M«#(il
Oant*B Principles of Surgery .. 17
Osy on Varicose Disease .. .. 17
Heath's Minor Surgery and
Bandaging 90
Do. on the Jaws 90
Higginbottom on Nitrateof SiWer 20
Hodgson on Prostate 90
Holt on Stricture 91
Lawrence's Surgery 93
Da Ruptures 93
Lee oil the Rectum, Ibc . . . . 93
Listen's Surgery 94
Logan on Skin Diseases . . . . 94
Macleod's Surgical Diagnosis . . 25
Macleod's Surgery of the Crimea 95
MacUse on Fractures 95
Manden on Cancer Vi
Mannder*8 0poraiiTe Surgery.. 96
Kayler on Skin Diseases . . . . 97
Nunneley on Erysipelas . . . . 97
Plrrle's burgery 99
Pirrle * Keith on Acupressnro 99
Price on Bxclslon of Knee-joint 99
Hamiay and Coles on Deformi-
ties of tlie Mouth 80
Sanaom on Chloroform . . . Z%
Smith (Hy.) on Stricture . . . . 33
Da on Uaiiiorrhoids .. ..33
Doon the Surgeryof the Itontum 33
Do. (Dr. J.) Dental Anatomy
and Sursery 33
Spender on Ulcers 34
Steggail's Surgical Manual .. 34
Swainon tbs Knee<Joint.. .. 34
Tliciipeon on Stricture .. ..34
Da on Prostate . . . . 35
Da Lithotomy and Llthotrity 35
Da on Urinary Organs.. ..85
SUSGEBT— eoff/MvedL
Tomes* Dental Surgery .. ..36
Wade on Stricture 87
Webb's Surgeon's Ready Rules 37
Wilson on Skin Diseases . . . . 39
Da Portraita of Skin Diseases 39
Tearsley on Deafhesa .. ..39
Da on Throat 89
VETEBIirART XSDICIHB.
Blaine's Veterinary Art .. ..10
Bourguignon on the (battle Plague 1
Haycock on Shoeing Horses . . 19
Tttson's Pbarmacopceia .. ..86
»^l*»/^^^»^^S^
WOKBH AKD OHILDBEK,
Diseuoi of.
Ballard on lufiuits and Mothers 7
Bennot on Uterus 9
EUlK on Children 15
Eyre's Practical Remarks ..15
Harrison on Children . . . . 19
Hood on Scarlet Feror, Ac . . 91
Klwisch(ed.byClayionOTaries 13
Lee's OvsrUn A Uterine Diseases 94
Da on Speculum 94
Ritchie on Ovahea 81
Seymour on Ovaria 89
Tilt on Uterine Inflammation.. 86
Do. Uterine Tlterapcntlcs ..36
Do. on Change of Life . . . . 36
Underwood on Children . . . . 86
West on Women 38
Wright on Uterine Dlsordsrs . . 39
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EYE, DISSASE8 07. With oolonred Plates and Engravings on Wood.
By C. BIacnamara.
MATERIA XEDICA. With namerons Engravings. Fifth Edition.
By J. FoBBEs RoTLB, M.D., F.R.S., and F. W. Headland, M.D., F.L.S.
MEDICAL JTIBISPBUDEHCB. With nnmerons Engravings. Eighth
> Edition. By Alfred Bwainb Tatlor, M.D., F.R.S.
PBACnCB OF MEDIdHE. Second Edition. By G. Hilaro Barlow,
M.D., M.A.
The MICB08C0PE and its BEVELATI0H8. With nnmerons Plates and
Engravings. Fonrth Edition. By W. B. Carpenter, M.D., F.R.8.
HATUKAL PHILGSGPHT. With nnmerons Engravings. Sixth Edition.
By Charles Brooks, M.B., M.A., F.RS. Based on the Work of the
late Dr. Ooldmg Bird,
OBSTETRICS. With nnmerons Engravings. By W. Ttler Smith,
M.D.| F.R.C.P.
OPHTHALMIC MEDICIHE and STJBOEBT. With coloured Plates
and Engravings on Wood. Third Edition. By T. Wharton Jones,
F.R.C.S., F.K.0.
PATHOLOGICAL AHATOMT. With nnmerons Engravings. By C.
Handfbld Jones, M.B., F.R.S., and E. H. Sievekino, M.D., F.R.CJP.
PHTSIOLOGT. With nnmerons Engravings. Fonrth Edition. ByWiLUAX
B. Carfenteb, M.D., F.RS.
POISOHS. Second Edition. By Alfred Swains Tatlor, M.D., F.RS.
PBACTICAL ANATOMT. With nnmerons Engravings. Second Edition.
By Christopher Heath, F.RC.S.
PBACTICAL STJBGEBT. With nnmerons Engravings. Fomth Edition, f
By Sir William Ferousson, Bart., F.RC.S., F.RS.
THEBAPEUTICS. Second Edition. By E. J. Waring, M.D., M.RC.P.
Printad by Blawcbabo ft lloKt, Ol, MUUmoJi StnM, WMtmiiMterr
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