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NEWVOHK HOSPITAL UBSAilV.

THIS WORK MAY BE KEPT OUT
TfVO WEEKS.

« J'

I I

DISEASES OF THE SKIN,

INCLCDINe THX

EXANTHEMATA.

FERDINAND HEBRA, M.Dj^^^ ' ^^

rKOFRBSOE ri-E DKBMATOI.(K2IK AN URK tNIVXRaiTA'T. rHli4%^Mf"]>*m AlftltiWWPIO tVti
IIAITKRAKKIIKITKIC IM K. K. ALL6. KKANKKNHA^E IK WIXX, XTC. ITC.

THAN

C. HILT

MKXBBK or THX BOT]^4!OU.IOB 07
AS81STAnT-PnTS1CIA!l TO, AlfD DKMOItifKXTOS -OrlCUTAlfXOVS DlSXABXa AT,

0U1*8 BOSnTAL.

AND

P. H. PYE. SMITH, B.A., M.D.,

MEMRXK OP THK KOTAL COLLROK OP PIIT8ICIA58;

LCCTVBEX ON COMP4KATIVK AITATOMT, A5D DKMOHSTKATOX OP AlfATOMT. AT OCT'B BOSPITAL

A8S1!«TA?IT-PHT»ICIA?( TO THB MKTXOPOLITAIf PKKB BOSPITAL.

THE NEW SYDENHAM SOCIETY,

LONDON.

MUCCCLXVIII.

■4
I

THE NEW SYDENHAM

SOCIETY.

INSTITUTED MDCCCLVIIL

VOLUME xxxvn.

^' V.

DISEASES OF THE SKIN.

INCLUDINe THX

EXANTHEMATA.

FERDINAND HEBRA, M.DjS^^"'

rmorKMom riim drbmatoi.ooik an dkk i'mvxesitat. rmmA^^wyf^tiTjjS^mii

IIALTKIAKKUKITKIC IK K. K. ALI^. KKANKKNDpME 1> WIXX, XTC. ITC

\^^:.'<^

TRAK

C. HILT

AND XDITKD BT

MKXBBB or Tint BOTBki«GOI.LBOB 07 FSXMefAKS ;

AMirrAirr-pnTBiciAR to, ah d wtuomtxtcm, -oT'cvtaneous dibxabbs at,

GUI's BOSriTAL.
AND

p. H. PYE. SMITH, B.A., M. D.,

MBVBBB OP THK KOTAL COLLKOK OP PRTSICIANS:
LBCTUBBB OH COMPABATIVB ANATOMT, A5D DKMOIfBTBATOB OP AHATOMT. AT OUT'S BOSPIT
ABS1STAHT-PHTSICIAN TO THB MBTBOPOLITAIf TBKB BOBFITAL.

THE NEW SYDENHAM SOCIETY,

LONDON.

MDCCCLXVIII.
O

• • •

» • •

• •

• • •

PSIKTKD BT J. B. ADLARD, BABTBOT.OXKW CtOSE.

Tl.». S'-

CONTENTS

THE SECOND VOLUME.

CHAPTER XVI.

Class IY. — Exudatiokes Cutakeje (continued).
Cbbonic Exudative Debmatoses.

FSOBIASIS

History

Characters

Diagnosis

Prognosis

Etiology

Anatomy

Treatment

.- • ••

LltSjSEK

X. %erofulotoruw
L, ruber

CHAPTER XVII.

27895

2.Tt95

CONTENTS.

CHAPTER XVIII.

Pityriasis bubba .

PAGE

CHAPlTiR XIX.

Eczema . . . . .

History . . . .

Definition . . . .

Varieties . . . .

Aeuie eczema

Acnte eqiema of the face .

of the genitals

of the hands and feet .

Universal acute ecsema

Chronic eczema

. 97

Chronic eczema of the scalp

. 100

of the face

. 102

of the trunk

. 108

of the genitals

. 109

Eczema marginatum .

. 112

of the joints .

. 114

of the hands and feet .

. 115

of the legs

. 116

Diagnosis . . . .

117

Prognosis

. 122

Anatomy

. 124

Etiology

. 125

Treatment

. 140

VIU

CONTENTS.

CHAPTEB XXII

Acne dissemivata
History
DeQuition
Yarieiiea
Coone
Diagnosis
Etiology
Anatomy
Treatment

278
284
285

287
288
289
291
293

CHAFrEK XXIIl.

Sycosis .

300

History

. 300

Definition

. 306

Diagnosis

. 308

Prognosis

. 309

Etiology

. 309

Anatomy

. 312

Treatment

313

CHAPTER XXIV.

ACVB B08ACEA

. 319

History

. 319

Symptoms

323

Conrse

. 324

Diagnosis

327

Prognosis

. 328

Anatomy

328

Etiology

. 328

Treatment

333

CONTENTS.

CHAPTER XX.

Scabies ....
History
DcGnition
Symptoms

Natural history of the Acanis scabiei
Scabies Norvegiea
Diagnosis
Prognosis
Anatomy
Etiology
Treatment

lifj

1«

CHAPTER XXL

Prurigo .
History
Definition
C!ourse
Diagnosis
Prognosis
Anatomy
Etiology
Treatment

CONTENTS.

CHAPTER XXV.

VAGE

Pustular eruitions

• 337

History

. 837

Course . .

. 851

Diagnosis

.853

Prognosis

. 354

Etiology

. 354

Treatment

. 358

CHAPTER XXVI.

PBMPmOUS CHRONICUS

. 361

History ....

. 361

Definition ....

. 367

Description . . . . ,

. 369

P. vulgarU

. 369

P,foUacetu

. 371

Etiology ....

. 375

Anatomy . . . . .

. 388

Diagnosis . . . . .

. 893

Prognosis . . . . ,

. 394

Treatment . . . . .

. 395

CHAPTER XXVII.

RUPIA

. 399

CONTENTS.

CHAPTEB XXVm.

PAGE

Class V. — HiEMOBBHAOiJE CuTANEiB .... 403

History . . .403

Process of extravasaiion ..... 404

Furilier changes in the blood .... 408

Seat and forms ...... 409

Idiopathic cutaneous Kamorrhages 413

ExtravataiionjTom contusion .414

from wounds .... 418

from mechanical disorders of the circulation . 419
Symptomatic hamorrhages .... 421

Purpura rheumatica .... 422

simplex, .... 424

hamorrhagica . .427

febrilis — Fariola nigra . • • 433

! NOTE.

/ The Chapters on Psoriasis, Lichen, Pityriasis mbra, Seal

Sycosis, Acne rosacea, Pemphigus chronicns, have been transL
by Dr. Hilton Faggb. Those on Eczema, Prurigo, Acne cliss(
nata, Pustular Eruptions, Rupia, Hsemorrhagise Cutanes, by
Pye-Smith.

DISEASES OF THE SKIN.

CHAPTER XVI.

(CLASS IV.-CHRONIC EXUDATIVE DERMATOSES.')

PSORIASIS.

{SekitpprnfltekU : trvdtmi FltfkU ! Ltpra WUlaiii : Uerpej squamosia, j
ceui ; Dartn iguamatit centrifuge 6/ Aiihert ; Dartn Kckt; drg Sealt.

Since Willan's time, tlie name of psoriasis has been applied to

a disease of the skin characterised by the developmcDt of white

scaIcs piled one above luiotlier, fonniDg miliary or leutil-sixed

, musses, or discoid plates, or circles, and segments of circles. These

I scales are seated upon a base which is red, slightly raised, and easily

made to bleed.

In psoriasis the inilividoal patches, which may be defined as little
I masses of scales resting on a red ground, are always at first distinct ;
it is only as the disease advances that they approach one another, or
coalesce. The affection, although it has a special predilection for
the elbows and kne^, generaily attacks all parts of the body. Uut
each individual patch is for the moat part separated from the others
by a. tract of healthy skin of greater or less size. As a rule, the
dunilion of psoriasis extends over many years, in the course of
which, however, it undergoes repeated changes in form, and often
subsides during longer or shorter intervals.

' In the works of Hippocrates. Galen, and Aetius, we find that

' As Deari; sll ibc CliapteTB in the present Tolume rerer to diseases bcloug-
iog to this Mctiuu of Cliss IV in Professor Hcbra's cUasiriMlion, it lias not
been tlought necessar; to repeat tliii leading at tlie commeDceneDt of each
iDdiiidual clmptrr.— [En,]

* In oij 'Atlas uf Culancoui Di&cuw»,' (lablithed Ij; llie Imperial Aca
of SciuaMj, I laave full/ trcKlcd of the liistor; of iLia affection, t '
here uolj IIiomi points wliicb are particularly iuiportsot.

^^■■^■HiHw * m^hyf^ lvVi9W^*v *^p'>^is occupy.

«M ^ IhM Mid ^ aw»»>lK *Mt thai ii il» dM&lgtt)>lw>ij from botli the
Y^y^ WMfc« ^ w>* V^*'** tlTAMlnk Thw» although tliis nnme
WM,«m4 V ^ V*««*L •«.*«* *<J iH»|J*«' •' '"* " «•'>« difTcrent
(MM M«* %^ ««»* ^«ni fc» BtWM ttivet |«uM«t^ of tim authon
W «Wm » fc«« «rfMM4 •»! KtiHiKP «*^'> <^ I*»Miu8 .Egineta

A.. L^ I Iktl hy !>«' ""niM Lepra, Alplios,

^'\iM(t««tr*l "k'n ■fffPtioiia in wliich
..<a Ht>t il» wIk>I« thickness, was
. ..( .inJ*^ ««^"' formnl. and which
.l.4»-nc«ii.'" *" n-wyiiiae with cer-
■■ ■. witiolt »<• ">* »"w concr-rncd.
,.| u» vti«'»*<* Hiinwpring to our
....nl .|Wiw "f imiwigo, which he
■ j/^-«w y*"i« ('"i^/tfWM) . . .

•. mwm/ t^'* •fitettiuHt

' . .y«- rfw*"**. lf»««i f nor, /m/M-
. ■m<,<*/ur " 'I'll" othrr is tlint form

' >l<»llt> ..f ltll'll«>». Rllc) of w|,i,.|, |,g

' » MM «*-•/•<■ .■ Mfm/HM fCliaN

.'1 '4»#M WJ"'-"

Cfcy** \^'i' VV "''*"* "' ''"' ^'**'*'»" m'Ii.hJ lliw .wniB to have

n l][|jMil|l)Mri*[ U t«i tl)t> iMuiMiiit of tltr> tli*t>H«(<M whjoli by the

^ ^ lf*MW«* **'*»*■ *V1»«. *". 'l'l'"»' "•"I" AlMliaravins

^^* ""V *H* HUHtw I'f "wiy4(#*t mtd «/i*roji n j^^i,, g|.jjj

„, VWUI«1) t"'tll»' (ttwwi'r ri. luir iworinnia, Se'rapion
\,%mm\m h^t*^'^ (p.|.«l«) 10 Jr.iK.mtf a disease
yWW% »'"» ""' ft'Tmtitltm ..f hniiiiy walea, ,nd with
1 lBWU*m »' t litlivl^, .\|pm.. wp rtud that tlali

t*^ I'r '1 ■ "' ri^ ^ '*'^*' " "kin alfcction

\%^\\i* llM*. ..f n.l.«. Mta.ki„K iho surface of

^W« MW (.. m. .,...rl«t.m«. Lastly, w, „,„t ;„

H« *««! w,v«.. « torm whidi wns also used

■ " ""'"i'tl"i'«, Mtendod witli the forma-

' '"'dl" »KPs it was the practice

■ ■■! MivMtiKnlioii, hut merely by taltinrj
'•" ""J Itoii'iins, and commentiiig

■ I'l' », nip, »H (17 ct rg).

^^" wei

apon them ; and this was, no doubt, the reasou vehy le»i attention
was paid to iiidependent observations than to frivolous commentaries
upon the works of preceding writers. Thus, in no one of the books
which appeared between the thirteenth and the eighteenth centuries,
ineludiiig those of Mercurialis, Hafenreffer, Manardus, Sennert, &c.,
do we find any definition which answers to paoriaaia belt«r than
that of CelsuB. Neither Lorry nor Plenck gave an accurate account
of this common affection, although it cannot be denied that both of
them possessed historical knowledge, and were also accurate
observers of nature. In fact, they allowed themselves to be carried
ftwaj by the then prevalent misuse of the word lepra (leprosy),

id tliey consequently described as species of " lepra" all affections
>m which the skin presented a " loathtome" appearance, or which
were particnlarly obstinate and covered the whole surface of the
body. The meaning of the terms lepra, psora, and psoriasis, as
used by the physicians of antiquity and by those of tlie middle ages,
was, then, so obscure that we need not wonder at Willan'a having
been influenced by the opinions of the time, and supposing that
the diseases which he termed lepra and psoriasis were the lepra and
psora of the Greeks. Upon the statements of Paulus .^gineta — that
the lepra forms circular patches upon which are scales like those of
large fishes, and that the psora is more superficial, presents various
forms, and leads to the production of a branny substance — Willan
split up into two the disease (psoriasis) of which I am now speak-
ing. Of these two affections, he termed one Lepra Grrecoram,
because it presenled circular patches ; the other. Psora leprota,
or (to prevent mistakes) Psoriasis, for, as is well known, the word
psora had also been used to designate another skin afi'ection, namely
scabies. Since Willan's time it haa been shown that there is nc
ground whatever for thus arbitrarily dividing one disease into two,
and these again still further into numerous species. Nevertheless,
to this writer belongs the credit of having been the first to draw
attention to the peculiarity of this skin affection, and of having
originally described and figured it as a disease siii gentria.

Thus I fully recognise the merit of Willan in describing this
disease ; but I must, at the same time, point out that several of bis
varieties of psoriasis do not at all deserve that name. Thus tlie
affections represented in fig. 3, pi. ix, in fig. 3, pi. x, and also

pi. xi of Bateman's work,' under the name of Psoriasis diffusa,

■ ' Dulineationi pi dilaneous Biaeases, exhibiting tha appeanmces of Ibo

really belong, not to psoriasis, but to that dry form of eczema in
which tlicre are no cnistSj but merelj reddened patciiea covered with
scales — a diaeaee which at the present day rightly bears the name of'
Eczema »quamo»itni, seu filyriagU rubra. It must, therefore, bs
cluar to every one acquainted with the subject that Willan's
definitions of psoriasis and lepra are not correct. In fact, even hiS'
contemporaries were opposed to the splitting up of psoriasis into two
diseases, as is shown by the remark of Plumbe, that cases frequently
occur in which the physician is in doubt whether to call the affectioa
psoriasis or lepra. HowcTCr, Erasmus Wilson, -Thomson and
ParkeH, and other modern Englisli authors, have adopted the nomen-
clature of WiUan, To this Mr. Hunt is, indeed, an exceptionj for
he slates clearly that the psoriasis and lepra of this writer aie one
and the same disease.

In his day, too, Aiihert opposed the use of the term Lepra vul-
yaria \a Willuu's sense. He aptly remarked that the terror-inspir-
ing name of lepra is n very inappropriate one for a disease of so little
importance. But, in spite of his example, later French dermatolo-
gists (Biett, Hayer, Cazenave, Gibert, Devergie, and Chauait)
adopted the nomenclature of Willan, and treated of this affec-
tion under the two distinct he^ds of lepra and psoriasis. I am glad
to say, however, that Hardy and Dnchesne-Dupnrc are exceptions
to this rule ; for they recognise the unity of the disease, and term it
simply psoriasis.

On tlie other hand, German writers on cutaneous diseases (Fuclia,
Riceke, and Simon) have stated that one Bau»e should be used to
embrace both the affections, separately described by Willan and Bale-
man, as psoriasis and lepra. Again, as far back as the year i^^if
I endeavoured to expbin how psoriasis comes to present the annular
form, which was regarded by Willan ns characteristic of lq>niJj
I thus placed it beyond dispute that between these sffectionu
there is no distinction beyond a difference in form which is nojf
eaHential ; and I also showed that there is no ncccsnity to divid/
psoriasis into spedea, since the various ajipcaranccs presentoil by th'
diseasr may all be ullributed either to itx oix;upying particular jia
of the body, to the way in which it is developed anil undcrg
involution, to its degree of extension over the skin's aii rfai%|
lastly, to liie manner in which thi; patches are grouped. ^^V
prinrip*! genera and •peclci in tliD claMiHoatinn of Dr. WiiihO^^M
iten 1817. fl^F

CHARACTERS.

Ckaraetert of Psoriatu.

Al its commencement this affection always presents papules whicli

E wliile in colour and of tlie size of pins' beads, and which are, in

bet, simply collections of epidermic cells detached so as to form

■Kales piled one above another.

In certain works it is stated that psoriasn's may begin by the for-
mntioTi of cither papules or vesicles. But I cannot say that either
of these terms is a good one, for it appears to me that this disease,
both at its commencement and subsequently, consists simply in the

I Aocumulftlion of layers of e|)idermis, so as to produce little heaps
of scales, like so many mole-liills. These masses arc never solifjiry,
but always present in considerable nnmbers. They are, however,
invariably separated by tracts of hesllhy skin of greater or less
extent. These masses being, then, at first punctiform, the affec-
tion may be termed a Ptonan* pttnclafa. However, they increase

I more or less rapidly in size, and thus become as large as lentils, this
often taking place within a few days, but sometimes not until a
longer period has elapsed. At this time, they resemble drops of
mortar insiKe,colour,anJ appearance; and hence the name PsoriaaU
ffvttata. But while the iiret-formed spots are thus growing bigger,
sew ones, presentin;^ the punctiform character, are being developed

t in the healthy intervening spaces ; so that with the " Psoriasis gut-
teta" there is in fact always associated a " Psoriasis punctata."

By a process similar to that of which I have already been B]>eak-
ing, the spola of psoriasis go on enlarging at their periphery, and
thus gradually become discoid and attain the size of peas, hazelnuts,
or even walnuts, without any other change in their appearance.

\ During this period of psoriasis, therefore, we God numerous discoid
patches, of the size of some one or other of the coins in ordinary use,
|])d covered with a quantity of white, firmly adherent scales. At
the same time, however, spots of tlie P. punelala and P. guttata
may always be recognised, which have developed themselves at other
^ints, while the original spota have been increasing in size. A
nriasis presenting this appearance is that described and tigured fay
nthors under the name of P. itummularif, P. circHmKripla, or,
lllich is better, P. diaeoidea.

\ "When a large number of patches of psoriasis have in this way
relopcd themsulvcs, they no longer remuu perfectly isolat«H.

--"-

6 PSORIASIS.

For, B3 they keep incrensiiig in size, tbeir margins c
tact and coalesce ; and thus fhcir form becomos irregular, and thdr
size various. Nor do«a even this couditiou put a Binp tn the pro-
gress of the affection. Not only tloea a coiitinunl eulnrgement of
the individual palclies occur, but ne» ones presenting the nsusl
characters are always breaking out. This may even go so far ikat^
on the one baud, the patches atiain the size of the palms of the
hands, or become larger still ; and, on the other hand, fresh small
ones are formed in so great numbers, that almost the whole of the
body appears to be diseased. Such a condition constitutes lh«
Psoriatic dijiua, invettraia, agria. Even in cases of this kind, how-
ever, with extremely few eiceptions, the skin is never universally
diseased. Between the affected Imcts, there always remaia spots
of greater or leas size, wliich are still healthy.

When psoriasis has covered a more or less entcnsive area in the
H-ny I have been describiug, the form of the patches always sooner
or lat«r undergoes another change. This sometimes consists in the
separation, at certain points or even universally, of the white mortar-
like heaps of epidemic scales, which fall off, disclosing bright-red
spotA, a little raised above the level of the healthy skin, In other
instances, the denudation is more partial. The scales then gene-
rally separate, not from the whole of the discoid or nummulu-
patches, but only from the centre of each, the scales at the margin
remaining adherent, and the patches presenting a circular or annular
appearance, as in the forms described by Willan under the name of
lepra.'

This annular character is, liowever, more marked at a still later
stdge of the affection, when the skin in the centres nf the patches,
at tirst red, becomes pate, so that spots of healthy skin are observed
surrounded by rings of scales, or, if the scales have fallen off, by
rings simply presetitiug a red colour.* Each of the«e rings, whether /
it is or is not covered with scales, still increases in site, Uke the
original patch in its punctiform, guttifonn, and discoid stages;
while, on the other hand, the process of healing goes on continuall}
towards its inner burUt^r. The circles are, therefore, of various sizes.
Moreover, like the ordinary patches of psoriasis, they come inlt
contact as they increase in sixc, and coulesce, tliuit giving invjf
now forms. Indeed, the new figures which are produced 'flV

CUABACTSRS. 7

bleading together of two or more sacli riags are far more striking
in appearance tban those hitherto described.

The figures observed under these circumstances afford us an oppor-
tunity of verifying a law wliich obtains not only in psoriasisj but in
all other eruptions in which the individual patches coalesce by
spreading at the circumference. This law may be briefly stated in
the following words ; — " If two or more patches of a cutaneous
affection come into contact as they increase in size, their further
advance is checked at the points where they meet." ThuSj so far
from the one ring passing within the other, and their both con-
tinuing to spread (as might be espected to occur), neither of the
two s^ments is formed. When there are two rings, a figure of 8
is the result ; when there are three, one resembling a trefoil leaf.
The figures thus produced may still continue to enlai^e, and may
again coalesce with any fresh rings which they meet ; and in this
way the most remarkable serpentine lines and patterns make their
appearance, which vary, in fact, so widely that it is impossible to
predict their exact character. But, whatever their precise form,
they are ala-aya made up of segments of circles. Hence it is im-
possible that they should present the appearances described and
figured in certain works, and even in the twelfth of "Willan's plates,
under the title of P. gyrata. However, I retain this name for the
serpentine figures which are produced, according to the law above laid
down, in allprotracted cases of psoriasis, in my ' Atias of Cutaneous
Diseases,' ' tliere is a faithful representation of this form of the
disease, by which I was enabled to show that the V. gt/rala and the
P. orbicularu (the lepra of Willan) require no special name, but
are merely accidental modifications, being, in fact, accompanied by
other patches which present all the characters above described as
belongmg to the early stage of psoriasis.

Carrying on our observations of the natural course of this affection,
ire find that it may either subside spontaneously, or remain for a long
time without diminishing in severity, or undergo exacerbation from
time to time. When this is the case, new spots are continually
making their apiwarance, which are at first punctiform, but which
pass through the same changes as the others, until they at length
LBSume the serpentine character.

The indication that psoriasis is beginning to undergo spon-
I taneous involution, is the fact that the masses of epidermic scales
' 3 l-icfr^., Ti.f. vi.

Fofj us ihcy I,.
tact and coiti--
size varioas.
gresB of the n .
the indiviclunl ,
characters »rr
on the one li j ■
hands, or Iwcr ■

ones are fufDi

bodj npiw'i'-

Ptorias'i' . '

ever, wlii

diBessc.!

of great 1

WhM

tra; I I
or iait'L

I spots,
inst^r

ra!]/

patd

:1..

apjic.
]ej>ri

stag"
atli'

ring*

it is

origin

while,

, towar>

\ Morei>

I contac'

■ new

fo:

I.HARACTEB8. /

I'blendiug togetlier of two or more such rings are fur more striking

ftifi appearance than those hitherto described.

The figures observed under these circumstauces afford us an oppor-

\ tUDity of verifying a law whicli obtains not only in psoriasis, but in
all other eruptions iu wliich the individual patches coalesce by
spreading at the circumference. This law may be briefly stated in
the following nords : — " If two or more patches of a cutaneous
affection come into conlact as they increase in size, their further
ndvance is checked at the jwints where they meet." Thus, so far
from the one ring passing wilhiu the other, and their both con-

I tinuiug to spread (as might be expected to occur), neither of the

■ two sf^ments is formed. When there arc two rings, a figure of 8

rb themeult; when there are three, one resembling a trefoil leaf.
The figures thus produced may still continue to enlarge, and may
again coalesce with any fresh rings which they meet ; and iu this
way the most remarkable serpentine lines and patterns make their
appearance, wliich vary, in fact, so widely that it is impossible to
predict tlieir exact character. But, whatever their precise form,
Uiey arc always made up of segments of circles. Hence it is im-
possible that they should present the appearances described and
figured in certain works, and even in the twelfth of Willan'a plates,
under the title of P. gyrata. However, I retain this name for the
«er{)entiue figures which are produc«d, according to the law above laid
down, in all protracted cases of psoriasis. In my ' Atlas of Cutaneous
Diseases,' ' there is a faithful representation of this form of the
disease, by which I was enabled to show that the P. pyrala and the
F. arb'umlarii {the lepra of Willan) require no sjiecial name, but
are merely accidental modifications, being, in fact, accompanied by
other patches whicli present all tlie cbaractejs above described as
belonging to the early stsgi; of psoriasis.

Carrjing on our observations ofthenatural course of this affection,

I ve find that it may either subside spontaneously, or remain for u long

without diminishing iu severity, or undergo exacerbation from

i^me to time. When this is the case, new spots are continually

Baking their ap}waraDce, which are at first punctiform, but which

ass through the same chaiigea as the others, until they at length

uumc the serpentine cliaract«r.

< like indication that psoriasis is beginning to undergo apon-
meoos involution, is the fact that the masses of epidermic scales

•aLicfrg^Tif, .i.

become less adherent to, snd more easilT sepanble btahi ti
reddened aorface on which they rest; and, after a time, that thi
fall off of their own accord, so as to expose reddened patches of
circular form, or annular, and but little raised abnre the level of tl
healthy Bkin. Subsequently these patehea themsdves lose the
deep-red colour, the skin graclually growmg more and more pale, an
finally becoming perfectly na.tural in appearance. No scare are lefl
nor any pigment deposits, nor anything to show that the part hi
been affected by the disease. In some cases all the patches ^
psoriasis pass through this process of involution at the same timel
in other instances it is more limited, and fresh spots continue M
break out, so that, although certain patches disappear, the disea
as a whole does not undergo cure. This last, indeed, is the mol
common occurrence, the patches at which involution takes plac
being for the most part just those which were most inter
affected ; and thus, although the exact seat and form of the eruptio^
are altered, it doe« not entirely subside.

In other cases of psoriasis, however, while fresh patches are cou
stantly being developed, none of the old ones disapi>ear. The disi
then gradually invades all those spot* which had remained free froi
it, and at length covers the whole surface of the skin, being, in fao
a Pgariatis vnwer»aH* {P. diffuaa, P. agria, &c.).

Patients affected with this disease complain of no subjectivj
symptom, beyond more or less severe itching. Indeed, even thi
sensation is not always ejperienced, being in general present meren
during the early part of the development of the patches. Thu
itching is felt over their whole surface, when they present
characters of the P. punctata and P. guUatu. In patches of oldt
date the borders alone itch, and not even these, unless the patchd
threaten to increase in size. Parts of the eruption which have h
ecmtehed may be easily distinguished from those which have bee
left alone by presenting brown or black crusts of dried blood, in
stead of being covered with shining white scales. These little hlog
cmsta may either occupy the whole surface of the patches, or 1
confined to their borders ; and this fact especially shows that psoriaa
is attended with itching only when it first ap[>ears, and when fra
spots of it are breaking ont. Even Ihni, too, it Is less severe a
less persistent than in some other skin affections. It never reuiuiq
present during the whole coiirxe of the disenik;.
_ In the majority of cases, psoriiwis bn^nks ont at different f

spBllercd over the surface of the body, but it is soraetiniea limited ti
a few special points, eitlier Bt first or even lliroughout its whole
daration. The elbows and knees are, above all others, the parts
wliich are apt to present this limited variety of the disease, being
then occupied by a few discoid or circumscribed patches. Next to
these the head is the region most commonly affected by psoriasis, which
then generally exieads n little beyond the space covered with long
hair, so as often to fornij over the forehead, ears, and neck, a white
or red border encircling the sculp. When this disease attacks the
skin of the external eaij it mostly covers its whole surface, and
r.xleuds into the meatus auditorius; and the masaea of scales which
then accumulate within tins passage may block it up, and thus give
rise mechanically to a temporary impairment of the sense of hearing.

Psoriasis is less frequently observed on the face. There is, indeed,
DO part of this region which is secure from an attack of the disease ;
but i cannot, from my own experience, cuiilirm the statement that
the eyelids (and even the eyes) are commonly iifft'ct«d with it, so as
to warrant the use of the term Psoriasis ophthalmica, employed by
Willsn.

The other regions of the body are indiffercnliy attacked by
psoriasis. No special hahility Is exhibited either by the trunk or by
the limbs, nor on these last does the disease alTect in preference
either the flexor or the extensor surfaces. The palms of the hands
and the soles of the feet are, however, peculiar in being very rarely
the seat of a non-syphilitic psoriasis ; whereas they are well kuown
to be very subject to a syphilitic affection which (from the special
aoatomical structure of these parts) presents characters supposed to
resemble those of psoriasis, and which is therefore called the PaorianU
palmarit lyph'd'dica.

Besides the eruption above described, there is in some cases of
psoriasis a morbid condition of the nails, which is generally conlined
to certain of the fingers and toes, and more rarely attacks them all.
The affected nails are thicker than natural, and of a darker colour,
being vellow or brown. Tliey are abo devoid of lustre, uneven, and
brittle, 90 that they do not project beyond the tips of the Angers,
and are broken otf and Scored at their extremities. When a nail is
first becoming diseased and is still transparent, one may sometimes
see beneath it on its bed a little spot of psoriasis, just like those
observed on other parts of tlie body. It is, therefotr, evidtnt that
th« morbid process which gives rise to (he change in the nail is

1(1 PSORIASIS, I

essentially the same as that whicL leads to the formation of thtfl
potches constituting the eruptiun. I

Even when the scnip is the seat of psoriasis the hairs are bufj
eeldom affected, and then onljr at certain spots where they fail ouf'
more than is nature]. As a rule, there is no alteration in the
hairs themselves aa regards either their colour or their lustre ; nor
ia their growth in any way iJiterfered with.

The mocouB membranes are absolutely unaffected in cases of
peoriasis. This disease never attacks even the red part of the lips,
80 that I cannot admit the existtuce of the Ptoriatis labionim
described by Willan.

Among the numerous cases of psoriasis which have come under
my observation, (here has not been one in which any organ other
than the skin could with certainty be proved to be diseased. In no
single patient has disease of the lungs, heart, liver, spleen, or any
other internal organ been discovered. There is, therefore, great
probability in favour of the opinion that this cutaneous affection is
unattended with any disease in other parts of the body. The fe»
post-mortem examinations w}iich I have had an opportunity of
making (in persons who died accidentally of other comptainLt, eucfa
as delirium tremens, fever, or pneumonia) a^ordcd no ground what-
ever for supposing that causal relations exist between psuriasis and
any audi complaints.

Any other complaint, external or internal, may, however, coexist
with psoriasis. For example, syphilia in every form (primary and
secondary) may accompany this affection, and is in no way modified
by it. 1 have also seen it associated with tuberculosis, though only
in one ease ; and persons suffering from it liavc been attacked by
measles, scnrUtiua, variola, and aeabie». I have nut, however, as
yet observed ichthyosis or prurigo in patients affected with psoriasis.

Among the more frequent complications of tliis cutaneous affection /
are neuralgic complaints (especially eciatica), and [iricking sensations
(Kriebelti) in the lips of the fingers and toes.

Liagnotu. — The characters of psoriasis may, then, be brieff
summed up as follows: — It consists of rough, uneven patches, mad
up of masses of white siatles. These masses may be puiietiform, r
sa large aa half-arown [lieccn ; or they may be annular, or of
serpentine forms. Tlio baac ou which they rest is red, and
n like diversity of outline. When the scales are

I annular, or of vaB|r
»t is red, andj^V
)cale« are pU^V

TROGNOBIS.

> geiierallv separated from ow aiiotlicr by tracts of skiu of uatural
colour, healthy in every respect. They increase in size at tlie
circumference, and, at the same time, a spontaneous involution
goes on from the centre outwards. They are not bable to any
faither change, such as suppuration or ulceration. They leave no
cicatrices, although they are sonietioica followed by persistent
pigmentation. Sensations of pricking or itching arc complained of
only when the patches first come out; afterwards there are no
subjective symptoms. The system generally appears to be nn-
sfTected. Sooner or later the disease is almost certain to recur.

DiffeTfniial diagnotii. — Altliough this description of the symp-
toms and course of psoriasis is sufficient, for the recognition of the
complaint, it may not, perhaps, be superiluous to point out what are the
diseases which occasionally resemble and might be mistaken for it.
These are — (i) PityriaEisrabra,s. Eczema squamosum; (2) Lichen
exudotivus ruber ; (^) Seborrhea capillitli ; (4) Eczema capillitii ;
{5) Favus ; (6) Lupus eifoliativus; (7} Herpes tonsurans (in the
macular form) ; (8) Syphilis cutanea fquainosa. When describing
these various afTeclions, I shall give in detail the characters which
distinguish them from psoriasis.

Prognog'u. — In previous paragraphs I have stated that relai»scs
are very common in psoriasis, so that a single attack, without
any subsetjueiit return of the disease, is a very exce)itional occur-
rence. 1 have also mentioned that it does not all'ect the general
liealth, even when it has existed a long time. But although this is
generally true, it is tniposeible to say, in any particular case, how
long the disease will last, whether a relapse will occur, or for what
period of time the patient will remtiin free from psoriasis.

Certain conclusions may be drawn from the different appearances

presented by the patches themselves. The Psoriasis punctata,

guttata, et nummularis being early forms of the uflection, uud the

P. orbicularis, gyrata, et circuniscripin belonging to n later period in

its development, experience warrants us in inferring from the

I former varieties that the disease will remain for some time ; whereas,

I we observe those last mentioned, we may assume that the

J attack of psoriasis is already subsidjjig. On the other

ind, it is obvious that when all the varieties above named are

sent at the same time, and when fresh spots of the P. punctata

:istautly breaking out, we must be prepjired for a pro-

1 form of the disease.

12 PSORIASIS.

Among the most obstinate cases of psoriasis are those which affect
the whole body (P. diifusa, P. universalis), the patches being inter-
rupted by only email islands of healthy skin, or even by none at all.
In fact, these cases are often incurable, and may even termin&td
fatally. This exceptional form of the disease developes itself from ai
ordinary psoriasis which had ruisted for a long time, and was of no
particular intensity, but which undergoes sudden exacerbation, aiii
attacks, in a somewhat modified form, all those parts of the skin
previously unaffected by it. A.3 in the common variety of the disease^
there appear white scales j but these form lamellre, of great size, piled
one above the other in large masses. They are shed rajjidly, and
expose a deeply pigmented surface of a brownish-red colour, and
a smooth, satiny appearance. This, however, secretes no fluid, and ia
dry and even brittle, so that it is very liable to become cracked and
fissured over the flexures of the joints, and on the fingers and toes;
and these fissures (rhagades) interfere with every movement, and
may even give rise to severe pain. The quantity of scales produced
under these circumstances is so enormous, that heaps of them may be
removed every morning from t-he patient's bed.

Edoloffy. — From continued observation and esperience of psoria»ia,
we have as yet derived very little positive information as to tha
causes of the disease. Among the circumstances stated in the
various works on dermatology to be concerned in its production are
the following : — Climatic conditions, dampness of the air, certain
seasons of the year, habits of life (such as an insufficiency of
nourishment, irritation of the stomach and intestines, and the in-
gestion of some kinds of food and drink, especially brandy), drinking-
cold water while the body is heated,' catching cold, certain dya-
crasiic (particularly chlorosis nnd arthritis), urinary disorders (whe-
ther of secretion or excretion), rachitis, scrofulosis, tuberculosis, the
diathesis herpetics, the diathesis [isorica, the sanguine and tho ner-
vous t«mperamcnta> the previous occurrence of acute or chronie
cutaneous affections, pregnaacy, disorders of menatruatioii, the f
cewHilion of hubltunl hiKinorrhoidnl discharges, mcnlnl emotions, '
want of cleantincsf, irritation of tlie skin, particularly by bUst«>ra, or
by the contact of metallic bodies or substances in a finely divided,
state), anil certain oecitpatiouei, among which are meutioued tliose
of the Rhoemaker, wnshrr woman, baker, cnpiiersmith, silversmitt'
linfounder, and whitesmith. (Sec the works of Bayer, Kochar

jJ«^^gjMj|^M

■ ETIOLOGT. 13

I Devfirgie, Alibert, Hardy, and others.) Every nnprejudiced observer,
I however, who reads through this list, must at the first glance be
[ latotii^hed to find it asserted that a single disease is the result of
I eouilitioiis ao numerous, anil differing so widely from one another.
I The matter is so important, that I will go iiit« it in detail, and will
I not confine myself lo a simple denial of the eiisteuce of these
I BUpposed polentite nocentes as caus«s of psoriasis.
I In the first place, the complaint is said to be generated bj certain
I external agencies affecting the akin directly, such as wout of cteanli-
I ncss, mechanical irritants (especially pulverulent and certain mc-
I tallic substances), blisters, aud the occupations enumerated above.
\ Kow, I can with confidence assert that none of these cim by
' themselves give rise to psoriasis. In support of this statement
wd of those which follow, I must point to the fact that in tlie course
of the last twenty years I have had under my care, and have had
occa-fion to watch for years together, so large a number of cases of
cutaneous disease as has surely been under the observation of very
few physicians, except, perhaps, certain specialists prai^tisirig in
London and Paris, Among the patients treated by me in the
General Hospital at Vienna (numhenng more than 3000 each
year) have been persons of each sex, of every nge from five years
to eighty, of every occupation, aud of tiie most varied habits of
life; and of these there have been, on an average, fifty {thirty-
three uieu and seventeen women) affected with psoriasis. Now
these have, without exception, beep persons of strong constitution
and firm fibre, who were well nourished, and whose bodily func-
tions were in |)erfect order. In a word, they have been blooming,
healthy individuals. Out of all the patients affected with this
disease who have been under my observation (and of whom the
number far exceeds 1000), there has been hut one who was rachitic.
This man had formerly suffered from hfemoptysis ; but even he was
in good health when I treated him for his psoriasis. In this case
the psoriasis disappeared very rapidlv, as the result of a most simjile
plan of treatment. I have known this man now for fifteen years,
. during which time he has suffered from repeated attacks of heemo-
■jltysis ; and his is, among all the cases of psoriasis which have come
■licfore me, the only one in which there has been no return of the
^- affection.

Now, among the nnmerous gratients who have been under my
caxc for cutaneous diseases, many were of the labouring class, and

FSORI&StS.

there were some belonging to ail occupations, besides many wiio
were idle, morally depraved, and of iiot very cleanly Irnbita. And of
lliese a Urge iiumber, either in conaequence of their occupations, or
from neglect, were blackened by coal, or covered with dirt, dust, or
some powder or other. Yet such persons were by no means
affected by psoriasis. Indeed, my experience points to the very
reverse, the occupations whicb have furnished the largest proportion
of cases of psoriasis having been the very ones which involve fre-
quent ablutions, as is the case, for instance, with butchers, bakers,
wail«rs, and the like. In a word, I differ from other dermatologists
in having failed altogether to connect a special disposition to this
disease with any particular occupation.

It is well known, and admitted by every one, thnt cutaoeons
affections, particularly eczema, may be produced artificially by the
application of irritants to the cutaneous surface, whether by accident
or intentionally for therapeutical purposes. But, ao far as my
experience goes, there is no reason tu believe that psoriasis is among
the diseases generated in this way by irritants, such as alkalies, acrid
substancea of v^table or animal origin, heat and cold, &c. On
the contrary, the growths of epidermis which constitute psoriasis
are never produced by the irritating Applications which were for-
merly (and are still) employed in the medicina erudelU, and whicb
give rise cither to simple redness of the skin, or to papular, vesicular,
bullous, or pustular eruptions. The only case in which such appli-
cations are followed by psoriasis, is in persons already suffering from the
disease, in whom it not rarely happens that when the ordinary effects
of an irritant (such as a blister) have subsided, patches of psoriasis
ari» over the area to which tlie irritant liad been applied.

Climatic conditions, again, are generally enumerated among th«
predisposing causes of jMonasis. But, although it is a well-known
fact thnt there are diseuses of the skin winch especially abound in
particular climates, I cannot find this to bo the case with ])soriasts,
which, on the contrary, as appears from tlie works of various writers, i
must be called a pandemic disease. It is met with in northent
btitudes and in southern regioua, in damp as well as in dry climates, in
every quorUir of the globe, at all seasons of the year, in every rac
of man. Of course, however, it is only among whites that the con
plaint presents the characters which L have described, lit men
olive-green, brown, or black colour, the dark pigmint conceals t
reddening of the skin. In the negro, for inetuiCF, the only e'

r ETIOLOQT. ■ 15

I dence of psoriusis besides the presence of masses of scales is the

I occurrence of slight bleeding when these are torn off by scratching,

I The diversity in the appearance of the disease in the different races

of uisnkiad, nnd the fact that practitioners versed in dermatology are

not to be found in all parts of the vorld, explain sufticientlj how it

is that the word psoriasis is not universally employed to designate

it, and that it has been sometimes spoken of as leprosy (lepra), and

ooiifounded with that complaint, or with ichthyosis, or elephantiasis.

Different writes enumerate among the causes of psoriasis certain

c-ondilioiis of life, insufficiency of food, and the habit of indnlging

in particular kinds of food or drink. This, again, is in no degree

coniinned by those observations of my own to which I have above

referred. Among my own patients there have been persons who

belonged to aJi ranks of life, and who were under every variety of

conditions. There have been some who revelled in luxury ; others

who earne<l tlieir bread by the sweat of their brows, and who had

no opportunity of enjoying gastronomic pleasures. Some were

I children, or Indies belonging to the higher classes, who never touched

I alcoholic liquids ; and these seemed to be no less liable to the disease

' than those who had grown gri^ in drunkenness and vice. In a few

instuDcea it has happened that a patient wbo had been under my

observation with psoriasis has died of delirium potatorum. But I

am no more justifled by these cases in maintnining that the cuta-

I neous disease was the result of the alcoholiam, than I am warranted

I by those above referre<l to in asserting that abstinence may be its

cause. I have been equally unable to find that psoriasis is ever

generated by the articles of diet to which cutaneous affections are

•o commonly aacribed — such aa herrings, anchovies, smoked meat,

bam and other salt provisions, cheese, butt«r and othpr fatty or city

kinds of food, highly spiced or very acid dishes, salads containing

a quanlity of vinegar, ic. My own personal observations afford no

, ground whatever for the notion that these articles of diet give rise to

I psoriasis, or even to other skin diseases,

I Uow "drinking cold water when the body is heated" can be
' mpposed to be the cause of any cutaneous affection, and particularly
of psoriasis, is to me perfectly inexplicable. The rarity of this
disease, in comparison with the large number of persona who swallow
I oold drinks or ice when heated, especially during summer, renders
■ nch a notion altogether inadmissible.
I Again, among the conditions imagined to give rise to psoriasis is

PSORIASIS.

cold. This scema to be regarded by most people as n sort ofi
Pandora's box, from which almoat all diseases may be derived.
There are no espressiona of whicli medical writers are more lavish
than of such as " catching cold," " chills," " draughts," " sup-
pressed perspiration," &c. But how little reason there is for as-
cribing jisorinais to such conditions as are ijicluded in this category,
is at once evident from the disproportion in their frequency. Catch-
ing cold is a thing of daily repetition; whereas, in the Genera]
Hospital at Vienna, the proportion of psoriasis is i in 60 cases of
cutaneous, 1 in 500 cases of all, diseases.

Orlaiu writers name as the cause of psoriasis a disordered state of
tbe secretions and excretions. In my case*, however, there has
neither been persistent diarrhoea, nor habitual constipation, nor any
disorder connected with tlie secretion of urine, nor even (a? some
have 8lat«d) any excess or diminution in the uric acid, urea, or other
constituents of this secretion. Moreover, I have been quite unable
to detect any morbid change ill the functions of the skin, at least in
patients affected with psoriasis in a less severe degree ; for in cases of
Psoriasis universalis, the perspiration is undoubtedly diminished ia
i]aaQtily, or even altogether suppressed. This, however, is not peculiar
to psoriasis, but is well known to occur in all dermatoses which affect
the whole cutaneous surface. It is, in fact, to be regarded aa a
consequence of the disease, and not as its cause.

Contrary to what is stated bj other writers on this subject, I have
fuiled altogether to discover that pa^t or present attacks of tbe
exanthemata — or indeed, of any other diseases of the akin, acute
or chronic — arc in any way concerned in the causation of psoriasis.
Indeed, according to my own observation, 1 should rather be inclined
to assert that those who suffer from this complaint are actually leas
liable to other cutaneous affections, not only while it exists, but even
before and afterwards.

That various eruptions are connect«!d in women with tbe sexual
functions, both when these are performed naturally and when they
are disordered, is a fact well known to me. But I have not met .J
with o single case in which an attack of psoriasis could he brought^
into connection rither with serious menstrual disorder, or with prcg-,
natx^ or childbirth. [

Again, the suppression of an habitual hsmorrhoiJal fiux is cnume-^
rated by certain dernutologista an one of the causes which give risr

t. in 1

I disei

[isuriasis; but I have not known if to occur in peranns HllVclt'il
ith this comiilaint.

As iu past centuries, so at the present tiini-^ the believers in h
itunoml pathology have always beeti able to state without hesitation
the causes of cutaneous eruptions, and psoriasis has only shared the
fate of ail other chronic dermatoses in being regarded as the product
of arthritis, rachitis, scrofulosia, or tuberculosis. Indeed, these con-
rtitutional disorders have not been sufficient, and a dgncraaia ker-
-jpeliea s.pDorica has been invented ; while otlnir writers have ascribed
psoriosis, in common with almost every other diseaKc, lo hereditary
syphilis. The sup^rasition that psoriasis is due to a dyscrasia is at
least rendered improbable by the fact above mentioned, that it occurs
in well-built, well-nourished individuals, whoSe health is in every
bther re8]>ect perfect. And as to By]ihilis, I may assert most positively
it it is never the cause of an ordinary psoriasis. I'or it is well
lown that all the cutaneous affections to which sypliilis gives rise
(and in particular the so-called squamous syphilide, or P. xypAi-
titica) are distinguishable from llie ordinary non-syphililic eruption
by several infallible characters.

Of all the causes to which fisoniLsis is asrrihed by dermatologists
there are none which sound less likely than mental emolhiii*. Yor,
in the 6ist place, it is never stated wliat kind of mental emotions have
this effect, or whether they are ofa depressing or of an exciting nature,
Nor has any single cue ever been recorded in which this cutaneous
disease was set up by joy, terror, anger, distress, sorrow, or the like,
~iere is, therefore, ait entire absence of positive evidence in favour of
opinion as to the cause of psoriasis, althougli its erroneousness
o doubt, difficult of proof.
Uaving thus, from my own experience, denied that the con-
hitherto enumerated have the |Kiwer of generating psoriasis,
fiOtae Rually to hereditari/ irantmirsion, which is admitted by most,
not all, dermatoli^^sls to be among the causes of this cutaneous
affection. Now, there are many cases of psoriasis in which it is im-
possible to [irove that the parents or other relatives of Hie patient
are, or ever have been, affected by the disease ; but in the majority
of instances this can be shown lo be the case. The complaint is, in
feet, quite naturalised (einheimisch) in certain famdies, and descends
parent to child. It generally, however, altncks some only, and
all, of the ufTspring of the same parents. When psoriasis if
ismittrd in this way, it does not appear immediately after birth.

PSORIASIS.

but only nt a Inter period, tnoat commonly in tlie sixth year,
all other hprcditary complaints, too, it is often obsprvcd that one
generation is passed over, the disease descending from their grand-
parents to children whose parents had been free from it. Now, 1
shall not endeavour to employ the hereditary transmission of psorinais
as an argument for attributing it. to some nuire serious disease, or to
a dyscrasia of any kind. I suppose this fact to depend u)ion the same
law as that by which {for instaiiec) n^o children, even when bom
in temperate climates, possess black skins like their pureuts, and
by which fair- or red-haired indi-vi duals produce offspring presenting
tlie same peculiarities. It is well known that numerous examples of
this law have been observed in the lower animals.

Psoriasis is not conUyioM. It cannot be communicated either by
direct contact, by inoculation, by suckling, through the air, or in any
other way.

Morbid Jnahi«i/.~~[ have hail several opportunities of examining
after death the skin of persons affected with psoriasis, who hod been
admitted into the hospital on account of some olher disease, such
as pneumonia or delirium potatorum ; but I am sorry to Iiave to
confess Ihnt the resulta afforded by my investigations in these cases
are not at all more satisfactory than were those of Bokitansky,'
Wedl,' and 0. Simon,* all of whom examiaed patches of psoriasis
microscopically. The cause of this is, partly, that in the dead body
the characteristic appearance of the disease is found to be almost eo-
lin^ly obliterated ; the red macnlse which support the masses of scales
have lost their colour, nnd the scales themselves adhere but loosely to
the surface. No deviation whatever from the normal state can be
detected, either with or without the microscope, in the papillte or
other dermal «tructurea of the port-.^ which were the seat of
pKoriasia during life. Hence I have always been obliged to limit
myself to the examination of tbe morbid produr't.s, which consist i
simply of piles of epidermic cellt!, as is suthcimtly evident to the i
naked eye even while the patient is alive. In reference to this, 1

' ■ Lebrbuch der path. Aott..' 3 Aufi., \%<: Band ii, »- 65. [TliB traaaU-
tion uf lbs earlier edition published hy lli« S; deuluuii Booietj dwa not Dootfu^i
tlifl punge rrftrrcd to.— E11-] ""

* ■ Grundiiij^ (let patli, nistotogiE.' Wieo, 1834.11. 141.

* ' Die HauHtnukheitnn dnrob anit. CnlcnuohuaKca erlaateri,'J

Itljll,*. II!

THKATMKNT,

lave merely lo express my concurrence m the. sUitemnits of G. Simon.
I have found thiil most of the henps of scales lire made up entirely of
epidermic cells, seat<?d upon an hypefiemic cutis.

All that I know, then, a» to llic eBscntial nature of psoriasis is,
that it consists in au excessive growth of epidermis, nr in a pro-
liferation of the epidermic ce!b, and in their accumulation upon cir-
iscribed spots, at vrhich the papillie of the corium are hy|>enFtni<!.

Trtatmmt, — Kor the cure of peoriasis, and inde<id of chronic

of the skin generally, two methods have from early times

proposed. The first of these stjirted from the supposition that

the chronic dermatoses arc the children of one parent, the product*

and the same dyscrasin or morbid change in the blood ; and,

wforc, that these diseases are to \w cured by purifying and

irrccting the state of the i-irrulating fluid, or by expelling acrid

liters (acrimonia: sanguinis). For the practice of this mode of

treatment, no accurate diagnosis vrns required. It came lo nmch

the same thing whether the patient was suffering from psoriasis,

' [o,or ecthyma. In each case Ihtisame remedies were employed,

, the so-called hiemnto -cat hart ica.

By some physicians, then, this wns regarded as the only legitimate

!tbod of dealing with such diseases. They would not hear of any

plan of treatment, and condemned as (Ungemus all looal

lications, on the ground that such applications might " drivr

m/ji" the cutaneous affection, raiising it In " rivetU" from the

in and undergo " Mrtngfani/' tn some import.ant internal organ.

even those more intelligent and experienced practitioners who

not entirely oppose the u«e of local treatment nevertheless

lidered it to be admissible only when the fluids of the body had

thoroughly purified, and freed by n ioiirse of medicine of

kind or other from the aerid matters of the eruption (von den

liirfeii der Fleehte). The liistory of pa.'tt ci-ntnries sliowj> suffi-

itly how far this notion conid be enrried, although it rested on

itl^'.rly speriilativc basis.

The unsntisfnctory results yielded by ihis plan led physicians lo

mter upon an entirely dilferent path, that of experiment and obsena-

tioii. Now thi- path is, I must confess, the one which I myself

exclusively in the treatment of ciitaiicou;' alfections, and,

of disease in general, 1 srt not the slightest value on any

y except those which (sfhnr repeated tnal^ aad. wbdu 1 an

prurigo,
Ikmely, I

PSORIASIS.

nocuratcly acquainted with the coinplai
favorable change in its course, or, in t
patient. I never attribute therapeutical powers to a medicine
unless 1 observe its employment lo be invariably and constantly
followed by some cbai^e in the morbid products, and by thi
termination of the disease iu a shorter time than when it is allowed
to undergo spontaneous involution. I do not care in the least
whether this result is obtained by iiitroducing the remedy into thA
patient's slimcntury canal or by bringing it into contact with his skin.

In tlie previous volume,' I have drawn attention to the fact that
the skin, as well as the intestinal canal, has tlie power of absorbing
medicinal substances, as well as coDtngia and olher uoicious agentSi
and that remedies applied to the exterior of the body reach tha
blood, like those which are swallowed. In reference to this, I nvcA
but point to tlie well-known fact that a shnrt time after their aiiplica-
tion to the cutaneous surface, preparations of mercury or iron, and
even tar, appear in most of the secretions and excretions, and can be
plainly delected in thein by ch«micnl reagents. And not only is the
skin well adapted to absorb medicinal subalaneirs, bat their exlemnl
application, when t he skin is diseased, has tlie advantage of bringing
them into direct contact with the part affected ; a very great gain
indeed, when it is desirable to dissolve, softeji, nr macerate the
morbid products, or to modify them in any other way. A further
advantage of ijitruilucing remediefl through (he skin is, Ihnl the whole
intestinal tract is left undialurbcd, so that the disorder of the nutritive
fnnctions is avoided to which medicines often give rise, and tlut
proper nourishment can be tnken by the patient ot the same time
riinl he i» undergoing the treatment from wliich a cure of bis disease
is looked for.

It must not, however, be inferred from the remarks I have been
mnkiug, that I am entirely opposed to the administration of internal
remedies, and would in no case have tbem employed. On thi
tmry. I never hesitate to prescribe sticb medicines in all caMs iu
wliich their success has eetabliabed their value. I object merely to'
those inert, oh»oIettr drugs, tbe belief in the curative powers of whiel
haH been transmitt«d from teacher to pupil without inquiry, unc
from text-book to test>book without examination or criticism, nni
which are prescribed in prxctice without thought and as a matte/
of routini^. Unfortunately, too, thsee m«liciiies are not always entin-'

TREATWENT-

f Jifgativc in their (iclioti, nssre,p(Tliaj>3,theliomwo|iatliicmedic:in(;ai so

that we cannot but regret, instead of smiling at, their administration.

Of the drugs which I have been candemiiing in the preceding

lentpnccs, I Ihink it well to mention expressly those which are most

iBommonly emplojcd, and many of which I have mjself repeatedly

ried. Such are the following: — The StipiUs DuUamara, Millffo-

wUiim, Trifolium fbrinum, Fumaria, Inula Mcnium, Ulmu* eampen-

r trU, fiorea PedetHontame, Viola irkolor, Radix el Baecre Janiperi,

Juniperua lablnti, Riu» railicant, Rhui toiicodendron (Dufresnoj),

, Supalw^Hin cannaUnwm el perfoliatum (Barton), Conium maculalum

V (Talenfin), Puh'ia/oliorum Bdladonna fTlieden, Schark) , PuliatiUa

Xmiffricant (August Gottlieb Bichter), Solanum nigrum (Alibert),

i Serba Seabio*a areena\», Daphne mszereum (Loiselleure and Delong-

\ champ), Orohanche virffintana, Sajionaria, Radix PigUtdia amara,

Deeoclum Carhonum (Busch), In/umm Sassafras (Sachse), Ledum

' faluttre (Schopf), Succna Nicoliaaa, Polia et putamina Nucnmjug-

landttta, Sartnparilla, Bardana, Guaiacum, and i\\e, Species liijnorum.

Some of these ditTiTcnt substances, or the iiifuaious, decoctions,

or estracta made from them, were, as is well known, formerly used

bj medical men in alt parts of the world in the treatment of every

obstinate chronic catnncous affection. And yet, although they were

«a generally employed, they had not even the rrpulalion of being

remedies (in the projier sense of the term) ; and, to use the mildest

expression, I must say that their ijifluence on iliseuites of tlic skin is

entirely imaginary.

If these drngs failed, it was in former times the pradice to havi^.

recourse to olhcr medicines supposed to lie more jwwcrfid. Such

. yiiSK ihi" crude An fimoni/," ox Antimonii tersulpkuretum; .-h'tAiops

Wautinionialis ; Manganum nigrum, or Binoxide of Manganfte ; Gra-

^mhitift elulrialus, m prepared Bl-icS: Lead (Weinhold) ; Bargl-a muri-

m, or Citorid« of Barium; Calx Anlimonii sulphurata, or Sulphuret

' AuHmony and Calcium (Hufcland) ; Sulpkurelum Kalii H Soda

JjChaussier); Tarlarized Andnion^ {ft^h); GoUlm Sulpknret of Anti-

o»jf, or Anlimonii pealatulphurctum (Vogel) ; j^lAiops Mineral, or

'Black Sulphurel (f Mercury (Dzondi, Kopp) ; Mercuriuapritripit^tus

Nitrico-oxide of Mercury ; Mereurius aeetatut, or AcetaU

f Mercury (Hufeland) ; Titrpelhunt mincrale, or TelloK' subsulphate

f Mercury (Alibert) ; IfUrale of Mercury (Qodard) ; Chloride of

m and Golil {Ebcrle, Rayer) ; Liquor Cupri ammoniato-mvrialicus

vMsa) ; Chlorate ifPslati (Chisholm) ; Altmvn tt dec/c/o Sarta-

parilla (Hiirelarid) ; llie preparations of [mn fUajcr),aiid Ani
kali^ (Polyii).

' PerlmpB it maj not be known to some oi mj readers tliat tbis a
was reeoinmeoded bj Dr. Joseph Polja, of I'eath ^l'hJltiku■ i
Freijtadt Fesl) for tlie cure o( all eTuptive affections, and ■was tauutod >i a
Bpeciflc in liis work on these affectioos (' Bcobachlungen iiber ilie Fleohleu
und jiue Verbindimgeii,' u. a. v.), a work which baa been Innslate'l fnim the
Lalia manuscript or the salhor b; Dr. C. L. Sigmund. The aietbcxl uf pre-
paring the drug ia dcaoribed in this book (p. 134] aa follawi : — " Anthreooksli,
the name of which ia derived from the worda anthrax (coa!) and Lnli (potase),
coiisista of a solution of coal in cnastic potass. Two fomia uf il are uaed, the
tinpk and the mlphunlhd anthraeokali. In making them the fbiiowing suV
stBooea are required : 1, a niiitureofnlcohol with powdered coo/ (■ die schwaree
Steinkohte alcobolitirt'), the best beiug that which ia dug near Fuiifkirohen, a
lown in the district of Boranja in Hungarj ; 3 and 3, hgdrale 0/ lime (slaked
lime) and carbonate of polasi (tlicse two substancca serving merely for the pre-
paration of the caustic potass} ; 4, washed ^owFri o/taipkur.

" The aiuLple antbracokali is made in the following waj : — Some carbonate of
potass is dissolved in ten or IweUc parts of boiling water, and aufflctent hy-
drate of lime ia added to the boiling liquid, lo deprive the potasa-salt of all its
carbonic acid ; tho completion of this chemical change being shown bj the fact
that the clear fluid is no longer made to efferreace b; acids, and docs not become
turbid on the addition of lioic-wati^r. The Quid is then filtered as npidlj aa
poMihlc. placed over tlie Bre, and evaporated till it uo looger Troths, and flow*
smoothlj like oil. The mixture of cool and alcohol is next added to the solu-
tion of potass thus prepared, in the proportion of five ounces of the former to
seven of the Utter, tlie vesael beiug atirred without interruption. Even when
it lias been removed from the lire, tlie maaa ia still rubbed with a warmed
pestle until a black homogcneaus powder is obtained, which is then put Into
warmed glass bottles, each holding an ounce, Tliese bottles must be kept in a
dr; place until required Tuc use.

" The siilphnreltcd aulhraookali is made bj adding half an uunce of washed
^wera of sulphur to livo nuncea of the niiiturr of coal and alcohol, rubbing
them down into a houogoncous powder, und mixing thia with the caustio polasa
f prepared in tho same waj as before) as soon as the potass flows sntootlil; tike
oil. Tlic antbracokali made b; this process ia a bhtck powder, so Gjib as to
slain Bubatanoea wllb which it oomea En contact. It has a somewhat alkaline,
acrid taste ; it excites a burning eansation when applied to the tongue. It haa
either no amell, or one resembling that of soot."

Anthraeukali lb given in doses of two graiua. mixed with Ave graina of the
['alv. UI;c;FrhiziP. three or four times a da;. Its chief elTcet, according to
PoljH, is In JDcreue Ihe activitj of tho akin, aa ia shown bj Its giving riae to a
Kcaeral persjiiration, and to a sensation of tingling in the integument. The
good effects of this medicine are not v nr; rapjdlj produced. Uuder favorablr
QiroumstMiciis, aaja Polja — that is, " when the patient sweats within a few da;
•Iter bfl iiat bagiia ta tak* Uiu tMantft «rl>«u lu u ;uumb vlwa lbs &it»i

TREATMENT

Ag&ii), tlie tltlTtTviit acids, miiierai aiid vegetable, bave been pre-

Knbed iatemall; iu this disease : hydrochloric acid hy Jugler aud

Huljiburic acid by Home ; nitric ticid by Cbiaholm and bj

[Jos. Frnnlt ; miJic acid by Gmeliu; leraou-juicc by Scbindlor and

idschied ; vinegar by Joa. Frank ; hydrocyanic acid diluted

rith alcohol by Schneider.

Other substances vtbicb have been vaunt«d as remedies at least
iilTer nidcly from one another. Thus, Willan recommended Liq.
BFotassic, Galen lh(^ flesh of vipers, Hiirniua cucumbers, Marcellua a
■ plant called Britaiiniea, &c. &c.

Another medicine, sent direct from Brazil, is the Hura Braztheasia,
i phinl belonging lo the Eiiphorbiaceie, which in said to have been
Vised in that country with success in syphilis, as well as in forms of
f leprosy, among which psoriasis was wrongly included. I have pre-
•ciibcd it to about twelve patients alt'ccted with psoriasis, and to as
' many suffering from syphilis. In these cases I used sometimes a
decoction made from the dried ba,rk (jj to 3vj), sometimes certain
preparations derived from it in liie recent state. One of these
prepuntious, which is known as Assacou (succua receus Ham Bra-
nlien»is) is given in doses of tt'u grains, either alone or with the
decoction. Another preparation of this drug is termed the succus
Hune alcobolicufl, of which there are two forms, ibat known as
No. I being a mixture of the ftcsh juice with an ec^ual quantity of
slcoboi, while thai which is tenned No. t contains only one part
of the juice to ten of alcohol. Tlie former is given in the dose of
half u drachm, the latter in that of a dmthm, daily.

lliis drug, whether in the form of decoction or extract, produces

' very violent effects; in some palieols vomiting alone, in others

both vomiting and st-vcre purging. Thus, as many as twenty evu-

disMse a simpie, and when he ia moderii.te in bis diet, living on Tegetable food,

— ibe cimttive action Kcnerallj bagint v ilLia lix weeks. Wtien, however, per-

a^iratioa is not at (int Ml up, or even altogether fails to be produced, uti

irheti the Age of the patient ia between fortj and aistj, one or two jeara ufteu

fu* before Iho good offeots of this medicine make their apjiearouce."

f Tha w utracls, which convoj the main f»cta of Polja's book, snd in which

~ tin ao very litlle skill Is sliown in viiinting the powers of this speoiflc.

bnfficieut to Mtiuff liie reader as to its true value. Yet, iiithracokoli

IcnooiDUi ended in man]' Englisli and freocli works on cutaneous dia-

■ Is the Genenl Hospital of Vicuna it was repeatedly tried, lil! tlie dnig-

l»t*»bitl for it acnuuDted lo uoo florin*; but unfortunatelj, it was entirely

aancceaful— except, indeed, in giving a block eoluut to the fieeee of the

■Btienta who took it.

P80KIA8IS.

cuatious (in both directions), bavefoHowed the adininiatratiou of the
concentrated decocliou with the Assacou. Ilencc AmcricaD physi-
cians recommend thiil. the decoction should he given only every
fourth day, and keep the patient in bed and on low diet. Now, when
the drug is preserihcd in tliis way and continued for some time, the
nutrition of tlie patient suffers to so great a degree, that the psoriasis
ipears, just as when the nut-rition ia violently disturbed from
t any other cause. But yet the power of curing this disense cannot
I be said to be possessed by the Hura Bra^iliensis ; for lu every case
I in which a psoriasis has subsided while this medicine was bdiig
I taken, the affection has always returned when the jmtient has reco-
I vered from the ill effects produced by it. In fairness, however, it
must be added that I have never seen any permanent harm done by
the drug, even when it was continued for as long as three months.
All the patients to whom I administered it recovered very quickly
from the injurious effccls to which it had given rise.

jVnolher mode of treatment, analogoos to that last mentioned, and

I adopted, not only by many of the older prat-titiouer.", but evnn by those

of a more modern school, is that of giving purgatives. Among the

remedies of this kind are, for instance, the simple neutral sails (such

as sulphate of soda, sulphate of magnesia, pbuspliote of soda, &c.),

the mineral waters of Saidschiitz, Fillnau, Carlsbad, Marienbad,

k Kisfingen, and tither saline springs, and certain vegetable catliartics

r (including jalap, aloes, colocynth, gamboge, colchicum, and croton

oil). Lastly, calomel has been greatly extolled, especially by Eng-

I lish and French writers; among the former by Willis, among the

I latter by Biett and Bayer. Among these drugs, there ore many

I which I have myself in the course of time repejitedly prescribed ;

I and I have besides seensevend jmtients suffering from this obstinate

I disease, to whom they have been given during lengthened periods,

I kud evi-n for years, by different medical men practising in this or in

I other countries. But, unfortunately, the good effects which have

rWn ascribed to cathartics in the treatment of psoriasis have not

I occurred in my experience. Now and again, the patches may bavr

I dimiiiisheil under u long-continued course of drastic purgatives ;

I hut this conid always be attributed cither to a spontaneous involn-

I lion of the disease, orio the fact lulrejuly mentioned tliat all modiw of

I treatment by which the nutrition is lowered do, for the time during

I which they arc continued, bring about a rliminntion or even a coio-

I plcte disiippianiiice of this eniption.

TBEATHCST.

Now, it is not (Hiseible for a iiiun. to go on taking purgatives all
liis life through witliout uoderminiog his health. Moreover, when
the patches of psoriasis have disappeared, the patient no longer sees
the necessity of persisting in the treatment. Hence in all these
s there comes at last a time when the purgatives are discontinued,
iod then the eruption always sooner or later returns. It follows,
lierefore, that these remedies cannot effect a radical cure of the

Yet another method of treating psoriasis consists in the administra-

1 of diuretics, such as the salts of tartaric acid, squill, Herba

Iquiseti, Badix BardauR, BaccEe Juuiperi, Ononis spinoaa, Petrose-

Apiuin, Bhamnus cathartica, Folia Uvie Ursi, Digitalis,

louito, Galium aparint-, and the tincture of Cantharides. Of these

9, those first mentioned, which act mildly upon the kidneys,

B altogether inert in eases of this disease; but the last of them

t be admitted to be noxious, if not indeed to the psoriasis, at

t to tlie patient atfected vrith it. In every case in which I have

tsoribed the Tinctura Lyttje (bei^inning, as is directed, with four

ps, and increasing the dose to thirty drops daily), severe effects

lave been produced. As soon ns the quantity given has amounted

to fifteen drops, the patient has suffered from difficulty of micturition,

■ud the urine has acquired a very dark colour, containing albumen

•nd afterwards btood. In fact, the presence of these substanct^s iu

the urine may be said to be a constant effect of this drug, Rayer,

^ indeed, and the translator of his work into German,' state thai tliey

uve in several case» of psoriasis given the Tineturn Ly ttii? in closes of

drops, and once in the dose of 150 drops, with the result of curing

file disease witliout injury to the patient. But if the reports of

! cases he considted, it will be found thnt the treatment

eluded siilpliur-batlis; and, in my opinion, there is no difficulty in

iciding whether it was tlie tincture of cantharides or these baths

li contributed most largely to the removal of the psoria-sis. At

f rate, I have never succeeded in removing the eruption by mvims

r this {Irug ; whereas I have often seen it lead to albuminuria or

icmaturiu, although I have given it with alt caution and in

lomparatively small doses. But I have known many iiisljinces in

I sulphur- baths uione, especially those made with the Calx sul-

i or Hcpar sulphuris calcnrcuni {Kttlkschwefelleber) , have

i ptoriasis, in so far as this disease cat) ever he stiid t<i be cureJ.

' L.C., ISfiiid ii, p. jgi.

2G i>soa)A»«i^.

Uorrusive sublimate, agaio, and tii<i blue (jiiitiutiil, huve been
reco in mended in the Ireatnient of psoriasis by experienced observers ;
but I bave repeatedly found them to be inert, In proof of thia
stuti^iueiit, I ujay refer especially to cases in which syphilitjc
eruptions have been roinbined with the uSectioii in question ; as, for
insiauce, when a syphilitic ulceration (Helcosis aypbililtca) has pre-
sented Itself in a patient who had for years suffered firom a non-
syphilitic psoriusis. Under such circumstances, the former disease
has been entirely removed by a mercurial treatment, while the latter
has remained unaltered.

Equiilly powerless agaiiixt psoriasis are iodine and all its prejiara-
tioiiH. 1 have seen not a few cases in which other practitioners
had continued to give iodine for yenrs without the slightest
benefit.

Unrortunalcly, too, I must say the same of cod-liver oil ad-
ministered internally. As is nell-known, this remedy has by many
medical men, and with great justice, be«n recommended in various
cutaneous atfections, particularly lupus. But in psoriasis it is
altogether vtUu fleas.

Araenious acid, on the other Iiaud, has been known from remote

times to possess the power of mothfying the horny tissues in man,

as well as in the lower animals. Everybody is acquainted with the

fact that it is given tu horses with the object of making the coat

sleek and glossy, aud tlint it at the same time improves their

nutrition and mettle, so that horse-dealers employ it to increase the

beauty of these aniuinls. Most probably it was this circumstance

which suggested the idea of using arsenic in the treatment of

t cittaot-oua affections. Its eflicucy in certain eases in which the

, cpidiTiiii* is ihscased is undeniable, so that it has been believed by

le to be a proper and sure remedy in all thti scaly forms uf

eruption. !t has been extolled by writers of every country, and

there are very few books or papers upon any chronic dermatosia in

which urseuio is nut mentioocd in laudatory terms, lliis is, al)ovc

[ all, the case in the works of JJiett (edited by Cazenavc and Schcdel),

\ Uevcrgie, Uardy, Erasmus Wilson, Thomson, and Hunt. The last-

nicntiunetl writer,' in fact, makes arsi^nic play so very impoctjuit a part

1 in the ticatmcut of cotaneuua utTectiuuii, that 1 cannot but draw the

L nUentioii of my renders to his Btatcmcnt«, — not, indeed, because 1

1 vi&li thrm to imitate hia j)rBclice, hut bmuiMi I am aDxioiii> li> kIioh

' ' Pnuliral Uljiervatiniu,' &o., LondoD, 1^4;, p. i^,

THEATMENT,

how Jiiiigtroiis it is, uTid to prevent his direclioiis bemg tbllaweil by
others who have not Lud so large an experience as mjself in this
dep&rltiient of iiicclicine, I feel it to be all Ihe more necessary for
me to give this warning, bccauee I know that some most distinguished
and scientific mi-n have been misled by Mr. Hunt's work, which is
generally referred to upon Ihe subject, and which m 1H60 was
biuislated into German by Dr. E. B. Ffaff, of Plauen in Voigtland.
hjD8t«ad, however, of entering on a detailed criticism of this book,
.% will simply cite from it one passage to show the standpoint token
tj tlie author. " The dise.ise," he says in p. 16, " wiU either get
wvll spontaneously or nut : if syphihtic, it must be treated accord-
ingly ; if othernise, arsenic is the best alterative remedy." I quote
tliia an a specimen of tlie principles which guide Mr. Hunt, and
of the summary method of procedure which he adopts in cases of
mtaueous disease ; but I must also mention that, besides giving the
arsenic, he bleeds hia patient several times usqjie ad dulit/uiuot, or
bas him cupped, and that he applies leeches to the red margins of
those patches which have most recently made their appearance, and
presertbes strong saline purgatives, or blue-pill, Hydr. c. Creti,
colchicum, and colocyntlu And yet he is obliged to confess that, in
apite of this treatment, relapses took place repeatedly in the cases
which he describes. Tins result is surely not such as to induce
any one to adopt Mr. Hunt's method, or to coincide in the remark,
quoU.^ from an English journal in the preface to tlie (Jerman
banslation of his work, lliat "Mr. Hunt hss transferred these
leases from the iucurahle cljiss to the ciirahle."
[ cannot, then, give my assent to the views of lliis writfT. But it
I, nevertheless, quite true that arsenic has a decided curative action
iCB of psoriasis, and can make this affection imdergo involution
lime, if not [jcrmanenily, And I must further remark that,
igh this remedy may be taken regularly for months or even
without (he disease being cured (by which I mean, cured per-
lenlly as well as for the time), I have never seim it give rise to
lasting injurious ctTects, even when given in pretty large doses.
he following are the prcpamliiina of arsenic which, like other
rmat<ilogi8ts, I bnve employed in the treatment of psoriasis and
ler cutaneous ntfections : fowler's solution (ursenite of potass),
eolation (arseninte of soda), Donovan's solution (iodide of
jc and arseniuret of mercury), the Asiatic jnlls (made of arsenic
pcpiK-r), and lastly, pills of arnenie tmd opium.

1i» PSORIASIS.

Fowler's solution (iu a draehra and a half of which there is a grain
of arseuic) is employed in doses uf six drops dailji. It is generally
given before a meal, either in water, or in some aromatic infusion,
sucb ns the Inf. Mentha:, the Inf. Melisste, or the Inf. Chamomilla:.
If it does not di-iagree with the patinit (jiroducing some ill effect,
such Hs nausea, gastrodjnia, or vomiting), the. dose amy be raised at
the end of the first two days by one drop, and at similar intervals
it may in this way be gradually increased till it reaches twelve drops
duily, hy whicli time, some effect will generally be produced. This
consists in a diminution of the number of scales on the different
patches, in a lessening of the redness observed in the macules after
removal of the scales, or in their accjuiring a brownish tinge, and,
lastly, in the cessation of the itching. The remedy mny now be con-
tinued in the same dose (twelve drops] for a long period. Iii casea in
which, although well home, it has produceil no change in tlie cuta-
neous disease, the (juautity may be still further increased, but a1
longer intervals (as, for instance, every four days), until twenty drops
(■Jths of a grain of ursenious acid) are given. And if this quantity
should give ri.ic to no decided alteration in the psoriasis, there is, in
the majority of eases, no reason why the dose should not still be
increased, until it amounts to tliirty drops a day, or ^rd of a grain of
arsenic ; for even so large a quantity as this may be continued for a
long time, without any harm being done to the patient. If, how-
ever, some smaller dose is found to be sufficient by its producing a
favorable change in the affection, that dose should be persevered
in until the red mocnlic have entirely diBa|)peared and have given
place to spots of brown pigmcut, or at least until the disease no
longer continues to break out in the punctifomi or guttiform state.
When this is the case, the quantity may gradually be reduced to tlie
minimum of six drops, with which the patient began.

I have several times given this preparation lor many months
without interruption, the quantity taken in a space of about sii
niontlis exce«'ding 2000 drops. And not only has the remedy done
no harm to the patient in these instances, but he bus been benefited
in every respect.

In other rases, sometimes hy way of experiment, sometimes Ije-
causfl the urwenite uf pjtass was not well bonie, I have employed
the solulioit nf Peiir-ion, in praise of which so much has been said.
This preparatiiin, the hi^uor Soiite .IrMniati*, eonsiMlf of the urKeninle
. of fwla dissolved in distilled walar in the prop<'rti»ti of one grain to

TREATMENT,

U'J

ounce.' Twenty drops contain T,-'^t!i of a grain of the salt, It is
« much less active thuii tlie rowUVs solution, anil is given in a
e of forty-five drops daily, or fifteen drops ihree times a day. It
I to begin with tlus qnantity, and to continue it without
! or diminution uutil the sbove-describcd ehanges in the
^Uncous disease make their np{)earauce. Another prepEtration of
; mentioned in many books on Dermatology as well m in
an Materia Mediea is one of Bielt's, the solution of arseuiate
'lliis, like that of which I have jast been speaking,
gruiu to the ouuce, and It is given in the same

Donovan's solution is prepared by rubbing together in a mortar
grains of nrsenious acid, j6i grains of pure iodine, and loo
rains of mercury, moistened with a little alcohol, the trituration being
Xintinued until the mass lias becoiDC perfectly dry. To this is then
i hjdriodic add, of which a quantity corresponding to jstJ grains
)f iodine b mixed with four ounces of distilled water. The product is
ibaken up wifb thrre more pints of distilled water and boiled down
~J a liquid is obtained weighing 1300 grains. This solution is per-
fectly transparent, has a high specific gravity, and yields no fixed
residue on cvaponitioii. It is given in a mi&ture which contains a
draclim of the solution and half an ounce of syrup of ginger to three
ounces of distilled water, and of which three tublespooufuls are given
daily. I have made trial of tills preparation in various forms of
cutaneous disease, but I have never seen it jiroduee any very good
^ecta.

' The "Asiatic pills," on the other hand, are a really good medi-
line, not only on account of their therapeutical value, but also be-
uise there is no difficulty in their preparation, and because their
e can be easily regulated, and they can be given without trouble.
Itcy are prepared by mixing 66 grains of arsenious acid and
) drachms of powdered black pep]>«!r with gum arabic and water,
) as to make 800 piiL«. £ach pill therefore contains o 0825 of a
rain of arsenious add. In most instances it is sufficient to give
c pills once a day, the best time for tbe patient to take them being
mediately before dinner. But in cases of obstinate psoriasis, I
kftve souictime^ raised the daily quantity to twelve pills (0*99
bf a grain of arsenious add), and have continued this dose for many

' The |ire)iaratiou of the Briliali Pbsfnisixijtmis is four limes u ilTong u
it referred to tij llip auLlior, — [En,]

luotiths without diminution. In this way, it haa sevnal times occumd
that the palient has (nki-n llie eronuous quantity of sooo Asiatic
[lilla (or more than 160 grains of arsenious acid) before he has got
ritl of the (hsease. It is, of course, absolutely necessary that [xMsons

' to whom these large doses of arsenic are being given should be care-
fully watched, and should be constantly under medical obeervation.
In no instance, however, have Iseen any ill effects produced; and

I therefore I can with conlidence recommend to my prol'essional bre-
thren the practice of giving tlie Asiatic pilla, even in such lai^e quanti-
ties as I have mentioned, to patients suffering from these intractable
diseases of the skin.

in some few cases, again, 1 have prescribed arsenic in combina-
tion with opium, under the idea that it would be more easily borne
by the patient when administered in this way. I huve ordered, for
instance, a grain of arsenious nrid mid four grains of opium to be
mixed with sufficient soap to make sixteen pills, and have given fonr
of these daily, two in the morning and two in tlie evening. 1
have continued tlie administration nf these pills likewise for months,
and with the desired effect.

'Hie preceding paragraphs show that 1 must have made mirne-
rous trials of the various preparations of arsenic. 1 hsvc^ in fact,
given it to more than 400 jiatient^ suffering from different forma of
cutaneous disease ; so that I can, from my own observation, assert
the therapeutic value of this remedy^ i can, however, by no means
ascribe to it the power of cvring infallibly chronic nffecttons of the
skin. To do this, arsenic should be able not merely to cause the dis-
iip^tearance of existing eruptions, hut loprerml th^r mcHrrmce. The
h<A is, however, that under the employment of each one of its pre-
parations, I have, in different cases, seen the disease break out again
or undergo relapse. Thus, whik tlie special action of the arsenic
» exhibited by its removing the scales from some of the older
liatehes of a psoriasis, and changing their reil colour to brown, new
spots often cuiitiuuc to break out at points hitherto free from the
disease. These rcmcdicB, then, possess the power of removing ex-
istiijg eruptions, but are not oble to prevent the nccurreiiee of

I fresh one*. They are, however, the most efficient of all the internal
medicines of which I have had to s])eak, and it may be said that

I tliey alune, among these inedieiiics, ran by most pcmmi 1w taken

I for a grrat length of time withimt injury to tlir lienlth.

TREATMENT,

ibli- loe to give an account of Ihe nutnerous lofal applications
jlrhich hfivc hven recoiuiucnded for the cure of this disettse, I murt
grange llipm under different heatls.

Wattr. — I will begin bjr s|>eaking of wat«r as a local remedy for

joriasis. Under this category must be mentioneil water-dressing,

Wtlis, vnpour-baiha, the " hydropathic" method practised by Priess-

llitz and othera for the cure of various complaints, hot ajnings, and,

HE>tly, the "continual bath," invented by myaclf.

And, first of ail, I may state that simple wat^-rireirnng, if
nntiuaed long enough, may remove s psoriasis. For this pur|)08e,
tdean strips of bandage are used. Thisv. are dipped in lukewarm or
rarm water, nnd are wound round tJieulfected parts, and covered witii
Ihin gntta-perdia or oil-silk, so as to retard evnpomtion of the water
tnd to increase the cfTcct of its application. Putients who are being
reatcd in tliis way need not to be kept in bed, or even within -door",
rat may be allowed to go out in Ihe open air. Iji the less severe
forms of psoriasis, and especially when the affection is confined to
the limbs, this method is very often sufficient to remove it entirely ;
but in all cases it may he i-mploycd as an adjuvant while internal
medicines arc being given, or as a substitute for the warm bath when
this cannot be obtained. Instead of the water- dressing, if anything
should prevent its application as above described, it may be sufficient
to wrap the alTected parts simply in thin gntla-percha or oil-silk.
The |>roducts of the cutaneous perspiration will then accumulate
between the skin and its impenneable covering, so as to form a
layer of fluid which, remaining always in contact with the skin,
. keeps it constantly moist.

It is generally supposed that warm hatht, at an agreeable tem-

kperatnre (90° — 100° Fahr.), are essential to a patient sutferiug from

nitaneous disease, and that, in psoriasis especially, they are of great

Now this I altogether deny so far as the baths in ordinarv use

e concerned, in which a person remains for only half an hour or an

Ainnr 1 for I have never seen them diminish, and certainly never care,

Qiis affection. It is true that wheii baths are continued for several

ir when my " con ti mini bath"' is employed, more marked

^ecta are observed; but even then they appear much more slowly

B this disease than in mnny others : conseiiiiently, 1 cannot rcrom-

lend tlic use of wnrtn baths in C4i:>ie» of psoriasis, excepting, indeed,

D so far OS they arc an essential part of other methods of treatment.

I See vol, i □[ the New Sjdeuliun Societ;** tnuislalion, p. 3J0.

32 I'SORIASIS,

Now, if 1 make the empiojmenl of warui baths, aud even of
the continual bath, a ven' subordinate part of the treatment of psiori-
asis, I attach still less value to vapour-baths. And yet, areording
t« some, these have special curative power? In the disease in question.
The only cases in which it seems to me desirable to order vapour-
baths are those in which water-dressing cannot be applied, and warm
baths cannot be used, either becaii se the patient's circumstances do not
permit it, or because the disease is situated on some part of the body
(as, for instance, the face or head) which is not accessible to the
ordinary warm bath. I do not, however, mean to say that the
existence of psoriasis upon the other regions of the body contra-
indicates the employment of the vapour-bath, but only Ihat it must
not be supposed to be more efliciurious than an ordinary warm bath.

The effects otpcat- and mu/f-Aadg are about on a par with those
of waler-dressing.

Bt/dmpatAy, however, atcerdiag to the original method of
Priessnitz, is a much more efTectiial mode of treating psoriasis. A
must essential part of this procedure is tliat in making up the patient's
bed, the directions which are given should be strictly obeyed. The
proper plan is the folluwiDg: — Over an ordinary bed, hamg a
straw-mattress as well as a common mattress, a sheet of thin gutta-
percha or oil-silk is laid, to prevent the mattresses getting wet.
Across this there are then placed two strong binders, or foldt^d
towels ; upon these, a thick, fleecy blanket, doubled and folded in
such a way as to project a little beyond eiicii end of the nuittresses ;
and upon this, again, ii hnen she-et ithich has been dipped in cold
water and well wrung out. The patient, who must Iw quite naked,
is now made to lie down on the sheet, with a boltle between his
thighs to n-ccive his urine. Hr is nest completely wrapiied up in
the wet sheet, so that the head and forehead are eoven-d as low as
the eyebrows, and the ears and checks round lo the chin, the sides
of the sheet being, of course, wound about the trunk and hmbs.
The blanket is then wrapped round him in exaftly the e«ame way ;
the nose, mouth, and eyes being thus the only parts left exposed.
Finally, the bindiTS or towels are tied so as to keep the blanket and
ylicet in close contact with the patient's body.

It is only at lirsl that uncomforlahle M-nsnIions arwe from tliis

procedure, wliich is known iu« "packing" ('Pie PriesaiiitKsrhe

Bin wick el ung'] ; thc'sc are at once followed by a glow, which,

I huwrver, doe* not exceed the iialural temperature of the body, and

_Which, besides being very beneQcial, is not disagreeable, provided
that perspiration is established. To favour sweating, and also to
cool the patient, wnter is frequently given him to drink, and the
"packing" is left undiatorbed for three or four hours; at the end
of this time, when he has thus been bathed in his own perspiration,
the second part of the trentment begins, tbat of cooling him down.
For tliis purpose, a bath [either in the same room, or in one close to
that in which the patient lies packed) is filled with cold river- or
spring- water ; and, when possible, a douche apparatus also is pro-
vided. The lower of the two binders, wliich surrounds the patient's

^knees, is now unfastened, and the blanket and wet sheet are
rawii away from his feet and raised, so that he ran get up from hia

|)wd and walk to the bath. When he has readied its side the second
Innder also is undone, the blanket and sheet are quickly removed,
Old he is told to plunge instantly into the cold water. While in the
nth he is rubbed with cloths, and is also made to rub himself, and
to move about in the water. By these means the disagreeable
sensation at first caused by the cold water is relieved, and is soon
followed by a feeling of warmth, which every one describes as being
very pleasant and comfortable. Next, if there is a douche apparatus
connected with the bath, it is made to play on every part of the
patient's body ; but when this cannot be done, sponges dipped in
cold water are used inst^'ad, or water is poured over him from a
can. Lastly, having been made to leave the bath, he is wrapped in
diy cloths, and frictions are ^ain employed. He is theu quickly
dressed and made to take a walk in the open air.

The whole of this process, including the cold bath and the douche,
as well as the " packing," is gone through twice in the twenty-four
hours ; early in the moruing {generally at 4 or 5 a.m.), and again
some hours after dinner (at 4 or 5 p.m.) . At the same time the
patient is kept on a nutritious, but simple, diet, is forbidden to
jtake of alcoholic liquors, and is made to drink cold water fre-

' Having myself had reconrse to this method of treatment with
tarked success on many occasions, both in hospital and in private
tactice, I call with a good conscience recommend its adoption in all
lose cases of psoriasis in wliich the disease is extensive, and in
■Irhich it is possible to carry out a practice requiring so much time
Bud patience. As I have already said, however, it is essential that
the " packing" should be done carefully, and that (if employed at all)

k
^

84 PSORIAETS.

it should be jiersevered in ; no; mast it be expected to do more good
tban other kinds of sj'stem&tic local treatment.

The method recommended by Priessnitz at a later period — that of
frictions — is very much less effectual than the process of " packing"
above desoribed. It oousuts in Trrapping up the patient suecwavel)'
iu leveral cloths soaked in cold water, and then employing friction
at once, without having made use of blankets. He is afterwards
simply made to take a cold bath, and to have the douche applied.

Faoriasia is so obstinate and -difficult of cure that every spa and
watering-place in the world has probably been vicited by patients
affected with this diseBse, belonging to the more wealthy classes.
Yet there is not one snch locality which has been able to earn a
perraaneJit reputation for its treatment. Neither sulphur springs,
nor those euntaining iodine, noT those which have brine as thoir
principal constituent, nor, lastly, those in which there ia no special
ingredient (indifferente Therraen), have shown themselves to be
possessed of specifia powers against psoriasis ; and although one or
two watering-places have gained somewhat more renown than others,
this has been due merely to the way in which tbe baths are used, and
not at all to the chemical composition of the water. Tbe remark
just made applies mainly to the baths of Louechc (Leuk) in Switzer-
land, which are frequently recommended by Gennan as well as by
French physicians to patients suffering from cutaneous diseases
(especially psoriasis), and have, in certain cases, been resorted to with
success. At this spa a ]jecaliar custom prevails which does not exist
elsewhere. Tlie patient does not merely spend half an hour or an
hour in the bath, but remains in it for six or eight hours at a time —
from early in the morning nntil dinner time. Thus, for equal periods
of treatment, the time devoted to the bath is about sixtimee as groat
as at other watering-places, I am firmly convinced that Louiche
owes to this circumstance most of its fame for the cure of cutaneous
diseases. For certain other s^ms (such as Baden near Vienna,
Odslein, and Krapina-Tophtz in Croatia), which nre made use of in
the same thorough way by visitors, pBrticuhtrly by persons who
belong to tlic country, do, in fact, enjoy u similar reputation both
abroad aiid at home.

Aa I stated in the first volume of tbia work,' when speaking of the

treatment of amalipox and of bums, 1 have bad an ap|iaiatus con-

atrncted by means of which the warm bath may be continued for a

' Vide tfoL I, pp. a&i, jjo.

TRBATMKNT. 55

long time, the patient in lact reinaimng uninteiTupledlj day aud
night in worm water. I have made trial of this apparstns in
psoriasis, as well as in the diseases above mentioned. The effect,
howeveTj has merely beeu such as I could have arrived at by using
lotiona or any other topical applications by which the cuticle would
be kept in a state of maceration. The complaint has not been
cured.

In concluding the subject of the treatment of psoriasis by means
of water, I must also mention bathing in the sea, or in ponda, iaken,
or rivers, but only to state that it ia oaebra.

Soap. — The well-known action of alkalies u^ron the cuticle, and
upon the horny tissues generally, explains why soaps have been ao
commonly employeti for therapeutical purposes, as well as to cleanse
the healthy skin. It seems as tbcogb instinct leads men to use wal«r
and soap in all cutaneous diseases in which epidermis is formed in
excessive quantity, and accumuktcs in the form of scales upon the
Eurfuce. It is therefore not surprising that we find soap praised as
n local remedy for psoriasis ; and the praise is in fact deserved,
provided that the right kind of soap be employed, and in the right
manner. Common washing soap (soda-soap), used in the ordinary
I'-iray, as for washing the hands, will not, indeed, answer our ex-
I pectations for by it tlie disease is either not cured at all, or only
after a very long time. But if potass-aoap be employed, and in a
methodical and enei^tic manner, very successful results may be
obtained.

I will speak first of the soap itself, and then of the way in which
it is to ho applied. And, in the first place, I must remark that, in
endeavouring to procure a good potass-soap, one should not go to
the apothecary's shop, but, if possible, to some manufactory in
which it is made on a large scale. Pfeuffer, and other medical
writers, have, indeed, taken the trouble to lay down a formula^ for
Uie prcparwfion of noap in the pharmaceutical laboratory, but they
luive forgotten that saponi6cation is not to be effected by merely
' This i% u fullows :— ^ Lixivii caosttei sataroti (poDderia speeiQci 1333)
partem nnam, *dipi3 ceti partea duas. Handtcbah redncea the specific gnivitj
of the cMistic potoas to 1*330, atid emploji pig's lard instead of Irain oil.
Otben direct that ordiniLrr boap- boiler's lej should be used, and that it should
bs neutralized with cod-li^er oil, or with cocot.buller, olive.oil. &c. But
neither thcj oor the authors whom I have mentioDed b; name have ■nccwdcd
in Ibe ot^fct to bo aimed at, — the prepantioa of a good soft wap devoid of
caattio properties.

mixing certftin quantities of alkali and fat togetlitir, rttiil that it is
important to be acquainted witli practical details known to those
oDly who are engaged from year to year in the soap manufacture.
Eepcated observation has taught me that most variable effects are
produced by soft soap prepared by these methods in the apothecary's
shop. At one spot it wilt completely denude the skin of its
epidermic covering, and expose the corium ; in anotiier place it has
no more effect than so much oil. In the first case, it produces a
number of painful excoriations, by which further treJitment is
interfered with; in the second case, it is altogether inert. In
asserting that it is not advisable to use potass-soap prepared by the
apothecary, I do not, however, mean to say that wliat is procured at
the druggist's shop is never well made. On the other baud, I am
quite aware that the soap of commerce is by no means necessarily
free from faults,' for it very often contains small carbonaceous
particles and ashes, which render it gritty, and make it very apt to
produce irritation when ajiplied to the skin.

Good "soft soap" or potass-sortp (Schmierseife, griine Seife,
sapo viridis, sapo kalinus, savon vert), should be somewhat
thicker than syrup, or of about Llie consistence of Eoob Laffecteur,*
BO as not to Bow out when the jar containing it is turned upside
down. It sliould be of an oUve green or brown colour, and should
have an acrid alkaline taste when pnt on the tong«ie. It ought not
to bo at all gelatinous, but rather of a pulpy character, and perfectly
homogeneous. It should have no rancid smell. It should be
dissolved by alcohol without any residue of consequence. Lastly, no
particles of sand should be discoverable in it, when it is rubbed down
between the fingers.

To remove the unpleasant smell which always belongs to potass-
aosp, it may be dissolved in alcnhol (in the proportion of two parts
of soap to one uf Alcohol), and this solnlion, after being filterml or
allowed t« settle, may be scent^id by the spiritus lavaudultc, or any
other aromatic spirit. In this way all the tberapcntical cfl'ecta
of the soft soap may be obtained, while it;* disiigreeable odour

. is RToided, and the purticles of .^nnd whti'b it ruiilains nrv got rid
of. To LJislinguish thiii solution from tliu ordinary spiritus sapanatus,

I made from soda soap, I term it the apiriltu taptmalui katinut.

* I hsvc for Mime jean past ohtuaed froB ttje hou«« of DuTsmoit, dJ
b 6tutiK«rl, all the pota«*->oap I havo rcqaired.
' Vida ToL i, p. 40.

TREATMENT. 37

In the use of tliia liquid, or of ths potaas-soap itself, the main
points to be attended to ate, that the application should be brought
into iumiediut« contact witli the surface of the skin, and be left
there for a long time, II is not sufficient to rub in the remedy and
immediately afterwards to wash it away. The soap must be allowed
to remain upon the discard part for several days, and sometimes
even for weeks together. It mast, in fact, be employed in the same
way and on the same principles on which we should make use of
water dressing or of a Jotiun (in Oestalt und nach dem Principe vou
Umschlagen). There is a very wide difference between rnbbing in
in ointment of which the constituents are expected to penetrate the
" 'erent layers of the skin, and to be absorbed by the vessels and
tiius to enter the circulation, and nsing a remedy whose main action
supposed to be to soften and macerate the epidennb, or to destroy
it. The longer such a remedy is left in coiiluct with the cutaneous
surface, the more certainly will the object of its use be attained.

It was in the so-cnllcd "English method" of curing scabies that

the practice was lirst introduced of wrapping patients starkn&ked

in blankets, and rubbing sulphur ointment or soft soap over the

whole body. It was then observed that by this plaa of treatment

the epidermis was extensively softened and destroyed, and tliis

naturally led to the employment of the same, or a similar, method in

other cases of cutaneous disease, particularly those which, like

[isoriasis, are widely diffused over the surface of the skin. Thus

FfeufTer recommends that the patient should be wrapped for sis days

at a time in blankets, and should be rubbed twice dady with soft

■oup. Of this he gives him i8 ounces, divided into six portions,

three of which contain four ounces, and three two ounces each. On

each of the first three days four ounces are used, half that quantity

being in the morning rubbed over all parts of the body by means of

pieces of flannel or fle.ih brushes, and the remainder being apphed in

llie same way at night. During tlie last three days of the treatment

ounce is sufficient for each time of application — for not only is

le epidermis itself now to a great extent softened, but the blankets

imprcgnatrd with a good qunntily of the soaji. At the end of

six days Ffeuffer advises that the patient should be ollowed to

:e a bath, and this completes a course of the " soap cure,"

In some of Die less severe cutaneous diseases, such as pityriasis

irstcolor, herpes tonsurans, etc., in which the morbid prodacis

ipy only the most 8n|<erftcial layers of the cuticle, a cure may

be effected b^ mokiug the patieut lie in blankets for sis dajs, and
mb m soap iu the maimer above described. Bat psoriasis, eveii in
the mildeat form, is not one of the complaint's which can thus be
removed bj a "soap cure" of six days' duration.

A fortba- disadvantage of this method of Pfeufer is that its com-
pletion within the period named is merely nominal. The patient i^
unable to get up for aefveial days afterwards, for he can generally
neither walJc, nor stand, nor move his arms. The skin over the
flexures of the joints is, in fact, so tense and painful, thai he cannot
cxt«nd his limbs.

These defects, which must be apparent to every one who employs
the soBp-cure in practice, have caused me to modify somewhat this
method of treatment. For instance, in a ease of psoriasis ditTusa
inveterata, in which the whole surface of the body is affected, 1 have
soap rubbed in twice a day, iu a quaiitity which varies with the age
and size and also with the susceptibility (Tulnerabilitat) of the
patient, but which is generally from about two to four ounces daily.
Young women, in whom tlie skin is delicate and contains but httle
pigment, naturally require a smaller amount thau strong, heavy
adults, whose epidermis is of a dark colour. It is, however, essential
that the soap sliould be firmly rubbed into each individual patch of
psoriasis by means of a piece of flannel or a brush, till the accumu-
lated masses of epidermis are removed, and a little blood is seen to
ooze from the red base wliich Itas thus been exposed. To diminish
the painfulness of this procedure, the body should be divided into
regions, and a different region idiould be especially nttejided to each
time the soap is used. For instance, on the first occasion, some
particular part, f uch as the right arm and forearm, should be rubbed
forcibly till it bleeds, while the remedy is only applied gently to the
rest of the body. Next time, on the other hand, the more energetic
frictions may be limited to the left upper limb, and so on, until at
tJie end of six or eight days every part of the cutaneous surface haa
been rubbed in such a way as to produce alight bleeding. Within
the period named, then, accoidiug to the severity and extent of the
~ ction, the frictions are completed ; but the patient must not bo
tnitte<l to take a bath, or to give up lying iu the blanket im-
glinted with soap. In this he must still remain for al It-^aat three
r days after the rubbing is discontinued, in fact leaving it
wtten extensive dr.»i|UBmatian has commenced, so that the
bio cnticle is peeling off in large lamellae Moreover, uutil this

TBEATMKNT.

I takes place, he inust not be allowed to take a bath, to change hia
I bed- and bodj-linen, or to dress himself. It is, however, in but
I few cases that even this energetic course of treatment eiTecIa the
lesutt aimed at, the cure of the psoriasis. But the repeated eiDplo;<
ment of the same treatment, or a comhinatiou of it with other pro-
cedures to he hereafter described, will nevertheless often be successful.
Moreover, I frequently apply the soft soap without wrapping the
patient in biikuket^. In cases of psoriasis and other skiu affections
I often have this substance forcibly nibbed into the skin, in order
to soften and remove the masses of epidermis, and thus to smooth
the way fur the cmploymoit of other remedies, and enable them to
produce their full effects.

When psoriasis affects only a few parts of the body, such as the
elbows and knees, ot is confined to any other special region, my
nauiil plan is to mnke a sort of plaster by spreading soft soap, like
an ointment, over pieces of flannel, and to apply these to the spots
affected, until they soften the epidermis and remove the masses of
[acalcs.

The variety of psoriasis in which I have found the soft soap (and
['particularly the epiritns saponis kalians) most usefid is that affecting
1 iiie hairy ecatp. I must, however, mention the remarkable fact tliat
' the disease is much leas obstinate and yields more readily to treat-
ment when it occupies the head aad face than when it is seated on
other part's of the body. Li fact, in cases of psoriasis confined to
the head I have never foiled to cure the complaint pretty quickly by
having the part repeatedly washed with the epiritus saponatus kali-
l.ftU3, without Diokiug use of any other remedy.

Medicated toapt. — These substances, which have been made both
Whj chemists and by manufacturers, may be employed with advantage
■ ^ the treatment of psoriasis as well as of many other cutaneous
Psffections. A great argument for the use of soap as a vehicle is
uodoubtedly the fact that that substance is so easUy and so con-
veniently apphed} and the pota^ (or soda) and fat which these
medicated soaps contain, so far from interfering with their efficacy,
' frequently promot* it by softening the epidermis. A variety
\ medicinal substances, among which are iodine, iodide of potaa-
sulphnr, iodide of snlphiir, tar, graphite, benzoin, Carlsbad
Sl-c, have been introduced into such soaps. Efforts liave also
ten made to increase their good effects by the addition of glycerine,
1 to give some of them a fluid form.

f 40 PSURIASIS.

I have repeatedly made use of these medicated soaps in every
v&riety of CQtatieous disease. Bnt, although I cannot mention any-
thing as especially contra-indicating their employment, I have found
very few of them to possess the efficacy which their inventors and
makera would like to claim for them. The most important among
them are those which contain sulphur, iodide of aulphur, or tar.
The last of these is particularly to be recommended in cases of psori-
asis, and therefore I shall refer to it again, and in the next paragraph,
when I am speaking of tar us a remedy in this disease, I shall giva the
indications for the use of tar-soap, and tlie mode of applying it.

Tar. — ^Thia substance waa employed in the treatment of cutaneons
affections even by Theophrastus, Dioscorides, and Plinius ; hut later
physicians, following Oalen in ascribing all diseases of the akin to an
acrimouia sanguinis, rejected ail local treatment, and so tar became
forgotten.

Li the year 1 744, however, Berkeley, Bishop of Cloyne in Ireland,
wrote a treatise on the tar-water, which he recommended as a uni-
versal remedy, and especially far the cure of phthisis ; and the
efficacy of tar in the form of vapour was afterwards vaunted for
various internal complaints by many writers, including, among the
English, EUis Lind, Ramspak, Crichton, Forbes, and Thomson;
among the French, Debois and ihe brothers Le Beau; and, among
the Germans, Hufeland, Neumann, Pageustecher, and Wendt.
Still it is only iu quite recent times that tar has again been brought
into repute, and that its specific action on the cutaneous diseases of
man and of the lower animals has been fuUy recognised. In Eng-
hind, Batcman and Wilkinson ; in France, Rayer, Cazenave, Girout,
Gauthier, Emmery, Bazin, Serre, Gibert, and Devergie ; and in (Jer-
many, Hertwig, Krieg, Otto, Cless, Teiel and myself, have repeatedly
demonstrated the remarkable efficacy of this agent in the treatment of
many skin affectioiis, and have aided in making it generaUy known.

Tar is well known to be an empyreumatic oil, obtained by the dry
distillation of coal or of difFcreut kinds of wood. Several varieties of
it are used in the treatment of cutaneous diseases. Such are Ihe
oleum empgreumaticum coniferum-,* derived from the wood of the

' The term pix liquida, which u Biwajs emplojeil in phirmioolo^ioal ntid

elhrr medical works. i» eviJcnil,)' inapprDpriBtti and incnrrect. For llin wrtnlt

k Pccl), flItMigm Pcch {pit li^mida), ucr liud in German to ninm, not > product

If di»tiUKlioii, hilt thn miuous mauwliioh exudM BpoatauFvuiilj from fir trea,

b McaDC* •buodtntlf when inciiiou ire made iatu them

TREATMENT.

■ Bpruce, the silver-, or the Scotch fir; the oleum /'agi, obtained by
dry distiUation from the beech; the oUiim cadinum (huile de cade],
distilled from the wood of the Jun-ipervt ojycedrus; aod lastly, the
oleum bettila seu oleum ruici, which cornea from the bark of the
Betula alba.

The effects of these four empyreumatic oils, and also of that made
from coal (the oleum ligni /ots'tlu) empyreumaticum) , are nearly iden-
tical, and therefore in countries in which they are all to be obtained
the one most employed will of course be that which possesses fewest
of the disagreeable qualities of tor. These are especially the sharp
peuettxting smell, the dark colour, of which it is so difficult to free
Uie skin, and the viscidity. Now, from this point of view, the
oleum rutci is to be preferred to every other form of tar, for it
possesses the least disagreeable odour, being, iii fact, the substance
which gives to Russia leather that peculiar smell which is ao fashion-
ftfale at the present day under the name of " par/um rutte." Next
to the oleum rutci must be placed the oleum cadinum ; then the
ol. eoni/erum, then the ol. fagi, and lastly the ol. ligni /otnilU
empyrevmalicum. which has a most disagreeable penetrating smell,
resembling that of coal-gas.

These empyreuinatic oils are aonaetimes employed by themselvea ;
sometimes they are cumbined in various proportions with other sub-
stances (sucli as soda-soap or the spiritus sapooatus kahiius), forming
in the one case a solid (feste Theerseife), in the other case a liquid
compound (fliissige Theerseife) ; with solid fats, in the form of
ointmenia; with fluid fats (such as the various oils, cod-liver oil
or glycerine), in the form of liniments; lastly, they are sometimes
suspended in alcohol, forming tinctured of various strengths.

By repeated distillation of these different tarry oils, and par-
ticularly of the oleum cadinum, three new products have recently
been obtained, which have been named by Feieira resinon, resineon,
and resiucin.'

Of these substances I have employed resineon without admixture

' These bodies are prepared bj adding eotnf potass to one of the tstrj oils
(such M the oleum tadinum), and heating the mixture in a retorl. Al a
temperature of 158° — 17*° F»hr., a colourless substance distils oter, wljich is
minoD. When tlie tint is raised to from 171°— 2g8° Fahr,, tbeie cornea over
cei*er aootlier prineiplR oliich is likewise coIouHrss, but is miipti

t abnndant ; this is resineon. Lutlj, when a IcmperBlurc of J98' — 481°
iched, resiiiein is obtained. Tide ' Die seit i8jo in die Tberspio

lefuhrteo AreaeistoSe, Ac..* ton Rich. Hsgen. Leipiig, i8>^i, p 153.

in many cases of psoriasis. My directions for its use have been to
first rub the individual patches with soft soap, and afteiwords to
pencil Ihem over with the re^ineon. Thia agent has, however, several
disadvantages; it gives rise to mor« severe and more Ion g-coD tinned
sensations of burning than tar, it dries slowly, and it has a very pene-
bating odour ; it also frequently sets ap a reaetive dermatitis, and is
:«pt to produce none. Tor these reasons ordinary tar is to be pre-
ferred to reaineon in the treatment of psonasis. When made into
in ointment, however, it does not give rise to so much irritation.

Again, I have used the carbolic acid in some cases, both locally and
8S an internal medicine ; and the experinients which 1 have made with
it have in part been very successful (theilweise sehr gelungcn).

As for the tarry oils themselves, and the preparations made from
them, 1 have bud opportunities of employing them in many forma
of cutaneous disease, and particularly in psoriaaia; and my oh-
Bervations have shown to me both the advantages and the dis-
advantages of their use, and have taught me their action on the
healthy as well as on the diseased skin. These are, in (act, pointa
which it is necessary to be well acquainted with, and to pay due
attention to, in employing tar ; for otherwise the beoeficia] effects
of the remedy may be overpoweresd by certain unpleasant results
which it produces. Thns, although the symptoms of reaction pro-
duced by the application of tnrry preparations to the heaJthy or even
the diseased skm are, in the vast majority of instances, veiy slight,
and may even be altogether absent (particularly when the remedy is
applied only to parts of the body), there arc some persons in whom it
Tery readily produces injurious effects. A single application of any
tarry subsUnce to the cutaneous snrface is, in these subjects, at
followed by swelling and redness of the part, an increase of the
imperature, sensations of tension und pain, and even by the fonna-
ion of vesicles and bulla;. In fact, we may in this way produce
symptom of a dermatitis, or ao Erysipelas vesiculosum s. bul-
, which, moreover, does not at oqc« subside even when the tar
quickly removed, but runs the ordinary course of an indammation
the skin. In other cases, again, tarry applications arc very well
ime fur a considerable time, and produce the desired effect ; when
iddcnly reaction sets in, and the above-dcsoribed symptoms of
latitis appear and prevent the further apphcation of the remedy,
invariable reault of the long-c<mtinucd use of tar is that the
Mies become inilamed and swollen, so w> to form papules uf lh«

TEEATMXNT.

in th

ip seeds, or even as large as lentils, and tlius that an

erBption reaembling an acae is prodaced, which is, however, very
easily distingaished from all other forms of thia affection by the fact
that a black tarry point like a comedo always occupies the centre of
each papule.

I propose to give to this eruption the name of tar acne (Thet-r-
ocne). Its occurrence, of course, renders the discontinuance of the
remedy absolutely necessary.

Again, tar hfis often and most justly been recommended against
the subjective aensations caused by cataneous diseases, but ita in-
fluence in this respect is liable to certain exceptions. In most
instances we do fmd that the itching is relieved or altogether
removed by the inunction of this substance. Sometimes, however,
an exactly opposite elTect is observed, the itching becoming iusup-
portable; and yet there may be nothing in the objective symptoms
to explain the peculiar action of the tar in such a case.

Moreover, when tar is rubbed iuto the skin of the whole body,
there arise symptoms which prove incontestably that it ia ab*
sorbed into the blood, and discharged by the excretory organs,
and particularly the kidneys and the intestines. In some persons
these symptoms appear within half nn hour ; in others only after a
longer interval, perhaps three or even six hours after the inunction
of the remedy. They vary in different cases. Sometimes the
patient vomits a black Suid ; sometimes he passes black fsces ; some-
times (and moat fre<]uently} he voids urine which, though transparent,
is of a dark oiive-green colour, or even as black as ink, and possesses
a distinct tarry odour, made still more evident by the addition of a
few dro[)a of sulphuric acid. In several cases m which I have employed
inunctions with tar, it has thus been excreted in the urine and in
the ffecal evacuations, and this fact is interesting to physiologists as
proving that, even while the epidermis is uninjured, it is possible
for substances to pass through the skin and be absorbed into the
circulation, and also as being opposed to the hypothesis that bodies
in the state of vapour can alone penetrate the cutaneous tissues.
One of the Viennese chemists who supports this by)Kitliesis has,

It^d, stated with reference to this point, that black urine is
reted, not only by those who have actually been rubbed with tar,

it also by those who are in tbetr neighbourhood, as, for instance,
by patients occupying the adjacent beds in a hospital ward. Uut
although I have many times looked for such an occurrence, I have

4-1 P80BU8I9.

iicver succeeded iii observiiig it. In my clintque black excremeuts
smelling of tar have beeii passed by tbuiie only to whom this sub-
stance had been applied, and never by any other patients or by any
of the nurses who were coiiEitaiitly in the ward. This surely goes
to prove that the tar is absorbed as such by the skin, and not in the
gaseous form through the longs.

The entrance of tar into the blood is by no means unattended
with signs of reaction. Sometimes the patient is attacked by
shivering ; sometimes he suffers from nausea and vomiting, and from
oppression of the head ; sometimes he passes several fluid evacua-
tions soon after the application of the remedy. These unpleasant
symptoms are, however, never of long duration, and subside entirely
when free diuresis has established itself. And they may very easily
be obviated by making the patient (both before the tar is rubbed
in and afterwards) take plenty of water, eau 8ucr&, tartaric acid, or
some other diuretic, so as to increase tht- quantity of hia urine.
When tar or any of its preparations, mstead of being nibbed ovof
the whole body, is applied to certain parts of it only, the effects I
have been describing are never observed.

Before applying pure tar or any preparation of it to the skio, it
is necessary that the morbid products which are present in greuter
or less quantity should be removed. In treating a case of psoriasis,
for instance, the scales must first be detached, in order that the tar
may be brought as intimately as possible into contact with the
vascnlar structures of the integument. Hence, to attain a successful
result, it is always requisite before using the lar to place the patient
under one or other of the above -described methods of treatment, by
which the epidermis may be softened and the masses of scales
removed. He may, for example, be kept in a bath for a considerable
time, or subjected to the hydropathic method ; or water-dressings
may be ajiplied to the parts affected. Afterwards either of the
above-mentioned kinds of tar may be applied, the beat being the
01. rusci. A small quantity ai it is to be placed on a brush made
of long bristles, and rubbed forcibly into the skin of the patient.'

Now, when he tms in this way had his skin impregnated with tar,

■ I sui ooaiinced llial it is not ■ gowl plan to *ppl; tar, as is f^enersll; done,
ia Ur^ qiiautiij, and witli but lilUc force. The objeet klioulil evidently be to
bnnit tlie rKuieit; u lulimatei; m poMible iulo wutnol witli the tkin ; and this
i», of cuune) effeclcd n.ore oom|ilel«lj b; euei^tio friction tiian b; iproidiaB a
ihiok Ujer of tar over the surface

TREATMENT ij

llhe patieul must not resurae bis ordinary dress, particularly if his
nnder- clothing is made of cotton or linen. For the capillarity of
these fabrics favours the penptration of the remedy into their sub-
stance, and thu5 removes if. from the surface of the skiu. Heuce
i is necessary to cover him with clothes made of textures which
lave little or no power of absorbing tar. Thus, a jacket and

ftrousers of sheep's wool may be made beforehand, and put on as
Boon as the inunctions of tar have beeu commenced. Or we may
adopt anotlicr plan, and spread over the patient's usual bed a large
blanket or (in the case of a dehcate individual) a sheet made of
flannel for the purpose- Upon this he is to be laid in a state of
perfect nudity, after having been completely covered with the tar.
The blanket may then be wound round him, or, if this be preferred,
a similar one may be spread over bim in such a way that he is com-
pletely enveloped in woollen coverings.

Thus clothed or wrapped up, the patient is to be left until the tar
on his akin has become quite dry, which will take from two to six
hours, according ag one or another preparation may have been
employed. When this has occurred, however, he may be allowed
to resume his ordinary linen and clothes, and need no longer be
couiined to his bed or even to his room. The same plan must be
adopted, when, instead of pure tar, an ointment, soap, or alcoholic
solution of the remedy has been used; but, as I have already
mentioned, the period during which the patient must remain en-
veloped in woollen coverings varies according as the substance ap-
plied dries more or less quickly.

This procedure is to be gone through once or twice daily, accord-
ing to the severity of the case and the degree to which the skin is
tolerant of the treatment. The same means which were employed
before the first frictions may with advantage be repeated before each
new application of the remedy for the purpose of removing the
older layers, and so facilitating the penetration of a fresh quantity of
tar into the skin.

The changes which show that a preparation of tar is exerting a

I curative action on the affected parts of the skin consist in the red
Hitches beginuiiig to grow pale, and in the renewal of the scales
icing place less quickly, and after a time ceasing altogether. There
I, in fact, a gradual subsidence of all the morbid symptoms. When
the diseased parts (in psoriasis, the patches) have lost their bright-
nA colour, and acquired a brownish- or yellowish-red tint, and

whii

then the morbid growth of scatea has entirely ceaaeil, it is time to
the effect of suspending the application of the tar. Ajid then,

at the end of a week or a fortnigbt no fresh redness has made its
ippearance, and no new scales have been fanned — tf the old patclies
continne to grow paler and their surface remains smooth and free
from scales — we may in this case entirely discontinue the treatment,
and wait quietly for the restoration of the stun to a perfectly normal
condition by the absorption of the deposits of pigment which remain.

Solution of suljtknret of calcium (KalkschwefeUeher-Losung).
This application was first recommcncled by Tlemingkx, a staff-officer
in the Belgian Array Medical Service, for the cure of scabies, and baa
proved to be of considerable value. I have likewise tried it in many
other cutaneous diseases, and among tbem in psoriasis, and have
found it very useful. A Viennese chemist, Professor Schneider, has
altered the method of preparing it ; and, for some years past, that
which I have employed in the General Hospital has been made

iording to his formula, which is as follows : — ft Caleit viva
IpAuru citriiti Udrat duaa. Coq. e, a^. fmHt liMt
iviffifid ad rcntanentiam librantnt ditodecim. Fluidum refrigerat*m
Jiltreiur, et defttr utui. This process yields a dark orange-yellow,
slightJy caustic fluid, which smells strongly of hydrotbion. The
remedy should be applied immediately before giving the patient a
bath, and the best way of doing it is the following. A bit of flannel
or a piece of pnmice-stone i? dipped into the fluid, and with tbia
each patch of psoriasis is rubbed till slight bleeding iakea [)lBce.
The solution is then once more applied to the spot and is left on it
to diT. When this has occurred, the patient is pnt into a warm
bath, in which he is left an hour. At the end of that time he is
further washed with pure cold or warm water, and his skin is then
anointed either with simple oQ or fat, or with one or other of the
ointments {to he hereafter specified) which are compatible with the

lphur-cotn|>ound. This is essential, because even hy the most
ful cleansing the sulphur cannot be entirely removed from the
face of the skin.

This treatment is so painful that it cannot be applied to a large
of the xurfflce nt one time. The aiTected spots muKt be attacked

laratcly : and tliis is the more practicable, bemuse a single applj-

lon of the Kilntion of sulphuret of calcium to a [Nitcb of psori-
iia, if done properly, is sufficient to destroy it cumplel«ly.

If, however, & loss painful (but, at the same time, a loss eSectnal)

are
I ben

I the

TREATMENT. 47

>nethod be preferred, the solution may be nibbed in less forcibly on
otdh occasion; but it wiU then be necessary that it should be
applied more frequently, or to a lai^r part of the surface.

Ouf effe-ct of the energetic application of this solution is that
black crusts, formed from dried blood, appear in the place of those
patches which bad been rubbed nntil they bled. At other spots,
where the sbin has been excoriated, a superficial suppuration may
take place. This likewise leads to the production of crusts, but they
are of a brown colour. The new epidermia which is developed
beneath them is always healthy.

Frictions with Vlcmingkx's solution must be applied more gently

tile skin over the elbows and knees, and over other joints, lest the

ision and pain produced by them should needlessly interfere with
the movements of the limbs. This method is therefore most suitable
to cases in which psoriasis occupies the trunk, thiglui, or calves of
the legs ; and generally to cases in which the seat of the disease and
Ha intensity are such as to render an energetic treatment practicable
and even advisable.

The frequency with which the application of this solntion must
be Kpeated varies with the degree of force employed, and the severity
of the disease. If the less energetic method is adopteil, the mil-
phuret of calcium must be applied every day, and be followed by a
warm bath on each occasion. But if it is thought desirable to use
such forcible friction as to make ea.ch patch of the psoriasis bleed,
sufficient time must be allowed after each application for the disappear-
ance of the effects produced by the caustic action of the liquid, or,
in other words, for the separation of the black or brown scabs
which result from its use. For this, as a rule, a week is long
«nougli.

In addition to the therapeutical measures which I have hitherto
been describing, adapted to cases of extensive psoriasis, I have still
to mention certain remedies which are often made uso of in the less
severe forms of the disease, or are employed in conjunction with
other applications, or, lastly, after other plans of treatment, for the
purpose of removing the last marks of the patches. Among these
»re the white precipitate, the acjd nitrate of mercury, the proto-
iodide and the dcuto-iodide of mercury, and naphthalin.

The first three of these compounds (the white precipitate, the
acid nitrate, and the proto-iodide of mercui^) are especially adapted
to cases of psoriasis of the scalp and face, their value in theae

PSORIASIS

local forms of the disease being due partly to their having a leas
powerfully irritant action, and {in the case of one of them) partly
to the absence of colour. They are prescribed in ointments of the
strength of a drachm to the ounce of Ung. gmplex. One of these
may be forcibly nibbed with the finger several times a day into the
parts affected, which must first have been cleaned bo as to remove the
masses of scales ; but, when practicable, it is still better to spread
the ointment upon linen, and to lay this upnn the patches. Even
when sncli an ointment is applied, particularly if the scalp is the
sent of the disease, an occasional washing with soft soap or the
ppiritus saponatns kalinns will cposiderably hasten the core. This,
however, might easily be inferred from what has been already
stated.

The deuto-iodide of mercury, on the other hand, is a far more
irritant substance, especially wlitn, having been previously prepared,
it is made up into an ointment in the proportion of ten or twenty
grains to the ounce of laid. In the form suggested by Bochard, of
Paris, its effects are, however, less severe. The salt is then made
at the time by fusing f«gether iodine and calomel. Itocbard's
formula is as follows : — fl lodittii puri gratia *epleia ; ealomelanoi,
tavpulunt unum. Lent igne fu»it adiU xnguenti eommuHig unciat
duat. A disadvantage of this preparation is that sometimes only a
prolo-iodide is formed, the ointoient being then of a yellow colour,
while at other times the dento-iodide is produced, so that the oint-
ment is reddish. This, of course, shakes the patient's confidence,
and tliercfore, to avoid such a result, I employ instead of the Ung.
timpUx the Unff. ro^alum, winch is iteelf red.

The Ung. kydrarg. deufo-unfuii, in the form recommended by
Bochard, must he used with greater caution than the other pre-
parations of which I have been speaking. It may either be used
na an auxiliary in cases wliidi are at the same time being treated
with baths or by the water cure, with soft soap or with the solu-
tion of Bulphuret of calcium ; or it may be employed by itself and in-
dependently of alt other remedies. In the latter case it is applied
to the patches once or twice daily for several days in succession,
until eicoriations are formed, or considerable swelling occurs,
sometimes even attended with the formation of bullte. Another
meth od of employing it, like thv ointmmls above mentioned, is to
upon small pieces of lint, of exactly the same size as the
i of psoriasis, and to continue applying these until the inflam-

b]
I Ui

TRKATMENT. *'J

itory symptoins of which I have just been speaking make their
appearance.

Naphthalin. — Thia substance, which has quite recently been in-
trodao^d into medical practice, is osed in the form of an ointment
containing one drachm of naphthalin to an ounce of tard. Ac-
cording to the laudatory statements of those who devised it, it
has proved of service in caaea of psoriasis of no great severity. I
can say very little as to its value from my own experience ; for I
have as yet employed it in too small a number of eases to be able
to express a final opinion with regard to it. It is certainly a deside-
ratum to find a preparation which should offer to the practitioner
the advantages possessed by tar, without the black colour and dis-
agreeable smell of that substance.

I linve now described in regular order the different remedies and
the various methods of treatment used in psoriasis. But I must
not forget to state that more than one remedy, and different methods,
must in most cases be employed in order to cure the disease. Sorae-
timea, for instance, the cold-water treatment may be combined with
of tar, the patient being first " packed" and treated with the
>|!Oold douche, and afterwards rubbed with an ointment, soap, or
tincture of tar. In other cases, if the patient for some reason or
'^otlter objects to the application of this substance, we may have to
employ inste&d of it Bochard's ointment, or one containing white
precipitate or naphthalin. In a third class of cases, it may appear
advisable to begin by applying soft soap, and when this has softened
And removed the epidermis, to employ those remedies (such as the
preparations of tar or the above-mentioned ointments] which are
shown by experience to extirpate psoriasis most rapiilly. The
quickest possible way of curing the disease is to use the solution of
■utphuret of calcium, rubbing it energetically into the skin before
giving the patient a warm bath, and after the bath applying the
Bochard's ointment or some preparation of tar.

It is, of course, to be understood that whether for the purpose of
satisfying the patient or on account of our own convictions as to
their value, we may combine the administration of internal medicines
with Biiy of these local methods of treatment. Thus, whatever
external applications we employ, we may at the same time give
the Fowler's solution or the Asiatic pUls, or any other preparation
of arsenic, or, indeed, any one of the many medicines already
eunsierated.

In prescribing miy of these remedies, however, it is always neces-
Hdry to remember the patient's age and sex, and to allow for the
individual i»culiarilicB of tlie skirt. In all cases, too, it is advisable
to employ ot llrst applications which have not very irritant proper-
tioa, rceorving for a later jwriod liiose which are more decidedly
caustic ill their aetion. Dae regard must also be paid to the con-
ditions under which the patient lives. Not every one who suffers
from psoriasis is able to devote his whole time to the cure of the
complaint. Most persons have to gain their living by their own
labour, and this often demands their whole time and activity,
Under such circumstances, it generally happens that treatment,
however rational, fails to remove the disease. Hence if we can
arrange tlie treatment in such a way as to interfere but little with
the ordinary occupation of the patient, and yet {though more slowly)
to attain the desired result, we shall certainly receive his thanks.
It is just in these cases that skill is required, to combine our reme-
dies and applications so as to suit the circumstances. For example,
I have sometimes had patients who in the day were occupied with
their husiuess, so that only the night was available for the treatment
of the disease by any of the methods above described. I have then
ordered " packiDgs" and frictions with cold water, and inunctions
with tar or with Vlemingkx's solution in the eveumg when the day's
work was ended. Other patients, again, affected with psoriasis, have
been able to devote an hour or two every morning and evening to
the cure of the complaint, and I have then availed myself of this

lort time to apply one or other of the irritant ointments, such
3 Unff. Aydr. deuto-iodidi {Ung. Jioc&ardi).

CHAPTER WII.

UCHEN.

Thb meaning attached to the word licAen {Xi!\w, lambtire) by

I U\o ODcients, and jiarticularly by liiiipocral£s, CeUus, Qalen, and

J the Arabian pliysicians, by no me-tms answers to the idea which

■"Willan aaaociated with it. Among the five species of lichen de-

I scribed by this writer, there are two varieties of eczema (X. agnua

\%nA L. Iritpieua), an scute disease of the skin (Jj. aimpkx), and

I tiro aCTections differing entirely in their nature from the rest {L.

Mfiiarl* and L. tividiu) ; but there is not one to which the definition

for Hippocrates is applicable, "\«i;(i)v, eat tumma attla vilium itl

}liii>pa ei Mvpa eu/n anperilate et Icvi pntriiu." ' This eliort

and clear definilion, however, wns altered in various waya by the

Roman and Arabian physicians, and also by those of the middle

ages ; and the disease was confounded with impetigo and sycosis,

and even with scabies and lepra. The confusion of terms thus

produced meets us on every side, and instead of being cleared up,

it is rather increased by the description given by Willan. This

author, as is well known, placed lichen among the papular dis-

I of the skin, wilh prurigo and strophulus; but he did not

constantly associate any fixed characters with his use of the term.

I. In his work, diseases of the sebaceous glands, guttiform (trop-

llenfonnig) extravasations beneath the epidermis, affections con-

■usting in a swelling of the apertures of the hair-sacs, nil are

^pecies of lichen, if only they present the common character of

' eing attended with the formation of papules. In fact, a number

Imusl llic tAtat as tint given bj Tlipgiocntles is tlie rallo<rin<; dniinitloii
-Snam-r eatit aiftritat cam mulla pmrisint, aqnamU, el fur-

F diseases differing essenttallj in nature as well as in the course
vhicb they take are made species of one and the same genus. Such
tn arrangement certaiidy does not conduce to an accurate knowledge
of either the form or the real nature of these affections, and there-
fore I am of opinion that the meaning attached to tiie word lichen
Bbould be that which was originally given to it by Hippocrates and
Galen, which has, even ia modern times, been retained by Manar-
dus. Lorry, and Plenek, and according to which it is conlined to
those cutaneous affections which are not merely attended with the
formation of papules, but are also characterised by having their
origin in a definite morbid process, and undergo no metamorphosis
in their whole course. In this way the name is made to answer to
a fised type of disease (ein stetiges Krankscin rep rase ntiren).

Now, observation at the bedside makes us acquainted with two
affections which possess these characters. One of them belongs to
an early period of life and is susceptible of cure ; and as it constantly
accompanies glandular swellings, caries, periosteal inflammations,
lupus, tuberculosis, and other expressions of the scrofulous diathesis,
I term it Licktn sero/ulosorum. The other is a peculiar disease
which in its external appearaTice somewhat resembles psoriasis, but
may be accurately distinguished from it by many differential cha-
racters. Since this affection is attended with the formation of red
papules in a most marked degree, T give to it the name of Lichen
nber.

I, Lichen acr^vhsorvm.

The characteristic symptom of this disease is an eruption of
miliary papules, which may be either pale-yellow, brownish-red, or
of the same colour as the rest of the skin. They never contam any
fluid. They are always placed in groups, and sometimes form
circles or segments of circles, within which may occasionally be
seen a few pigmented spots, indicating tlie seat of former papules,
and always covered with a very few minute scales. The papules of
Lichen scTofuloaorum produce but little itching, and, bemg con-
sequently not much scratched, present no excoriations and no little
black crusts of dried blood. They remain long unaltered, and are
subject to no metamorphosis beyond that of involution with shed-
ding of the epidermis.

This affection is for the most part confined to the trunk, occupy-

LICHEN SCI10FUJ.OS0RUM. 53

', tiie abdomen, chest, or back. It is very rarely seen on the
mbs.'
The course of the Licken tcrqfutoaorum is peculiarly slow. All the
roups of papules, or at any rat« b great mauy of them, generally
^pear simultaneously, and quickly arrive at their full development ;
t at this they afterwards remain for a long lime without change.
s I liave already stated, they give rise to no itching or other un-
pleasant sensation, and have no tendency to pass into vesiclea or
pustules. Hence their existence is commonly overlooked, escaping
notice altogether until the groups of papules have developed them-
selves in large numbers, or until the affection has reached so high a
pitch of intensity that other morbid appearances present themselves.
These consist in the formation of more or less numerous b!uish-red
tubercles, aa large as lentils, and quite distinct from one another.
They appear in the intervals between the groups of papules, and
also on parts, such as the limba and face, where there had been
none of the lichenous papules. The tubercles resemble those of
ecne, and undergo exactly the sajne changes as in that affection.
In some of them a purulent fluid develops itself, ivhich aftfrwarda
I dries op or is discharged, when the tubercles themselves disappear;
I others of them do not suppurate but gradually subside. In either
I esse they leave discoid, darkly pigmented tnaculic of the size of
1 lentils; and they arc followed by a fresh eruption at other spots.
I The cuticle of the surface between the tubercles is often cast off in
tfDiall branny scales, having a fatty lustre, and this gives the skin
{encrally a peculiar cachectic appearance.

The natural tendency of the disease is for the changes I have
been describing to repeat themselves, bo that it may go on uninter-
ruptedly for many years, if the conditions persist which originally
gave rise to it.

It is, however, a fact worthy of notice, that a large majority

(about 90 jwr cent.) of the patients affected with this form of lichen

are persons in whom tiie lymphatic glands (particularly those of the

nibmasillary and cervical regions nnd of the axillEe) are greatly

Lsffollen, or who suffer from periostitis, cariis, or necrosis, with or

I See Hebn'i ' Alias tter UanltrankbeitMi.' 3 Liefemnfr, T»f. iii. Ai

i|Crn>li writen lecm gpnerall; to l>e unn-hle to iilentir;' the Lichen tcrofuloiontm

ilh knj diMtee obsrrvtil hj llieinAFiTFt. it mi; b« worlli wbite for me to s>j

'liieli 1 saw in Prnffaior Uebrft'i climique id Vieana irere

M would here be tijled cases of Lulten eireumieriptia. — \G. II. F]

I 54

LICHEN SCRUI'LII.OBOallM.

witliout sdofDlous sgres, or who may be supposed to tiave dieewe
of the mesenteric glands, being of cachectic aspect and generally
badly nourished, and yet having the abdomen enlai^ed. Since all
these conditions belong to the g-enerat state known under the name
of scrofulosis, I am surely justified in ajiplyiiig the name of Lichen
tcrofuloBorum to the cutaneous affection which I am now describing.
It may perhaps occur to some of my readers to ask what hos
been the state of the lungs in pntients affected with this form of
lichen. My answer to this question must be, that in no one of
the cases (more than lifty in number} which have been under my
observation has there been any symptom pointing to tubercular
disease of these organs ; and as all the patients who have been under
my care with the disease have recovered, I have had no oppoitunity
of making an autopsy and examining the lungs. My reason for
alluding to this point is that some may suppose the disease which X
have termed the Lichen tcTofuhtorum. to be nothing more than the
PH^riasis tabetcefilium, scrofulosorum, pAfAiticorum. Tliis, how-
ever, is by no means the case, llie affection last named is one of
which I every year see many instances among persona who are
phthisical, scrofulous, or emaciated from chronic disease ; and I am
satisfied that the Lichen terofalosoriim possesses characteristic ap-
pearances which differ from those of this form of pityriasis. It is
indeed possible thnt these disea3«9 may both be due to tlie formation
of Bcbum in excessive quantity, or to a morbid development of the
epidermis and its saturation with sebaceous matter. But even if
this should be the case, there is still the distinction that in the
Lichen tcrofulMorum this condition is confined to certain points, at
which papules arise, collected in groups ; whereas in the Pitgriati*
tatietcentium it is more widely diffused and affects the whole surface
of the skin.

Diaffiiont. — The recognition of this complaint presents no diffi-
culty whatever when it is admitted to be a disease lui gmeri&,
and when attention is paid to its peculiar chBri)ctcn>. In the lirst
place, it differs essentially in the colour, arrnngemcnt, scat and
duration of the papules from the Lieim ruber next tii he de»cribed,
and the two affections occur in patieiiLt of different constitutions.
Secondly, it i." diatinguishi^d from the early papular form of eczema
{Eczema papuloium, Licien ectemalodei) by the colour and size uf
I the papules, by the pretence of scales, and »lill more by the nhsKnce
of the severe itching which cuiBtH in tlio laat-nsuied ilisi^ase, and

conci

^^ whilt
^^^^ col

^^^4b n

PROGNOSIS.

lich excites scratchmg, and consequently give rise to escoriatiaDS.
the Lichen »ero/uloaoTum, on the contrary, no excoriations are to
swn. Tliirdly, from the syphiHtic affection which takes the
of small papules (the syphilis cutanea papulosa miliformis,
syphilopsydrajt acutus of Fuchs} it differs in being confined to
Scalar n^ions of tlie body, and in the fact that its papules
'er become pustular. Moreover, it is associated with uo other
morbid appearances, eicepting, indeed, the acneiform tubercles
olreaily described; whereas many varieties of eruption besides the
papular always appear in the course of syphilis. Lastly, the only
concomitant symptoms of this form of lichen are those of acrofulosis ;
while the papular eyphilide, being merely one of the symptoms of
constitutional syphilis, will not fail to be accompanied by other

ifestationa of that disease.

Morbid anahmy. — Each of the papules is seated at the aperture

a hair-sac, and forms an elevation consisting of a mass of epidermis,

rhich may be completely detached from its bed, without any blood

iping. Tlie epidermic cells which make up these little elevations

not in any way differ morphologically from those of the normal

homy layer of the cuticle, or at most present merely a larger number

of fat-granules, when treated with a little caustic potaas. After the

^rooval of the semiglobular mass of epidermis which constitutes the

.pule, tlie mouth of the hnir-sac may be seen by the naked eye.

surrounding skin is slightly red and elevated.
Etiology. — The fai;t that this hitherto undescribed cutaneous
ftion is almost confined to persons of scrofulous habit is surely a
if that scrofulosis is the cause of it, as well as of the diseases
fecting the glands, bones and skin, aud of the other complaints
liich have been hitherto recognised as the effects of that coustitu-
loal malady.

I have as yet met with the Lithtit terofttlotorwn in males only,
id Ix'tween the ages of fifteen and twenty-five years. Some of the
itients affected with it have been iu a low state of health, thin, aud
cachectic appearance ; others, however, have looked in excellent
ludition, and have been well nourished. I have found no reason
supposing that any particular season of the year favours the
rence of this complaint, or that any occupation especially
induces to its development.

Progitotis. — According to my experience of the lichen scrofuloao-
a favorable prognosis may always be given, if the patient c

LICHEN SCROFDLOSORCM.

i onder such coaditions as not to increase the caiistilutioiml
disease, vhich is the cause of the eruption. I have invariably
Bucceeded in curing this form of lichen, and have never observed a
relapse. Even when there has been scrofulous disease of the bones,
accompanied b; sores of considerable extent, I have been sacces^ful
in removing the cutaneous aO'ection, even before the constitational
malady itself was cured.

Observation, then, shows that this eruption is devoid of danger
and readily curable. But I have found that, when left to itself, it
remains stationary for years, altlicuf;!i it does not in any way
interfere with tlie due performance of the functions of the skin, and
of other o^ana. "WhetJier it would ever disappear of its own
tccord I cannot positively say. But it is certain that such an
occurrence would require a considerable space of time, for I have
seen cases which bad lasted as long as five years, but which were
cured in as many months by proper remedies.

Titatment. — In a cutaneous disease caused by scrofulosia, it ia
natural to administer cod-liver oil, the most powerful antiscrofalous
medicine which we possess. I have, in fact, invariably given this
remedy, and with the most marked success. By way of experiment,
however, I have varied the mode of ita employment, sometimes
giving it intenially, sometimes applying it externnllj, and in a third
class of cases directing it to be used both internally and eitemally.
The result of these observations has been to show that the cure of
the complaint takes much longer when the ot. morrhuse is given by
mouth only than when it is merely applied locally, and that the lunst
rapid method of all is that of combining the external with the in-
ternal administration of the remedv.

Aa an internal medicine, I have beeji in the habit of preacribing

I the ol. jecoris aselli fuscura clarum Norvegicum, in the dose of from

r balf an ounce to two ounces. The administration of still larger qann-

tities, as is recommended by French writers, is qnite unnecessary ;

for, according to my experience, whenever the daily dose exceeds two

ounces, the oil is not assimilated, and appears onchanged in the

t^acuations. On t]ic other hand, lest than half an ounce, for an

■dult, fails to produce the full efTect of the remedy. I direct the

patient to take the medicine before his mcala, and without any

I ecrriffent, dividing the daily quantity above mentioned into two dosea,

rfinc for the rtiorning, the olher for tht evening.

In applying cod-liver oil locally, ihc most important poiut i) to

LICHEN BVBKR.

take care that it is kq)t contiuvallj in contact with the skin. Now,
tliis is not to be effected by merely rubbing a certain quantity of ol,
tDorrhuEE into ihe patient's body, and then letting bim put on hia
ordinary clotties nnd linen. It ia absolutely necessary that lie should
wear next to his skin some material which possesses but bttle capil-
larity, so that the oil may with difficulty be absorbed by it. Tlie most
suitable clothes are therefore such as are made of wool, particularly
those of flannel. If we tliink it desirable that the patient should
remain in bed during the treatment, and can induce him to do so, we
nay lay him naked between two smooth blankets or flannel- sheets ■
But if this is impracticable, or if it is thought more advisable to
allow him to go out intx> the air, wc may simply clothe him in a
tightly-fitting vest and trousers, made of wool, and knitted. Tlie
cod-liver oil must be rubbed into his body four times a day, during
the early part of the treatmint at any rate ; afterwards, when the
clothes or blankets have become sufficiently saturated with the oil, it
may be applied only twice in the twenty-four hours.

In treating this affection by the external application of cod-liver
oil, I at first intentionally avoided tlie emjiloyment of warm baths,
or vapour baths, in order to convince myself of the efficacy of the
oil; but when I had no longer any doubt as to its curative power, I
allowed the patients to have bath». I found, however, that this
interfered with the action of the remedy, and that its effect was to
make tlie cure of the complaint take a longer time than when the
animal oil was employed alone.

The repeated employment of the ol. morrhute ia cases of Lichen
tero/ultucrum having convinced me that it is an infallible remedy for
the complaint, I have as yet found no reason to make trial of any
icr method of treatment. It mast, however, be mentioned that I
,vc, in this disease, given a liberal allowance of nourishment, and
'tirularly of meat, but that I have not confined the patient ex-
lasiveW to a meat diet.

11. Ueinf:

■uher.

Among the many cases which have come before me in the General
Hospital of Tienna, in the department for cutaneous diseases
which is under my care, there has presented itself an aScction so
pecoliai in its symptoms, course, nnd mode of termination, that I
have Dot been able to identify it with any of Uie complaints described

68 LlClltN aUBKH.

or figured in worta upon this subject. I linve therefore felt it
to be specially incumbent upon me to study the iliseaAe in quealion
with the greatest care, to walcb its course, to inveatigiitc its mode of
origin and the conditions under which it occurs, and to seek for
reiDcdies by which it uiay be cured. And now that several coses
have come under my notice, and that I have been able to make con-
tinued observations with reference to tliia affection, 1 have found it
to be manifestly a special disease, and to be distinguished by a
sufficient number of characters from all other diseiises, however
similar. I have therefore, without scruple, assigned to it a place in
my system, and given to it the ikame of L'tehen ruber.

My reasons for choosing tliis name for it were the following: — In
the first place it leads to t)ie formation of papules, which remain un-
changed throughout the whole course of their existence, never
passing into vesicles or pustules, and, in fact, undergoing no altera-
tion whatever, except tliat the subsequent springing np of fresh
papules may cause tbeni to coalesce into circumscribed patches.
Sccoudly (unless, indeed, they are covered by masses of epidermis),
both the papules themselves and the patelies which are thus formed
from them invariably possess a marked dark-red colour, and retain
it under all circumstances.

Now, following Willan, dermatologists have been accustomed to
give the name of lichen to alt papular affections of the skin which
do not present the characters of prurigo. I have consequently felt
myself to be fully justified in applying the same term to the disease in
question, and in calling it Lichen, rwitr, on account of its rtd colour.

Courte of Lichen ndier. — When we have an opportunity of seeing
the disease at its commenceineiit, or while it is spreading, we find It
to consist in an eruption of miliary papules, which are at fb-st dis-
tiuct from one another, and are covered with thin scales. They
excit* but little itching, the patient does not scraich them with
violence or so as to make them bleed, and therefore no tittle black
crusts of dried blood are to be seen on their summits.

The*e papuUt remain of lie same site tkrou^hout the tehoU sjf
fAeir existence, and never under/fo peripheral fffiotli. The papule«
which afterwards appear may spring up cither at spots distant
from the seat of the first outbreak, or in the interval* bclwrcn
thi! original papules. Thus, as the disease JuivniiLTs, the papules
seem gradually to become more clo*ely nggn-^t«d together; tliu
LDtcrveiting spaces of healthy skin, at first cousidemblt!, ){row feiiLer

CtJARACTBKS.

', until at last the papules come into actual contact, sud

form continuous patches of variable size and shape, red, infiltrated,

and coven^d witli sciiles, Tiiese morbid changes repeat themselves

at diffi-reiit spots which liad previously been free from the disease,

and thus a state is at length arrived at in wliich the papules, and

the infiltration of the skiii to which tliey give rise, occupy entire

Kgions, or even the whole surface of the body. The appearance of

I file disease is then quite peculiar. The integument is uuiversally red-

■ dened, covered with numerous thin scales, and so infiltrated, that

when a fold of tlie skiu is taken up it is found to have more than

twice the normal thickness. The movements of the parts alTectcd

are. consequently interfered with, particularly if the flexures of the

joints are affected in this way, and if the hands and feet are

] attacked by the disease. The patient may thus have great difficulty

in effecting the complete flejion or estension of his joints, and en-

L desvours to maintain them tn au int^^rmediate })0.sition. The skin

I is, faowever, most markedly thickened on the pahns of the hands

I l&d soles of the feet, and on the fingers and toes. Tlie fingers are

I generally widely separated from one another, are kept semiflexed,

I and, besides being reddened and infiltrated as above deseri1)ed, often

present over the phalangeal articulations transverse fiasurea and

cracks, which frequently extend down to the coriain and bleed,

as to become bordered with black crusts, placed, like the fissures
I tliemselves, transversely. The surfaces which correspond to the

joints of the tarsus and carpus are likewise deformed in a similar
way by horizoul«l ridges, traversed by rJJHgades.

When this disease attacks the whole cutaneous surface, it always
•effects likewise the nails of the fingers and toes. Sometimes there

1 an increased growth of nail-sub?tance from the bed of the nail,
that this acquires more than twice its natural thickness, while it
t the same time becomes rough, opaque, of a yellowish -brown

iolonr, and very brittle, so that it does not grow io its usual length,
tat breaks olT before it has reached the tip of the finger. In other
inces, again, it« growth proceeds from the matrix only, and not
from the whole of ita bed, so that it forms a mere thin, brittle, homy
plate, which is of a lighter colour than natural, and projects more
r less away from the finger. In either ease, tlie change in the
Isils, added to the infiltration of the skin itself, interferes greatly
Vilh the use of the Sngers and toes, so that the power of walking
mi that of grasping objecta are very much impaired.

LICHEN BUltlill.

The hair of the bead, as well as that of the pubea and axillsc, re-
mains quite unaffected bv the Lichen ruber. The hairs od other
parts of the trunk, however, are never much developed, and form
a mere down or laiiugo, remaiiiiDg at aa early stage of their
growth.

^Vheii the disease is thus extensive, it is attended b; a very disa-
greeable degree of itching. But this is by no means proportionate
to the seventy of the complaiat, being indeed less troublesome than
in several affections of far less intensity, such as psoriasis, prurigo,
and eczema. We therefore never see in cases of lichen very severe
eicoriationa, nor any of the other changes produced by scratching,
all of which are so commonly met with in the affections which I
have just enumerated, and which may be termed, par excflUnce, the
"itciing" diseases.

The state of the general health, in cases of Lichen ruder, depends
on the extent of the cutaneous affection. At its commencemejit,
when the papules are scanty, and the infiltrated patches few in
number, no impairment of the vegetative processes is discoverable,
and all the functions go on normally, so that the disease is usually
altogether neglected. But as the eruption increases ia quantity,
the nutrition of the body begins visibly to decline. The patient's
appetite and power of sleep may be but little or even not at all im-
paired, but the amount of fat in the areolar tissue beneath the skin
is diminished ; there is, in fact, an evident emaciation. Even when
the disease has involved the whole cutaneous surface, the nutritioa
of the body docs not at first entirely cease ; but it decreases from
day to day, and the patient falls into a state of marked marasmus,
as a result of which the case generally terminates fatally.

Dia^osis. — Although certain forms of Lichen ruber are very
similar to some other skin -affections, such as Lichen icrofulotorum,
Ptoriatii, Eczema, and Pil^iasis rubra, it can always be distinguilhcd
frum them, if the charitcters which are peculiar to it arc duly
considered. The symptoms of the Ltekea rvier, when com-
mencing and of slight intensity, are, however, very different frum
those which it presents when it has lasti^d for a long time, and is
widely diffused, or even occupies the whole surface of the body. It
is therefore esseiilini to the easy comprehension of the dbtinclions
between this disease and those which resemble it, that it* conru
should be divided into tliree periods, corresponding to different
degrees in its development, and that each of iheac akould bo com-

CHARACTERS. 61

pared with those of the other complaints to which I have referred.
The three periods themselves are by no means very strictly defined ;
but, according to the plan usually adopted, I shall speak of them as
9tage9. I append a table showing the differential diagnosis of the
various diseases in question.

LICBEN RUBER.

The eniptioa consiaU of distinct,
red, miliar; papules, which are not
Mporiatedj and are covered with
a Tew miaute scales. Tliev are i
collected into gronps, and are i
scattered over tlie vbole surfaoe
the bodj, but are generallj confined
irtain parti of the akin, and
r especiull; on the limb^

ifiloresceuMConaislaofmiliatJ
papules of a pale jellowisli-red coIoHt.
distinct froni one another, buterowded
together in groups. These pa]
cofercd mlh a few scales; tlitf j
lent no excuriationi ; tbe; an
confined to the trunk uf tiie bod;.

le dark red inlllLrati-J pulclii
resulling from ilin ciMleaeence
eroiiB papules devcloued close to
another, arc corerea with thin,
«nd puper-likc, grRViab, not rer;
ndbereut scales. When tbese are
picked olT, the aperturca of the hair
arc seen In be dilaleJ. There
) oocing. and the patchi
bleed wben gentlv scral
the iiehing ts «liglit is nroTcd
b; the fact that the uxoonatioiis
are ler; superlicial.

Although the appeanincoa pro-
iluoed bj the changes just described
resemble those observed in other
cutaneous aOeetions, we are alwajs
enabled to make a correct dia;;nosis
b; (lie presence, in the iieiglibuur
hood of the inaitrated spots, of fresh
lUpules preciaelj similar to those
Hrtl formed. It is aUo particular!;
.0 be inaiated on that even in this
>ta(;fl the eileniion of the disease
ma; be iihown to be produced, not
b; an enlargement of the individual
papnlea, but b; their inereoiing in
numbers and ooaleaoinKi Biul b; the
I inBltntion of the skin which —
'-Ipaniee llime clianitn.

■dj

papules continue to
rant;ed in groups throu^bi
whole course of the disease, k few
fresh papules do, indeed, sometimes
appear in the neigiibourhood of those
first developed, so tliat ailjaceul clus-
' — iiiaj coalesce willi one anulher;
even tlicu new groups, present-
ing Ibe obaracters above described,
are alwa;a to be found at other
points, or else the original dusters
themselves remain separated b;sulfi-
cicnll; bii«e patches of health; skin.
Another cnaraoter which ma; ""—
be observed is, that while oei
pules are being developed at

peri pher;, those in llie centre of'.

group gradnall; fade and die awijri
and at last becomo little flat "■"
lentrd tiuitB, corresponding
on to tlie mouths of the nair-
ad of a dull jellnw or browni
jrellow colour. Itching b eatii
absent, and, consequentl;, there
ao eiooriaiions.

^^^^ mAGNOBIS. 68

Setfma.

L It begius Willi tlie for-

Tliiscruptianisattendeo
with the formation of pa-
pules the sice of millei

As in Ibis affection no

^^^'Sntion nC while, sbiniug.

papules are formed, it does

^^^bmI; moucs, tlie site

not at all resemble tbe

^^^^nnillct Btietla. Some ol

leeds or hemp seeds, of a

ariy stage of the lichen

^^^EU«e little maata of scales

)alu or dark red colour.

ubcr, ami the two diaeasca

^^H^in generally deitrojrd b;

ircaenting no soalca, bui

cannot possibly be con-

^^^■'■erKtcbioff, when a minulF

■ontaiuimt a trnnspareui

ouudcd at this period.

^^^Vifcluding mttace is exposed,

luid, which escapes ou

^B 'Vhich u. .rtenrards covered

aliubt prcaaure being ap-

^■^ b; a black crn>C. Thej

plied to them. Tlie sum-

»« not collected into

mits of moat of these pa-

pules are destroyed bj

ov=r .11 parta of tbe skin.

acratcliina, and are then
cofered by little brown

«itb an Mpecial prcdilec

lion for tie eitenaor sur-

crusts. Tliey are confined

faces of tlie Umbs. Be-

to certain parts of the body

lidei these small spots

over which they are (oal-

there mar generally hi
seen similar ones whioli

orcd irrcguhirly, and ihc)

occur very fivquenlly im

are of older date, and con.

.he anna, especially tlicii
leior surfaces. They an

aequentlj larger, looking,

for iDstnnce, like drops of

frequently accompauied bj

mortar, or eTen reaching

vMidee.

the aiie of half-cfuwn

jHeccs.

1 Bj the peripheral growth
^H of ttieac originall; puncti-

The ooiing which eilste

_ The absence of inliltra-

in all tbe hiphcr degree
of eczema, and the prescncr

,ioii and the presence of
M»lcs, although in vnry

^^k form ipob, and b; their

^^B eoalcscrnce, (bere are pro-

small quaniitv, characterise

^V duced (as is well known)

drying-np of the secretion,
are surely ebaractcrs which

the Pifyrieht rubra, and

^^ Un-o red patches. These

irevcnt its bring tnislaken

present so mo degree oi

prevent the possibility ol

'or the licifn mier.

thickening of the cnlis

lichen.

flrml;- adherent acslea

■ome lines tbick. Tbej

Dwj be of rarions forms

Armrnd them there are al

1 waya to be aeen annular oi

^^^^tovnimukr spots, or even

^^^^■Mne which are punctiform

^^^^■r like drops of mortar

^^Hpiese Uat, in fact, present

^^■bot the characters of this

^^KlkoM which 1 bare de-

^^^ftforibed above, and particv

^■^7 that of readiW bleed-
^^^Hg when acralchcd.

^^k

LICHKN RUBKR.

Lichtn Kro/kloiomm.

> a remit of tlie continued de-
velopment or tbeie pipules, the
whole akin at last becomes reddened

I tliickened, sad the epidermic
(ptrlicuIarl^T its external boni; lajer)
breaks up into a number of tliin

>, wliicL are of a grc}ish-}cll(
colour, and easily re moved, I
sifin of the formation of papules it
any longer to be discoyered.

I'bere Is degeneratioii of the naila,
rbagkdes appear, and tbe mote-
menls of the joints are inlerfeted
vicb.

The affection is also attended iritt
general Bjinptoms, namely. Impair-
■ of nulritiOD, loaa of flesb, anc

TbiiafFeclionianeverdiffusedoi ._
the whole cutaneout surface like tbe
lichen ruber, and tbereFure it is quite
uanecessar; to ^ive a differential dia-
enoais between tbe two diseases u
the tbird stage.

Among the pneral ajmptoois ari

'ellings of tbe Ijmphatio glands,

rtlcularlj in the neck, periostitia,

curies, cutaneoua ulcers, or, at least.

It cenerally baa a duratio:
iGvernl vean, and at lost (ermii
fatallj.

of tbe IB

Tlio ]>c(^uliar tendcnrJ In cues of universal
of tbia aireclion, eten after vckc ma ils pccu!Ur clmrnc-
luling ft long time, to UD- 'f'9 ire so luarkcJ — llif
der^o periodical involutioa.ji telling is so severe, ilii
makes it verj rare iiidee(!l|0(uii)ig so Hbundnal, thi
for psorinsis to dilTiisc il-;vesicles. pustules, uk
self over the wlinlc ciita-crusts so nunierous— tbni
neous surface. Evcnwlieiitt is liardlj possible li
it is ten severe, tnd UusjiDistake ILe diie^se iu tbis
existed lor jeari, tbe ori'jstage for ui; olbcr cuIH'
ginal patcbes inTarinbl} neous complaiul.
remaitt parliallv separated Sjmptom* Indicatlog itr
from one anotnec bj little aflrction of llie sjsteo:
intciTali of healtliy skin, geiicrallj -— ■

! disease also
many of its cbaracters, in-
cluding (hose of itching,
bleeding readilj wben
scratched, beiii|f attended
vith an eicesairo foruia-
tion of ejiidermis, a
liBviDg a tendency to \
dergo involution al certi
points, *t wliicli the hcaltlij
skin Ibrn reappears.

I'loriaais occurs chiefi;
in subjects who are iu
other retpeols atrong tad
beallby. Tbose who are
affected with it, even in ■
severe form, retaiu for a
long time tbeir good con-
■titutiou, and continue to
look quite wi'il, It is Dnlj
in ver; exceptional cues
" A it proves fatal.

. si together want-

Thcy are, therefore,

essential part of the

diseaae.

Pifj/riatit rubra,

Tf this rare disease
tncks the whole surface ot
(be body, il lo doubt pro-
ilucci a dJITuaed ruddenint:
of the skin, and is attended
with the formation of scales

mall uutnbera. B
. .. then a mistake is pi
fcnlcd bj the entire s
leuce of infiltration, b; tbe
desquamation and the itch-

ao slight, bv t!
skTa being still perfect
supple and moveame. ai
bj the naila remaining
quite healthy.

In Buch cases ofPiVyrta-
ii rubra tbe organism
jenerall; seems not to be
so pro found 1,T affected, a
it b in the Ucita ruber.

LICHEN HUfiER.

Morbid Attatomy, —-The autopsies nhicli li&ve beeii made in fatal
caaea of this disease have yielded no reault-s particularly wortliy of
mcntioUj so far as the riscera generally are concerned. As in all
other chronic cutaneous affections in which death occnra only when
the disease has been of long duration, the post-mortem appearancea
in Lickm ruber are summed tij) by the pathologist in the word
anatnia. AH the organs are pale, flabby, aud shrunken, end con-
tain but Kttle blood.

As to the skin, however intensely reddened and thickened it may i
have been during life, tt always after death appears pale, loose, and 1
devoid of fat, and no trace of tke thickening of its substance is dis- I
coverable. The only indication of tlie diseaae in the dead body la i
the presence of scales, still adherent to the cutaneous surfoce in 1
greater or less quantity. On exauuning thin sections of the skin 1
with the microscope, the chief morbid change which has been dis-
covered is in the raot-sheatba of the hairs. As is well known, the J
root-sheatb, in its normal condition, is a cylindrical tube, surround- f
ing that part of the hair which is imbedded in the skin. In cases of I
Lichen ruber it is changed into a funnel-shaped body, pomted below, 1
expanding towards the mouth of the sac, and looking as if it were ]
made up of several hollow cones loosely included in one another, j
and having the hair in the middle. Besides this, the cutaneous J
papillce have been found to be enlarged, and the vascular loops which J
tbey contain to be dilated, in this disease.

Etiology^ — IncAm rvlier (of which fourteen cases^ only have i
yet come under my obaervatioa) is so rare, and the individuals whom
it has attacked have been so different, that at present no safe basis
can be found for even a probable hypothesis as to the cause of this i
mysterious affection. Among my patients, some have been youths^
between liftcen and thirty years of age, of feeble constitution and I
lax muscular fibre ; some \iave been more than forty years old, and I
have appeared to be in other respects in perfect health.

I have never been able to find a cause for this disease either in I
UiB mode of hfe, the occupation, or the hygienic conditions of t))o»ea
suffering from it, nor, again, in any complaint with which they hada
previously been affected.

In reference to ses, it is remarkable that among my foarteenfl
patients there was but one woman. Hereditary Imnsmiirion, whiol^

' See the sole oa p. i<t>.

exi

[i Its

is considered with much pralinbility to be at least an occasional cause
of psoriasis, could not be shown to occur in Lichen ruber. In none
of the cases whicli came under vuy observation had the parents,
so far as I could ascLTtiiin, suffered from a similar disease. The
rarity of the complaint is in itself Buffieient to suggest that it is not
contagious, and this is iu fact the case.

Proffnoiit. — Like cveiy other disease which attacks the whole
cutaneous surface, and runs a verj" protracted course, the Lichen
ruber, when thus universally diffused, necessarily exerts an unfa-
vorable influence upon the whole system, from the simple fact that it
impairs for a long time the functions of the skin, which is so im-
portant an organ.

At first, indeed, the vegetative functions have gone on vithont
much disturbance, in the cases which have been under my observa-
tion, — and that not only when the affection was partial, but even when
it had spread over the whole surface. But when the disease has
existed for some years, it has never failed to produce loss of flesh.
My patients, in fact, not merely grew thin, but they looked quite
shrunken, as if the skin, which was liard and hung in folds, was the
Only covering to their bones.

I cannot say anything favorable with reference to the prognosis
Lichen ruler. I have in one instance' succeeded in arresting
its course. One of my patients was discharged at his own retjuest,
and I do not know what became of him. Another is now (July,
1862) under treatment. All the otliers perished before my eyes in
"le of careful nursing, and the administration of various medicines.
Treatnunt. — Having been unable to find, in any work on der-
itology, a description of the Lichen ruler as a special disease, I
ive received no aid in reference to its treatment, and have liad to
ly entirely upon my own obaervntions and esperimeuts.
In the first place, I endeavoured to cure it by the administra-
f Hie different medicines, which I described in detail when
ing of psoriasis. Unhappily, howeveij a regard for truth
me to state that, with the exception of arsenic, no remedy,
r internal or local, has succeeded in modifying the course of
ruber. I gave arsenic freely in every one of my cases. But.
e patients it was not veil borne, and I was consequently
b1i]$cd to discontinue it; and even when it did not fail altogether

■ fpiti

ipels D

68 LICHEN RUBER.

it proved only partially efiRcacious, prodacing an improvement in
the disease, or even removing it for a time, bat having no power
to prevent the occarrence of a relapse.

I have already mentioned that in one case the disease was ar-
rested. This result was not attained until nearly three drachms of
arsenious acid had been given, during a period of eight months. It
was prescribed in the form of Asiatic pills, of which the patient
took twelve daily, containing 0*99 of a grain of arsenic. He has
remained well up to the present time, that is, for a year since his
recovery.^

^ Prof. Hebra informs as that this patient has since had no recurrence of
the disease. He also states that, since the publication of the German edition
of his work, be has seen seven cases, all of which have terminated favorably.
The treatment consisted in the administration of arsenic in considerable doses,
from ^th of a grain to a groin being given daily. — [£o.]

The first writer who mcntionetl J'iti/riaali mlra was Batcmnn, in
his contiiiualioii of Willuii's work ' On Cutaneous Diseases'; but lie
gave no dellnitiou of it which can be applied to all cases of this
Affection, oi which exclndea other coinjilaints resembling it. In
ictj neither Satcmon nor those who have since written on the sub-
(Ct (including Eiett, Green, Cazccave and Schcdcl, Chausit, and
Bibert) have drawn any strict line of separation between the Pi'.^-
Tuhra and psoriasis, eczema squamosum or lichen. Some
Slier dermatologists, among whom are .T. Frauk, Alibert, Fucha,
pd Duchesne -Duparc, do not so much as mention the name;
pid others, such as Rayer, and £r. Wilson, use it in an entirely
ifTerent sense ; bo that it would appear that none of tbese writers
~ i seen cases of universal Pilyriaait rubra, such as I am aboat to
escribe. The only work in which the disease receives the attention
6 which its pecuharities entitle it is that of Devergie.' But I cer-
unly cannot understand why this writer terms it the Pityriasis
mbra aigu, for in his own description of it he insists on the long
Uration of the disease, and on its tendency to relapse.
' As appears from its name, the affection which is termed PUgriasU
THlira consists in a reddening of the skin, which is also covered with
scales. But, as is well-known, these characters are likewise found in
other dermatoses, such as FtoriatU, Lichen, Eae^ia, and Lupus ery-
~ 'hmalMm ; and therefore we have to give some additional symptoms
blonging only to the disease in question, and absent in those which
t resemble it. In doing this, however, wo must rely not so
ill on positive as on negative characters. In the above-named
lections, besides the redness aud the scales, there arc always other
'mptoms : eitlier there is infiltration of the cutis, with or without
c of fissures ; or there is oozing of a fluid secretion ; or
S pnliquo ties Malndic) de i\ Fcau,' Faris, aiimc filitioo, 1857,

PITYKIASIS BIBBA.

tliere ia severe itching, which Leads inevitably to scratchin^^StROT^
sequently to the existence of excoriations; or, lastly, the diseue
occupies some particular region, or presents certain peculiaritiea in
its course. But in the Pifyriash ruhra all these are absent. In it
there is nothing more than an intense redness, diffused over a large
part of the skb, or even universal, disappearing beneath the pressure
of the finger (when it gives place to a yellowish coloration), and accom-
panied by the presence of fine white loosely-adherent scales, which
result from the constant shedding of the most superficial layer of the
cuticle.

Now there can be no doubt that the recognition of an Eczema
sqtiamomm (a species first described by Cazennve) has, so to speak,
cut away the grouud from beneath the feet of PU^nasU rubra, and
that most of the cases which have been so termed would now, with
more correctness, be considered to belong to the ccKcmata, Thus
it often happens that an eczemaj cither il« commencement or while
it is in course of involution, reaches a stage in which no vesicles or
pustules are formed, in which there ia no oozing, and in which the
part afi'ected is simply in a red scaly condition. To all such cases we
may give the name of Eczema sqitamotum. But there still remain
others which may be fairly classed under the head of PilfriatU
Tuhra, in which reddening of the skin and gradual desiiuaniation are
the only characters, and in which there is no inriltratiou of the cutis
nor any other symptom. Such an affection cannot bo termed an
Eczema, because the oozing ninl the vesicles, which belong tfl that
disease, arc not present at any period of iUi duration.

Tlins, then, I give the name Pili/riam rubra to an affection in
wliich, throughout its whole course, the only symptom ia the per-
sistent decp>red coloration of the skin. In this disease there is no
considerable infiltration of the cutis; no papules or vesicles are
formed; no secretion is poured from the surfiicc; the itching is
slight, and does not lead to the fonnation of excoriations ; no fis-
sures make their appearance ; and, lastly, particular regiuns of the
body are rarely affected, the whole surface of the skin being generally
attacked.

Courte. — This disease, of which I have hitherto seen only three
cases, is so rare," and its progress ia so remarkably slow, and pre-
sents so very few changes, that there ia grrat diflicultj in carry-
ing out a complete obserration of any one case- In every patiei
suffering from PltyriatU rvtra whom I have seen, the alTeoliai

COURSK. 71

I miivRrsal and fully dcve]oi>ed when it first cnme under my treatment,

I Hence, so far as my own observation goes, I do not know how the

Icomplaint commenced; whether the whole cutaneous surface was at-

r tacked at the same time, or whether the disease began at particular

spots, and gradually diffused itself. According to the statements of

Ihe patients, however, all parts of the skin had been simultaneously

affected, becoming at first slightly, and afterwards more and more

L intensely reddened. The patients, inoreoverj described the skin

I of the lower limbs as having been of a deeper crimson colour, with

fa tinge of blue {the so-cnlled venoiig tint) particuhirly while the

1 erect posture was maiatained ; and they said that other parts, espe-

ioinlly the face, had been less reddened, and that the hue was also

r influenced by heat and cold ; the effect of warmth (that of the bed,

for exniQjile] being to produce a vermilion red, arterial colour,

while under a lower tempcratuic (as in an ordinary Bitting-room] a

bluish-red venous tint prevailed.

lliroughout llie whole course of the disease, then, the only charsc-

liers which it has presented have been those above described ; except,

I indeed, that scales, consisting of dead epidermic plates, have accu-

I mulatcd in greater or less quantity. Towards the end of the

I patient's life, however (for, unhappily, diiTu^ed PityriaaU rubra

f baa always Icrrainaled fatally), the skin gradually becomes pale,

and turns nl first of a yellowish, and ultimately of a dirty-yellow

tint. After death, even tliis is no longer to be discovered, and tlie

appearance of llie integument diiPers in no respect from that of a

n who has died of some inti-nial disease.

Before the occurrence of this melancholy termination, however,

lanj years elapse. During the early part of this long period the

ipalientA have remained in good health, and have even been able to

usuc ihcir usual occupations; and, if they had not been daily

*Temindcd of the existence of the dise4isc by the change in the

colour of the skin, they would themselves have been ignorant of

its presence, since it gave rise to no unpleasant sensations. Little

by little, however, they have begun to lose flesh and strength, so

t tliey have felt themselves no tonger strong enough to carry on

ustnesa; and it is this which has ultimately induced them to

y for medical relief. Such have been the circumstances under

!i caws of Pilj/riam ntlra h«vo come before me.

' "" 1 these patients liave been in the hospital under my care

^lUrasmuB has still increased very slowly; their appetite, at

72 riTTRlASIS EUBRA.

first hearty, has gnidually diminished; their muscular strength
has continually decliaed; and at last they have perished oF ex-
haustion.

SioffHOiii. — As to the diagnosis of PityriaaU rubra from
Ptoriatit, Eczema, and Lichen, I may refer to the table in which
I have already given the characters of the former disease, for
that table sufiiciently shows in what respects it differs from the
complaints in question. In this place, therefore, I may confine
myself to the consideration of certain other afTections, which, though
less easily mistaken for it, nevertheless reqnire to be mentioned.
AmoDg these is, in the first place, the ao-called " Erythema chro-
nicum" of Eayer. With the word Erythema, however, we always
associate the idea of an affection having an acute course. Again, in
the diseases to which tliis name is applied (entweder ?) serous infil-
trations exist, which give rise to swelling ; and, so long as the
Ergliema is present, the reddened skin is covered with healthy cpi.
dermis, there being thus no desquamation. These characters are
surely sufficient to distiuguish the Erythemala from Pilyriam
rubra, in which no swelling or serous infillration exists, but in
which a scaly condition is always present.

The Luptu eri/thematotus, a cutaneous disease wliich has only
recently been accurately defined by Cazenave and myself, does, indeed,
resemble Pityriaiii, in that the skin afi'ectcd by it is reddened and
covered with masses of scales. But this complaint is confined to
the face, and presents a pecuLifkr pattern, and is attended with an
ciihirgement of the mouths of the hair-sacs and sebaceous glands,
which are also plugged with masses of hardened sebum. These cha-
racters, and the absence of the other symjitoms belonging to PUy-
riam Tuhra, jufGciently distingaish Xujqm er^theraatosm from that
disease even in a local form.

I think I may spare my readers, as well as myself, the differential
diagnosis between Pilyriatit ntlra and other squamous diseases,
such as PityriaM simpltx, SeliorrAoca, and lehlki/otu. The possibility
of confounding it with Lichen ruber was discussed in detail when \
was describing that afftrtion.

Pathological anatomy. — It has alresdy been stated that in fatal eases

I alPilyriatia rubra noehangeain the»kin, resulting from the dijiease,

arc perceptible to the nnltwi eye. Ami rven the microscope fails to

disclose anything tending to explain this mysterious alTcction.

once, therefore, aa in ko mnyotbers, ivc h:ivc (o basftj

TREATMENT. 73

lowledge of the pathological anatomy of the skin, not upon post-
lortem esamiualions, but upon observations made upon the living
'^icnt, so for as this is possible.

Etioluffif. — Excluding the local forms of PHt/riasls rubra (which
are more correctly placed under the head of Eczevia gqitamotum),
nnd thus taVing into account those cases only in which the disease
is universal, I have again to confess my entire ignorance aa to its

as d
^^ stag

^^B affei

' ifl o

Prognosis. — According to my past esperience of Pili/riatis niira,
it has invariably terminated fatally, after a duration of many years.
How far these observations may hereafter be confirmed, must remain
an open question, But the fatal issue of the cases I have seen, and the
fiulure of the treatment which I employed, have been among the main
reasons which determined me to admit the PilffriasU rubra universalis
as distinct from Ecama iquamosum. For it ia well known that tiie
stage of Eczema, in which there is a resemblance to Pilt/riafis rubra
is just that in which it ia about to disappear, or is at least readily

•able by certain well known remedies; the termination of the
affection, and the results of treatment being exactly contrary to what
ifl observed in llic disease which I am now describing.

Treatment. — In the cases of Pifyrtasii rubra universalis which

have come under my observation, I have made trial of many of the

.Bedicines and plans of treatment, which I described in detail,

hen speaking of Psoriasis ; but unfortunately I cannot report that

have obtained tic same good results as in that complaint. Inlemal
ledies, in particular, have always failed to produce any change in
characters of PUgriniis rubra, not even relieving it in tbo

jhtest degree. Neither arsenic, tincture of cantharides, sulphur,

ttimony, decoctum lignorum, sarsaparilla, iodine, nor mercury, has

icceeded in putting a stop to the disease.

On the other band, it has to a certain extent been modified by
:peat«d employment of tepid baths (in which I have kept the

itieut for several hours at a time), and by the application of oils

id emollient ointments. Even then, however, the ciTcct of ihc

latmcnt has merely been to reudpr the masses of epidermis more

mvparent, and the skin itself mor« supple.

CHAPTER XIX.

Ec:fm. — NiUtende Flechle. — Moht Tettn.

HiSTOHY. — It is e dilficult, if not au impossible, task to Ik upon
those passages in ancient worka which answer to the characteristics
of what we now call eczema. For, since tJie name tloea not occur
in the Hippocrotic writings, nor in those of Galen, of Olsus, of
Piiny, or of the Arabian physicians, we are obliged to search for ,
this malady among the representations which the ancients give of
pruriginous diseases of the skin, under whatever title they may
appear. Moreover, the very imperfect descriptions of culaneoaa
affections, and the arbitrary changes of names and of their meanings,
which we Und throughout ancient medical literature, often render
it simply impossible to decide with any certainly what disorder the ,
author before us had in view. The conceptions which prevailed of I
eruptions generally, and particularly of those varieties winch i
now call " vraiclcB," " pustules," " papules " and so on, were not at
all clearly defined. One writer speaks of pustules which do not ]
conlHtu matter, another of yellow vesicles or phlyctirua;, and all lay
Jcs» stress upon the external appearances of a cutaneous djseasp,
than upon its supposed cause ; a cause sought at one time in a ]
bilious flux, al another in black or iu pale bile, now in bilious or I
s:Jt jililegni, and again in acrimony of the blood.

^*I<?tU ' describes under the name Kii^fnn two kinds of scald head, ]

I one t,( which may wiswer to impetiginous eczema. Uin Porriga |

l.tec/Ai'rji. * is a!«o perhaps a forni of eczema of the scalp, since he f

"fpeaJt- /n liis description of it of ulcerations and an ill odour, and I

' ' ti> ■gt*'^^ tiat the disease may invade those parts which arc J

toi-ejy, ."ijpy the beard and eyebrows. The same writer describes*!

*ipi(!g » reddish indnralioo {duritU-t) of the skin, upon wliich I

■■^^> und "dry" pustules aro found. Wo most, however |

«*. cap.

a 13.

e Vrh. vi, W. J.

* Wb.»,

ip. aS-

I teiDcmbrr Ihal the notion Cdsus hod of a [lustuUi aiipears lo
I have been a very confuseil one j for he says that there are pustules
1 formed from sweat, and others produced by Urdea Ureva. He
I nUo speaks of those caused by cold, fire or medicinal applica-
I tiouB. According to their shape and colour he describes red and
I livid, wbitisli uiid black, pointed and Hat pustules, to which he
I applies the terms, exanthemata, f Xuxroivai uud f Xv^ukio. In the
I following passage we may conclude that he is really speaking of
1 eczema : — " When these pustules discharge sanies, a persistent
I itching ulceration results, whicli sometimes spreads rapidly, in
I many cases disappears again of itjself, and in others returns at certain
I Bcasons of the year."

In the works of Oalen, the disease we arc concerned with is pro-
I bably to be sought under the heads of Psora and Lichen, names under

which he included most affections of the skin, while he employs
I even tbesc only to denote different degrees of intensity. La de-
[ ccribing the diseases of the .'•calii, he mentions Achor, liy which lie
I means "ulcers from which exudes through small openings or erosions
I e tliiu, tenacious, purulent fluid, nf a consistence between honey and
I water."

It b in the writing* of Actins of Amida (a.d. 543} that we first

meet with the term eczema. He says, " ena iKZiftara ali ebuUUnte
\^fivore 6ra:ci r«/ffO appeUanl;" nnd intends by this "hot and pain-
1 fill pldyctiJ-nsR which do not go on to ulceration;" a charactcristie
] which points to our eczema. Later, in Ihc 7lh ccutury, we find

the name used by I'aulus Jilgineta, who describes {hb. iv, cap. 1)
I AS "Ztc^lnara sivc "EK^tV/iora {from J^tw, hoi!, ItXiw, boil over) pus-
I luleswilhoutpusC'riVfii jr«nr(na") : but whether he intended the same

disease by this word as we do, curinot tie dctcrmineil satisfactorily from

his wrilingj. The Arabian physicians portray as " sahafati liumida,
I olcerv capitis manoiitia" appearances which correspond with our
I eczema of the scalp as well aa tif the rest of the body. Aviccnna
[ lias particularly described under llie name Sapathum (= sahafati), a
[ disease of the skin agreeing with our Gcnld head, which occurs
[ among the children of the poor, as the result of had milk, and con-
r «ists in nlccra which cover the affected parts with scabs. In the
I medical works of the middle ages there is, as is well known, little

original nutter to be found among their comments on the Greek and
I Bomnu nuthors. But in the beginning of the 10th century, there
I ari* already writers who describe eczema of the head and body witfa

kin. bifewboriiu

MKWkB. Ihmr HMfi sfffin to tbe

■Myi*i ^imw ■ bmI iM pU^rcteBs,

IV«^ ^lif^Min'M.of ttoaJfeeticBi,

^teiMrfv •*&« ' tKhmm ftptU" ua

«MM«i^* Hi ifefi^gw^hw tbem bom

Awwifti WM W dw ptnwiaiis Tinen.

It" to be the same

I (Ift. X. rap. S) and

lti^^3» i wib» iktfnl— aad <lc£ix5 achores

" "■* ; ex/ora-

k% to tie

eiik<n«.W9V9tWltkR arises first

» yalwrt tosmrtch biiB9flf,«nd thnt

\ dkltjt taM(«K«, Wh( wcn4cs a fluid,

* tkjllk II* abo KiMtlv thnt Ik-c

t iW Ww A>)bv<l^aad tluti it occurs

,vwuj|t lutfjfcb, especially

"-^1^ the hp«d of Herpes
. //. wiy*> (Turner),
'<-\i\i \v ecuiiiii. He

......;';^« ill liii chnptor on

UfihMntW librl xiiv. Franca-

fniirofwlii, iSOJi "De

^ IA*A> lib. Ttl, («p. 1.
_ Ulbs Wiiolll*, 1601.
i t'H«\ I'W '. I'' » J» J t™. it, p. 578.

HISTORY.

Tirica (Book II., p. 578), as an aflectiou of the forehead and
temples of young children, which begins with numerous closely
placed phlyctiena! or vesicles, at first white, but afterwards yellow,
and filled with an oily secretion. These become confluentj and
exude a (luid of unifortn white colour, which forms dry or moist,
white, yellow, or sometimes brown crusts. Tiic process is accom-
panied by itcLing, and when children scratch otf the scabs the
skin underneath a]»[)ear8 shining and oftpu perforated by small holes,
through wiiich a fiuid escapes and rajiidly dries up. After these
ulcers hove healed the skin appears uninjured. They are said,
moreover, to occur in children of scrofulous tendency, and at times
to spread to the back of the head, the ears, chin, neck, and even the
whole body.

We may clearly recognise eczema in Van Swieten's account,*
under the liead of Rachitis, of children who, when quite young, are
troubled by an acrid serous exudation, especially iipon the scalp,
the irritation of which makes them rub the head upon tlie pillow,
At this stage the disease is named Achor, from the acrid odour
peculiar to it at first. If the skin becomes red and granular, it
is called Herpes miliaria, because it creeps uniformly on, and shows
elevations like millet-seeds. Others named it Herpes ficosus, from
the resemblance of the papules to the seeds of a fig. Then the
exudation dries to crusts, which, at first thin and cribriform, be-
come gradually thick, from the serum that escapes through them
drying up. The secretion now collects under the scabs, becomes
purulent, eats into the skin, and may cause deep ulcers, with acrid
and ofi"ensive pus ; thus, as a moth eats away clothes, this disease
destroys the skin, and is hence named "Tinea."

Up to this time, then, we meet with many undoubted descriptions of
eczema, although the name is still seldom used^ and then not in its
modern signification. Lorry is the first who again speaks frequently
of intfLfiaTa sive iK^^tr/taro ;• but he by no means intends the disease
now so called j for he uses the terms in the same sense as the ancients,
of -ja-f-fpaivtKol vofial — afi'cetious, the description of which reminds
the reader of carbuncles and boils. AA^e find further {loc. cit., p. 253)
in the article "De Pustulis," a division of pustules into those
which contain pus and blood, and those which secrete serum [ichor

' ' Commentaria in lU'riDntini Buerliaare A[iLori3m03 do cognoaccndis ct
curandis motbi»,' Hiliibarglisnsse, 177.3, 1'o°k », ji. 590.

' Traclulua du Uorfals Culaneisi' Purisiia, 1777, o«p. 3, p. 77'

I f"l »■

— -.. i."*"_ir'«

.- :;j^." Ho

— •»- ".•^■riiiinir ■
-_ - In'ing up

: ncTfs on the
.^^- 3iaimer.
. ^ ufecrion

■ ■
7 - "''I'

■ ' . '

meaning lias been attaclied to it wliicii is now generally recognised.
Robert Willan placed eczema in his 6tli order, " Vesiculse," and
defined it as a non-contagious eruption of small elosely-act vesicles.
Ue admits four species, which he describes as E. impeiiijim»nm,
E. Tul/riim, £. to/are, and E. mercitrialf, and figures in his
55tb, 56th, 57th and 581I1 platea.' Although the waj was thus
opened to the correct diagnosis of eczema, Willan described and
delineated only certain forms of the affection, and thus left his con-
temporaries and successors abundant scope for further iuve^ligHtion.
It has been especially objected to his account, and I believe with
justice, that he gave different names to many morbid appearances
which belong to the several stages and varieties of eczema; and in
looking through the figures in his atlas, and the corresponding
letterpress, we have no difficult; in recognising in Lichen agriuii
(pi. 4}, in Ptonmit dijfuia, "peculiar to bakers" {pi. 11), in
Ptoriatii pa/marU {pi. 14), in ihe species of luijtetigo wluch he
calls rcspecrively /. figuraio, iparta, and tcaiida (pi, 34, 3^5, 36),
and in bis Forrigo larvalU, P./ur/urant, P./avoia, and P. /adei,
d''- 37> 3^' 4^j 43)1 10' ^** many distinct maladies, but simply
various forms assumed by eczema.

While Bateinan, I'lumbe, and other coutemponirics of Willan in
England accepted and repealed his names and divisions of eczema,
Alibert brought forward b I'aris another nomenclature and classifi-
cation of the varieties of Ihe same disease. Though we do not find
the term " eczema " in his first system, hia later published " Mono-
graphic des Dermatoses (1830)" contains a chiss "Dermatoses
eczematostp." This, however, does not correspond with eczema pro-
perly so called ; and we must look for his account of this affection in
both his works under the heads of Dartres and Teignes. ^Ve there
find it figured as Teigne granuk'e (pi. 2), T. furfuracee (pi. 3), T.
amiantac^e {pi. 4), T. muqueuse (pi, ,5), Doitre furfnraeee volaute
(Herpet fttrfvraceitt cc Wan*, pi. ii), D. sipiamense hamido (U.
tqnatHoaua vtadidant, \A. \^), which corresponds precisely with
ccuma, D. squamcusc orbiculaive (pi. 14), D. crustaci^ ilavcscpulc
[Mcii la ffra ^orescent, p\. 16}, D. ctosIbc^ etolactiforme (//. c™«-
iaceut alalacl^formit procH miens, pi. 17).

This arrangement of tlie forms of eczema by Alibert found no
followers ia France or elsewhere, and WUIaa's example was gene-
I ittlly followed. Bictt, whose doctrines were expounded hy bis
■ ' Udincklion) c( Cutuiniu* l>i9?Mc^' LoodoD, 181;.

^Mfa^.^

> disciples, Cflzenave and Schedcl,^ was the first who, with a just ap-
preciation of the various appearaJiccs presented lu the course of
eczema, first established Ihe" division of this dise-ase into the ncufc
and ihe chronic form. Unforlimately he made the mistake, in my
judgment, of placing Eczema iinipiex, rulrum, and impetigiwmim,
D3 species of E. aciitum, and laboured to establish the untenable dis-
tinction between E. imjirfi^inomim and true eczema. Jor I have
never been able to see the dilTcreuce between pustules (veritable*
pustules) as characteristic of impetigo, and pustular vesiclea (vfiai-
cules pustuleusca) as distinctive of impetiginous eczema — a difference
asserted by Biett (loc. cit., p. 139), but which he has himself in his
" Diagnostic " of eczema been unable to support by any convincing
arguments.

Eajer* advanced another step towards the complete understAnd^
ing of eczema. He parllj followed Bielt'a classification, but
pointed out the necessity of distinguishing the local peculiarities of

L the affection. We find accordingly, in hia work, fully and parti-

Icularly described — (i) eczema of the Scalp; {2} of the Face;

1(3) of the Ears; (4) of the Female Breast; {j) of the Umbih-
cal Hegiou ; (6) of the inner aspect of the nates, anus, and lower
part of the rectum in the Male, with the prepuce and scrotum ; {7)
of the corresponding parts in tlie Female, with the vnlva and
vagina ; (8) of the Extremities ; (9) of the bend of the Elbow,
Axilla, and popliteal space; and lastly, (lo) of the Hands, Nor
must we omit to mention that Eayet pointed out the various
appearances which eczema may assume in its progress {\es dilTerciita
tcrminaisons de f'er:tmn) and declared that forms of this disease

I only apparently different had been described under Ihe names

I Echaubouiurcs, Dartres vives. Herpes fongucux, Sca&ifi /era, S.

maffria. Dartre and Tcigne furfurac^c, Teigne amiantaci'e, Dartre erysi.

I|i^lateuse, CroQte Uiteuse, Teigne mutjueuse, &c. (loc. cit., p. 413).

■Thwc views of Hayer have been generally adopted by his counlry-
I, and repeated in Iheir writings with only few and uaimportant
comments. W'e lind accordingly in the works of Gibert,* Ciiaiisit,*
•Ahn'gi I'mtiquc dcs MalndiM lio la I'mii,' par H. E, Sclicdd ct Alph^
JCtitenave, ^mt tSdilion, Pim, 1647.

'TraitjS dei Maladies do U I'cnn.'par P. Rajter, Paris, i8j>;.
* Traitii |iriitiqae dci Milulics ip^cioJes d« U Pcau i par C, U. Gibert, i:
idilion, Paris, 1840.

'TnLil££l£mcnItLiro doMaUdict dc U Pcau)' put Uaurice Cliiiuuti Pit!*,

nrsToRY. 81

)evergie,' Cazenavpj' Duchesne-Duparc,' Hardy,* Rochard,° alraoat
identical views on the nature, the course, tlic cause, and the treat-
ment of ecztimata ; and, as a rule, it is only in the arrangement and
lomenclaturc of a few subdiWsions that these authorities differ,
>evei^e, for example (loc. cit., p. 230), divides eczema —

(a) After its tyiie — iiilo £. simplex, E. nimpoaitum, the latter
icluding the impetiginous, lichcnous, lierpetiform, and squamous
Uieties 1,^' Eetema psoriaai/vrm^').

I (5) After the form of the efflorescence — into Eea^me amorpke
mmulaire ((. c, in round scattered patches), Eczhne fenilUU, and
te:ema uniirjvamonim.

(e) After the region affected — into diffuse or general eczema
md the varieties localised on the head, thr ears, the root of the nose,
E nipples, the nave!, the vulva, tlie scrotum, or the thighs,
(rf) After the course — acute (E. nmplex rubrum) or chronic.
(e) After the duration — E./ugaj, E.permten», &c.
These Bubdiviaions do not appear at all marked by sufficiently
iaharacteriatic differencoa. Devergie, moreover, takes credit to
r himself for establishing the four diagnostic peculiarities of eczema
which, according to him, are — (i) Kcdne»9 of the diseased sur-
face ; (a) more or less roiislaiit itchiiig ; {3) secretion of a trans-
parent fiuid, which dries upon linen in the same manner as semen;
(4) the presence of liltle red points upon the skin {^tat ponctu*?),
which allow the secretion to ooze out.

Without contesting the aecnracj of these four signs of eczema,

I will only remark that while they by no means exhaust its

symptoms, some forms of the disease which undoubtedly deserve

Uic name, such as vesicular eczema, tlie so-called E. tolare of

I TVillan, do not exhibit a single one? of Devergie's diagnostic marks.

Hardy is of opinion that it will conduce to the better undcrstnnd-

bg of eczema, to divide its course into three stages, and in addition

■|io recognise the following varieties, namely — (1) According to its

*Tnil£ pratique des Maladies de la Peau;' par Alplionse BcTcrgie, Forii,

' •Le^oMBurlMMalndiM de U Pern,' par I'. L. A. Cucnnve, I'aris, iSgfi.
'Tnitc^iraliqiiRdrsDcrmfttnMs,' t>ar L. V. Duciic3De-Du|iarc, I'aris, 1851).

• L»VOW '"!■ Ict Miihrfin if^ in Vnn' (pnlilislifLl h-j ?fn,;,ai)l). PwU, 1858.

' ■■.j: uppenrcil in

'Gaining fuiilicr

ECZEKA.

appeannce {7an6l6s saivuit I'aspect), S. nmplex, E. ru6rum,
fcudilU and E. vmpetiginoium ; (s) according to ils coDGguration,
£. jiguratunt, E. numatulare, latpHigo tparia, and E. diffMum;
{3) according to its seat, E. pUare, E. capUU, E./acm, E. Ma«>
aantm, E, umbilici, E. genilalium, E. tnanuum et pedum. If tile
views I shall preseotlj developc be correct, this dassificatioB is
at once too wide and too narrow, admitting what is superfluous,
and lacking what is essentiaL

"Whik tlie French school were thus with greater or less sncoew
cultivating the diagnosis as well as the therapeutics of eczema, English
ph^aiciaus either followed prettj closely the doctrines of Wiilan
and Bateman, or else have conscientionaly translated the works
of their contemporaries on the other side of the channel, without
addiug anything new of their own. We 6nd, accordingly, in the
works of Jonathan Green,' and of Samuel Flumbe^ and Anthony
Todd Thomson,* the teachings of the French writers, and especially of
Rayer, faithfully reproduced. The chief efforts of these English jihy-
eicians were directed, not to ascertain the nature of the morbid change
of the skin in eczema, but rather to discover its successfol treat-
ment ; in spit«, however, of all their energy and of the liberal use of
numberless internal and external remedies, they were never able to
reach the result they aimed at. All English physicians, without
exception, but particularly Huntj* are remarkably fond of prescribing
arsenic, and look upon that drug as the universal remedy for all
diseases of the skin ; nor yet do they confine themselves to this
alone, for every one of them speaks at the same time and with
equal zeal of an antiphlogistic treatment, carried out to its full
cxtvnt, portly by preparations of mercury, partly by drastic pui^.
Although Brasmus Wilson,' the most prolific English derma-

^ 'Pncticol Compendium of Disotues of llko Skiu,' hj Jonatliaa GrMn.
A traiulation waspulluhedatWcinuuk 1836.

* ' A I'raclicnl Tmtiso on the I>iae«H9 of the Bkin,' bj Samuel Pliunb«i
Lontltin, 1^37.

■ ' A I'niclicBl Trtatuc on Diseues alTeotmg tlis Skin,' by tlie lite Antbony
Todd Thumun, U.U., completed uid edited b; EUmaitd A. FarlcM, M.D^
LonJoD, i&so.

4 Tnctical ObsErTstions on tlie I'stbologj and Treatment of tiertain Pis-
UtMS of lh« Skin,' bj Tbomu Uant, London, 1847.

* ' On DiscucB of llie Skiu,' by Enuuiut Wilaon. ;,fXi cJilian, Londun,
18(13. 'fortnili of dinues of Lbe ikin.' by tlio luno author, Ixiadon, '
1847-

4olf>gist, pays homage both in his surlier and more recent writings
to the samB principles as the rest of his countryinenj he yet
miikes a praiseworthy exception ia developing more views of his
own, and in looking for the mitigation and cure of cczcmata,
Hot only to internal medicines, but also to local applications. T
cannot, however, admit the correctness of some points of his
nomencluture and classification, which are wanting in logical
eounectioD, and in the lumen ttccum demanded by a scientific
work. For instance, I may at once remark, that his divisiou of
. Gczemata mto acute, chronic and local, is untenable, because
^s are not mutually ejclusivc ; for local eczema, aa
I well known, runs at one time an acute, at another a chronic
Bourse. Further, the subdivision of the acute form into E. im-
plex, rubruiK, impetiffinodei, and in/anlUe appears to me inaccurate,
because these varieties of the disease may foUow a chronic as well
_M an acute course, and may occur in adults as well as in children.
put it is still more to be regretted that Mr. Wilson has, without
my justification, identified chronic eczema with psoriasis, an innova-
which has been of no service to science, and has only added
the chaos, already great enough, of dermatological noracncla-
Excepting such errors (which this able writer will doubt-
s sec the propriety of correcting in a future edition of his work)
we find in Wilson's writings observations and experience which
show an accurate insight into the nature of eczema.

Of German literature, I must, unhappily, complain that it
has treated the field of dermatology with great neglect, and has
been content with the translation of French and English works
upon the subject. For example, in the extensive work of Joseph
Frank,' we do not find a single chapter specially devoted to
eczema, and must wade through a mass of quotations and names
to reach the few passages from which one acquainted with the
bjcct may venture to concluile tliat the writer meant to de-
^zema. The i8th chajiter of this work treats under
general name of "Tetters" {I'lfi^hten) of a miliary variety
'i corresponds partly with Eczema, but also includes Psoriasis,
I, Herpes pncputialis, Impetigo and Lichen, as secondary
We cannot pass a better judgment on Frank's hook than

Die EautkrsnkheJten,' iibersetit ton Dr. ChristUn Gotthilf Ym^I, Lcipztp,
13. Frnnk was professor nl WilBR iu Kiusiaa PoUad, and liiS work ma

I M ECZBUA.

in ■ppljring to tlie author one of bis own sUf emeota : " Batenian
hu nrtrodaoed diaorder into the stud; of iheae diseases."

It WW, thtation, with pleunre tliat the first odgioal and compre-
hensiTe work on Dennatology vhtcb appeared in Germany was
gnxUii il was bjr C. H. Fnclis.' Bat allhongh this handles
manj Icu important cutaneons diseases fully and tborooghlr, eczema
mxavas a very scanty and quite insnfGcient treatment. The author
forma the 5th bmilj of his " Dermatoooses " of so-called Eczema-
toaes, and defines them aj simple abnormalities of secretion, resnlt-
ing from ailectioue of the blood, and manifested bjr more or Uss
ditdnct congestion of the integuments. And it is in this family,
among diieaaea the most different in character and origin, — abnor-
malities of the sadorijiuroiu and seliaceous glands, siiver-staining,
pitjrriasis and pioriasLf, lichen and herpes, impetigo and stiopbolos,
ecthyma, acne and seborrboca — that we find eczema proper intro-
dnced with the name Fsydracia (loc. cit., vol. i, p. 181]. But inas-
much as Fuchs has, in his Love of classification, only described in
the class of "Dennatonoses" tlie diseases of the skin caused by
local irritation, be is compelled to bring in eczema fir^t, as we have
Ken, under the title Ptydrada, again among his ' Dermatostasen' as
ArthrophlytU, and a third time, in the same family, as P^gagrU
ffranulata. This division of one and the same disease according to
its eapposcd cause was natuiaUy no help to its compreiiension, and
hence Fuchs foond few disciples among his contemporaries. Wil-
hin's nomenclature was generally preferred, and the views of Fitnch
physicians were much followed, as presented in Biecke's excellent
trsiislation and commentary.^ At the same time, Fricse ^ rendered
valuable ten'ice to the spread of dermatological science by bis trans*
UtioDs of the English autliors, and Blitsius, Strnve, Bcbrend and
Froricp/ by the reproduction of English plates.

■ ' Die knuibbn^e Vcrundcruagcn dcr Haul nail ihrcr Ankiiiigc in nosO-
logischcT und tliorspouliiclier UeiieLiug,' Giittiugen, 1840.
* 'IlaailbucbuberdieKraDklicitcn dBrUwitiWoDDr.V. A. UieckCi Urtsdui

' ' Die BiuUnuklivilcn und ilire Bclutndluug,' von Rolnirt WiUu, ubcnttst
von F. 0. Friar, BrcsUa. 1799 and 1806.

< 'PrsclitdiGpsraleljuiigiler ilnulkrankbciten nnch dom Syetcme du Or.
WilUu. tibcraetxt von Krnsl Bluios, Iicip.Ig, 1841. Slruvu** 'Ucbcrnclit
dr.r JUitlkmnthcittD,' Berlin, iSi<). " Ikouujfnvpliudic Unnlcllung derniclit
iij|)liiliti«:lion llnulkmiillicilcri,' r<ni Dr. V. J. Uehreud, Ldiuig, iSjj.
wft ' Abbildaagflu det Ti«iititf "M.w[ ihii '

Nor must we forget to mention the labours of Veiel, wlio was one
If the Brat among German physicians to apply himself to the neglected
IherapeiiticB of akin diseases, and followed in this t)ie principles of
ttke French authorities. He does not keep in his several works to
' e same classification, for while in his first publications,' he calls all

ronic diseases of the skin tettera (Flcchten), dividing them into
3tlood-tetters and skin-tcttera ; in his later writings ^ he classifies all
cutaneous affections as "febriles" or " afebriles," and places the latter
in ten species, according to the anatomical system. Accordingly, he
reckons eczema among his hlood-tettera, as the result of cscess of
llbnmen or salines, and again assigns it a place in his second anato-
mical class among affections of the cutis with serous exudation in

t form of scattered superficial vesicles. As to tbe etiology of the
disease, lie inclines to the view that hereditary predisposition is the
moat frequent cause of its development.

Gustav Simon " has made valuable contributions to our knowledge
of the anatomy of diseases of the skin in general, and especially of
eczema and other vesicular forms, while Wunderlich' and Nie-
meyer' have paid more attention to its therapeutics. Quite recently
Dr. Anderson, of Glasgow, has published a monograph on eczema,' in
which he partly follows the views I have myself put forth, partly
those of his countrymen and of the French writers. Hardy ami
Devergie. Finally, I have communicated to the profession, both in
iny own reports and in (hose of my colleagues, my own cxperieneo
of tlic disease and the ojiinions formed therefrom, both which will he
fully detailed in the following pages.

Definition. — The name Eczema ^ is now applied to a disease of

' Grundxuge der Betiaudlong dot Flechten ia der Heilaaslalt la CauDstadt,'
^tonDr. Vdel, Stattgart, 1643.

" ' Jabresbcricht der Heilanstalt en CanMtadt,' 185a, 1853, 1854; Berlin,
BsSjJS- 'MiUlieilungeo iiberdcr Behandlung der ctifonischen Hanlktankhciten,'
"tutlgart, 1863.

' * Die Hautkraiikbeit«n durcb anatoinische UDienacliaiigan erliiutcrt,' ton

t. Oustsv Simgn, Berlin, 1851.

• 'Uaudbuch der Patbologie oad Tbciapie,' von Br. WnadcclJcli, Stuttgart,

Fi8s4. vol- ii. psrt I, p. ^6^.

■ ' Lehrbuch der speciellea Pathologie and Theraple,' voa Dr. F. Niemejer,

erliu, 1861, vol. ii, p. 401.

* A Practical Ttnatiie upon Eczema, 4o.,' by T. M'Cail AodersoD, M.D.,
Loodoo, 18C3.

' Id Oeruiaa, EHutm, aasaeade Fleclite, SbIiQius ; ia Freaob, dartre
■quameou bamide ; m Eaglisb, moist tetter.

KCZEMA.

the skin, of usually ciironic course, cliaracl«rised cither by ihe
FonnBtion of aggregated papules and vesicles, or by more or less
deeply red patches covered with thin scales, or in other cases by a
moist surface ; while in any of these forms there may be developed
in addition, partly yellow and gummy, partly green or brown crusts.
This affection is constantly accompanied by violent itching, which
leads to excoriations, and it is not contagious.

As the reader will see from this definition, I understand the t«rin
eczema in a different way from that hitherto accepted by former
and by most living dermatologists. I do not consider the forma-
tion of vesicles, and subsequently of a moiat surface deprived of its
epidermis, as sufficient to characterise the disease ; but take in as
varietiea of the same malady all Ihe morbid changes seen in the
course of development and rctragresaion of the ordinary vesicular
and moist cczenut. The justification of this lies in the following
facts: —

A. We are able by the action of irritants upon the skin to produce
eczema, and may then observe that vesicles or moist places do not
follow in each case, but sometimes only redness and desquamation,
sometimes papules not bigger than pins' heads, and occasionally the
rapid formation of pustules and crusts.

B. There are very many cases in which we may notice on the
same patient, in one place minute scales upon a red surface of skin,
in another red miliary papules, ia a third elevations of the qtiderrois
filled with watm- fluid, and in others again spaces partly deprived
of their cuticle, moist, infiltrated, and covered here and there with
yellow points of suppuration, or with partly green, partly yellowish-
brown cmsts.

C. Observation of the course of individual cases of eczema teaches
us that many begin willi the formation of smaller or larger vcsidca,
some of which devclope into pustules, others burst aad form moist
surfaces, and others become covered witli yellow crusts; while the
surrounding surface is occupiinl by & papular oni]ition, or is simply red
and dcsfjunmating. Towards the end of the morbid process dU th«
pustules will have liirned to scabs, and these, after completely dry-
ing up, fall olT and leave Uio nlTected parts oorcTcd with minute
scales, and more or less red and inflllraled.

The above facta will surely sufllcp, with the help of clinical obarr-

vntion, to lead all ex)>cricDoc<l iiliysicians to the same ronvictinn to

L which my own uludica have brought me, that rcfema mart he studied

AETIPICIAL ECZEMA.

r under fivR different forms. Inasmuch, however, as there nre still
sceptics as to the correctness of this vieir, and authorities who treat
the attempt to simplify the diagnosis of cutaneous diseases as a
crotchet of my own/ I may be allowed to set forth more fuUy
the above-meutioned tiirco grounds for my opinion.

(A.) A simple experiment which any one may repeat on his own
person, or on patients at his disposal, gives almost conclusive evi-
dence of the identity of my several forms of eczema. Let any appli-
cation which will produce artificial ecKema, «. ^., croton oil, be
rubbed into the same parts npon clifFeient individuals, say into the
flexor surface of the forearm, and that to the same extent. Or, if
the experimenter has only a single patient, this one willsuJGce;
different parta of the surface must be selected — the flexor and exten-
sor surfaces of the extremities, the palm or sole, the face, breast,
bock or genitals — and any convenient quantity of croton oil, say five
drops, should be carefully and equally applied with a camel's-hatr
brush to all these places. Within a few hours certain changes will ap-
]iear on such regions as the face, the hend of the joints, and the genitals,
which, however, do not in each case exhibit the same appearance.
I In some, as the scrotum and penia, a well-marked oedema and rcd-
I ness will be observed, and often innumerable minute veaicU^ in addi-
f Hon ; in the face the swelling is usaally greater, and the formation of
vesicles less ; while in tlie extremities the orifices of tlie hair fulUcles
will be swollen, forming nrd pofuki, and here and there vesicles
will also appear. If now these ports be left without further appli.
I cations, whetbeT irritating or medicinal, there will, in the great raa-
fority of cases, have ensued such a change within a few days that the
■swelling, the papules, and the vesicles, will all have disappeared, and
Bonly a slight redness and desquamation will remain in proof of a
Iprevions inflammntioii of the skin. But if on the day after tlie
V&rst experiment croton oil be again applied to the same places, we
Vriiall observe not only fresh eruptions appear where the first appH-
Vcaticm did not Ixkc eirecl, but the previous ones will assume more
Itriking and extensive forms — so that the papules already produced
"1 devrlope into vesicles, obviously because the amount of the
nbepidermic exudation has increased, and thus becomes visible be-
eeth the cuticle. As a rule, the effect," of the second application
ikewise pass away in a few days, redness and desquamation of the

< Cr. Veiel'i ' MittbeilunsGii fiber di« Beliandkng der cbraaiacbea Haat-
ikheiten,' 1863, p. 104

88 ECZEMA.

skin again marking the last stages. But if the affected parts be a
third time, and again and again treated with croton oi], the morbid
process will grow in intensity as well as in extent, "Wc shall see in
anch a case not only the parts actually brought in contact with the
irritant assume a greater number and development of papules or
vesicles, bnt also the surrounding skin which was untouched by the
brush will be included in the extending circle, and will exhibit the
same primary changes which were observed in the part originally
attacked.

An artificial eczema of this intensity will bnt rarely terminate aa
above described with desquamation. In most cases the quantity of
exndation vrill not merely allow the formation of vesicles, but will
break through the layers of epidermis which form these, and thus
oozing out will form moist or weeping patches.

While this form is being developed at some points, the con-
tents of other vesicles which do not buret undergo metamor-
phosis into pus. In this way the original vesicles become put-
tulet, and thus a fresh form of the disease is presented. More-
over, the influence of the pus upon the surrounding parts is not
without result in the change of symptoms. The redness and swell-
ing of the skin surrounding each pustule is increased, and the itch-
ing which accompanied the formation of vesicles is changpd to a
sensation of pain. But the difference between the contents of vesiclea
and pustules shows itself again in their further metamorphosis, for
while the former appeared disposed to dry up, but not to form thick
yellow or brown crusts, the pus contained in the latter, even without
direct contact with the air, dries up within its epidermic chamber,
and developea the firm concretions of various form and colour, which
are known as scabs or cruets.'

After the artificial eczema has ihna arrived at its climax, it
sooner or later begins to go through retrograde changes. As soon
as progress stops, and no fresh eruption appears, the whole of the
vesicles and pustules gradually dry up, the scabs thus formed are
pr(«sed npon by the encroaching healthy efiidcrmis, and falling
nil at last, exhibit the sktn benenth red, more or less iniiltrated,
and covered with ecaica — the dead remains of diseased epidermis.
This Appearance ii in fact what I have already described as occurring
a tile slighter forms of eczema.

If now wc analyse tlie morbidl oonditiom presented to as in the

' Cf. roL i, p. »i.

ITS PRIMARY FORMS. 89

«oraiilet« course of eczema thus artificially produced, we shall have
BO difficulty in reducing these appearances to five primary ones.
First, that observed immediately after tbe first apphcatiou of croton
oil, and characterised by the eruption of papules and of vesiciei ; next
that which is produced by the continued action of the same irritant,
the formation of red, weeping patches; then the further condition
zesulting from the development of puttulet and scabs from tbe
papules and vesicles; and lastly, the stage of redness and desquaraa-
tion.

If we give special names to these forms, we shall be abundantly
justified in laying down as a law that eczema appears and runs its
course in five different varieties, which, arranged according to their
relative intensity, will be —

(l.) Eczema sqHam03Km,=^Pilt/nasU rubra.

(a.) E. papulositm, also called E, licAenoides or Lichen eczema-
tedes.

(3.) E. veiiculosvm=E. solare of Willan,

(4.) E. rubrum seu madidans.

(5.) E. itnpetiginosum, or E. cruslosum of some writers.

Which of these varieties will follow the application of an irritant
depends upon its quantity and strength ; thus, tartftr-emelic oint-
ment, turpentine, cantharides, croton oil or mezereum, will produce
more intense forms of eruption than preparations of sulphur, sails
of copper, iron or zinc, or than potash and soda soaps. The length
of apphcatiou is another cause of difference in the efl"ects. Transitory
irritants are more easily borne, and cause slighter injury than those
which last longer, and especially those which are uninterrupted.
Moreo^'er we must take into account the specific vulnerability of
the patient, which may vary greatly. Tor while in some cases the
skin is as sensitive as a daguerreotype plate, and breaks into an
eczematous emption under the slight stimulus of light, in others it
will bear severe irritation before showing the least reaction. The
Btate of health of the patient at the time must also be remembered.
For persons who have home a cutaneous irritant with impunity
while in good health, may, as soon as illness supervenes, be at once
attacked with eczema. Lastly, the several regions of the skin
differ in their sensibility to the irritants above mentioned. Thus
the integument of the genitals, the face and the flexor surfaces
of joints, shows less power of resistance, and is more easUy
attacked by eczematous eruptions than that of the extensor sui-

ECZEMA.

faces of the limbs and of tlic bock ; while we find most indis-
position to reaction in the skin of the palms and soles, which la
destitute of sebaceous foUiclea.

{D.) When eczema spreads over large surfaces so as to include
at the same timo the scalp, the face, and the trunk and cxlremitics,
either continuously or in different patches, it is rare for all the
itffected regions to present tlie same form of the disease ; wc much
more often find its several varieties of forms represented in the
different parts. The scalp and face are more frequently the seat
of an impetiginous eczema, while the skin of the external ear,
the back of the neck, the axilla, and flexures of joints exhibits
E. rulimm, tlie extremities H. papulomm and E. vetictilosum,
and the trunk, E. squamogum. Now it will, 1 think, be obvious
to every one, that when we find the whole surface of the
body attacked at once, it is more natural to assume the disease
to be one and the same, than, according to the rules of diagnosis
hitherto recognised, to call the affection of the scalp porrigo, Ttnea
mueoM, or T. granulaia, or achor; that of the face, Porrigo larvaUt or
Impeligo faoiei ruhra, or Cniiia lacUa s. aerpiginosa, or Melilagra
I Jlaveaceni, while the title of eczema is only allowed to the moist
and veaicidar patches on the trunk or extremities. Nay, writers
have even chosen to call the crusts which appear at the same time
from the eczematous exudation drying up, by the special name
impetigo, and the red and desquamating parts, PilyriasU rubra, thus
separating them from the other phenomena of the disease.

Any one who has ordinary opportunities of observing such exten-
sive emptions of eczema in their rarer acute or more frequent chronic
form upon cither adults or children, must certainly agree with my
view, tliat all these appearances are symptoms of a single disease, of
eczema, and cannot endorse the notion of the public and of
many even in the profession who pronounce the patient to be solTer-
ing from n scald liead, a letter of the body, and an itch of the
bands.

(C.) But observation of the natural course of an attack of scxoma
famishes the most unassailable proof of the connection between
it^ various forms. In one case an eruption of vesicles begins tlie
Buries of fiymploms, in another it is preceded hy tlic appearance
of n-d, scaly patche;^, or groups of papului; or vesicles and pa-
j^dcs (irc developed together, some of the former rapidly chuigiRg
tpitttulcs. and forming yellow, gum-like crust* by the drying up

ITS ESSENTIAL TNITT.

I Iheir cont^nte. It is evident from this that even the primary
fonn of eczema is not necessarily vesicular, but that papnles
and pustules miugted with vesiclca, or red and infiltrated patches,
may mark the onset of the disease. Moreover, as the eruption
, it freriuently undergoes a change of form. Not only
loea the red moist surface of E. rubriim appear after the removal
f the crusts, but also the parts first affected with vesicles often
undergo repentcil relapses, and the super&cial layers of epidermis
being thus undermined, display the deeper ones of the rete
Malpighii. These last moist surfaces shortly exliibit the crusts
escribed above, and so the form of eczema changes with the
rogreas of the disease, until at length, when the more active
ative process lias ceased, and the period of involution been
w:he<l, we observe a more or less infiltrated, reddened and des-
mating aurfacc, which may be called E. squamosum {Pi-
_ > ruira). Here again it will, I believe, be admitted as more

probable that these forms are all metamorphoses of eczema, than
that, after the doctrine of former and even certain living authorities,
one disease has passed mUi another; eczema into impetigo, or
I porrigo, or tinea, or PUgriiiiU rubra, or Mditagra Jlave»cen».

I have thus demonstrated that certain ulTections of the skin,
"hitherto dewaibed under different names, must be regarded as
only parts of one and the same disease, namely, eczema. It re*
muins for me to describe more particularly the forms of eczema
which are portly the result of its greater or less acnteness, partly
of the secondary changes in the skin and sub-cutaneous tissue
caused by the persistence of the affection, and partly of its localiza-
tion in certain regions.

Although attacks of eczema usually follow a chronic and even
tedious course, they also assume in many cases an acute type, and
quickly result in recovery ; we must, therefore, in the first place,
separate acute from chronic eczema. And if the admission of an
I ftcute eczema appear to contradict the characteristics of the disease
I in general, and its place seem rather to be among acute inflam-
mations of tile skin, as dermatitis and Erysipelas vesictilofum, I
must remark that there appears in practice a far less intimate rela-
tion and slighter likeness between these inflammatory disorders and
»cute eczema, than between the latter and its chronic variety. The
Ismplc fact that every chronic attack of eczema exhibits the acute
1 in the first days of its coarse, and only differs from this by re<

ACrTB rXZEMA.

peated relapses each of wliich again repeats the acute type, together
with the observation that an originally acute attack of eczema often
ends by assuming a chronic chtiracter, is sufficient proof that we
have to do with one and the same disease in an acateorin a chronic
' form.

Acute Eczema.

Acute eczema is characterised in general by inflammatory redness
and swclUng of the skin ; yet not to that degree which we are acciu<
tomed to in inSammations of the skin mit' E^o^>ii>> as erysipelas,
where the swelhi^ of the integuments causes such an extreme ten-
sion as to produce a smooth, glistening surface. On the contrary,
we never find the skin in even the most severe cases of eczema, to
be stretched and shining, but observe it ocdematons and swollen,
and covered with a greater or less number of minute veaid'Cs, con-
tainiug either a clear watery serosity, or, sometimes even from the
first, a yellowish fluid. The size of these vesicles also varies, the
yellow ones being usaally much smaller, while those containing a
transparent colourless secretion may attain the size of hemp seeds
or peas.

The eruption of these vesicles usually takes place suddenly, and is
completed in a space of time not exceeding forty-eight liours. In
the most favorable cases they dry up after lasting from six to eight
days ; the layers of epidermis which cover them fall off in the shape
of minute whitish or sometimes darker scales, and leave a perfectly
normal surface behind. The sensations accompanying this eruption
are those of burning and tension, and it is only towards the end
of desquamation that the patient complains of a shght itching. The
participation of the system generally in the morbid process is shown
cither by irritation, sleeplessness, and a feeling of diffused chilliness,
without increased frcfiuency of the pulse, or by slight febrile symp-
toms, which accompany the erujition of vesicles and disappear in a
few days at most. An attack of eczema following this course has
been often and is still occasionally mistaken for erysipelas, but is,
L have shown, essentially distinct from it.
^ is more often the case thnt within the second week of the
I frnh outbreaks of eczema appear either all around the pre-
J affected parts, or only ei certain points, or in quite dif>
I ngioiu of the ho&j. Then follow a precisely nnailBr cotme,

I
I

ITS LOCAL VARIETIES. 93

id may themselves be succeeded after an interval by a third or
a fourtb attack, each running its own acute course ; or relapses
foltov each other so quickly upon the spots first affected, that
they produce the characters of chronic eczema. In these last caaes
R dilTeient set of sensations is experienced by the patient; a violent
itching leads irresistibly to scratching, and from this fresh morbid
appearances result — excoriations in all their varieties, and still
deeper changea in the skin which, in their turn, pass through
their own series of transformations.

Acute eczema is, moreover, frequently followed by the form of
disease produced by the rapid change of the clear watery contents
of the primary vesicles to pus, aud the desication of the latter into
yellow gummy crusts. This has been separated from eczema by
certain writers, and described by I'uchs as fmpelyo Jaciei ru6ra,
irhen it occurs in the face ; by Ahbert, as MelUagra favetcena, and
M. nigrkant, and by other authors as porrigo, Crutta lacUa, &o.
I As I have shown abovej these are but varieties of eczema, and
do not only occur io chronic caaes, but have often ao rapid a course
that we mast include them under the acute form of the disease.
When the srrum exuded in an attack of eczema ha« accumulated
under the epidermis, or has broken it through and reached
the surface, it dries into the previously described dark and
thin or yellow and gumray crusts, under which the epidermis repairs
iteelf, and after the scahs have fallen off appears with only a
slightly heightened colour. We may observe eczema running this
course, not only on certain parts of the body, but spreading over
ihe entire surface from the crown of the head to the sole of the
foot. Not a single region appears to be exempt from an acute
attack of this malady; but (here arc certain parts most frequently
alTected, and thus we may notice as the more important local varieties
of acute eczema the following : —
E. acutum faciei.

2. E. aautum geniUttium [penU el toroti).

3. S. ocnlnm matmunt ei pedum.
E. aculum universale.

Acute Eczema of the Face.

Of the above-mentioned characteristics of acute eczema in gene-
ral, the redness and swdliiig arc well marked in this ruiety ;

cue- ^H

■

ACUTE ECZEMA

vesicles, ou the contrary, are often merely indicated, so that it is
only by careful observation of the face in profile and with n side
light, that they can be detected in tbe form of minute, almost
papular, elevations of the skia. Swelling of tbe ejcUds is a eon*
stant §ymptoni, though varying in degree, and distinct from
ordinary cedema in not presenting the shining surface produced
by extreme tension. The skin of the eyelid in eczema has an
uneven, granular {drutig) and scaly surface, yet is frequently so
much swollen as to render it imposaihle to open the i^es. When
the skin of the external ear is affected, the tumefaction is also
considerable, so that t!ie auricle stands out from the side of tlie
head. In this part we may very often observe vesicles with their
watery contents quite plainly, and in immense numbers. The
concomitant sweUing of the skin of the external meatus produces
a dulness of hearing, wb'ch disappears, however, with the condition
producing it. In these cases the patient esperiences the above-
mentioned feehngs of tension, burning, and irritation as if from
rough flannel clothing, with slight itching during desquamation.
The only peculiarity of acute eczema of the face as to its course
is its liability to relapse without always an assignable cause, and
the consequent frequency of aacceasive attacks, wliich, at first
separated by considerable intervals, gradually pass on into the
chronic form of the disease.

Aeiile Eczema of the Qeiniah.

We find a similar group of symptoms in eczema of these parts
to that just described. Ilere also redness and swelling are more
marked than exudation beneath the epidermis or the vesicles
so produced. We may remark that this form of eczema attacks
males more frequently than females, and that it sometimes confines
itself to the penis, sometimes to the scrotum, and sometimes, again,
nlTecta both equally.

(a.) E. acttlunt jdcrm. -^Tlie disease always appears in this
n-gion suddenly ; its progress may be watched from hour to
^our, and it is frequently fully catablishr^d in a single night.

! first symptom ia usually ■ burning Hctixation, quickly toU
1 by tweUing nnd redness, with excessive increase of size.

I prepuce is higlily (ndcmntous, producing phymoais or para.
»B», and on the teusc surf-aco of the skin appear aumcrous

It peii:

ITS LOCAL VARIETIES. 95

inute vesicles, not bigger than a pin's point, and only obgerv-
Rble in ^ side light. After a few days this series of symptoms
usually disappears, and there remains a considerable quantity of
dead epidermis, which has been thrown off. Sometimes there
is no disposition to recurrence, but in other cases an acute attack
is only iiitrodQctory to a subsequent chronic eczema, which is
often of long duration, and accompanied by certain unpleasant
aensatioos which will be afterwards detailed. — (v. infra, p. 109.)

(b.) E. aculum tcroH. — When the scrotum is affected with
eczema, we find a similar swelling and redness of the skin, but
the eruption of vesicles is more marked, and on their bursting, a
conttidemble qnantity of flaid secretiun becomes exuded upon the
surface, which stains the linen after the manner of the spermatic
fluid, and quickly causes a most offensive odour by its rapid de-
composition. This last result is especially noticeable when, after
repeated attacks of acute eczema, there follows a kind of tran-
sition to the chronic form. I must also observe here that, in
certain cases, the amount of secretion is so great that, at the first
^ance, one might easily take the disease not to be eczema at all,
but a severe gonorrboea. The linen in contact nith the scrotum
is permeated by the exuded fluid, and appears so yellow and stiffened
that tliis mistaken diagnosis irresistibly suggests itself.

(c.) When the scrotum and penis are both affected by acute
eczema, the above-mentioned differences become very obvious; the
penis is swollen and infiltrated, but dry ; the scrotum is covered with
loisture. The diagnosis is accordingly easy, sad the course of the

sease is the same aa that just described for the two varieties

suning separately.

Acv/i Eczema of the Sanda and Feet.

Thi« variety is often seen combined with eczema of the face, of
the genitals orof otlier parts, but may also occnraloue. It begins by
the eruption of a multitude of clear watery vesicles, from the size of
seed to that of a pea, often upon one or two fingers, but eome-
3 on several, or upon the palm as well ns the back of the hand ;
ue accompanied by swelling, but never, at Urst, by redness,
days the vesicles have tocreased in size, and here and there
id form bullic without bursting. A Utile later tliey
up, snd ditappear in the form of minute brovnish

ACUTE ECZEMA.

scales, leaviug beliind a perfectlj normal surface. The patient
experiences at the outeet a feeling as if woollen gloves were on
his hands, and this is afterwards folloned hy itching.

Wlieii the skill is much swollen, movement of the fingers or
toes is completely hindered; and in cases of acute eczema of the feet
it becomes very painful, aud at last impossible, to walk or stand, or
even to wear a stockuig. This form of the disease also may, aft«r
repeated eruption of vesicles, assume a chronic character, and the
more readily in proportion to the rapidity of relapse. If, however,
the attacks are separated by long intervals, if, for instance, they
recur only every year or every six months, the disease never renohcs
the characteristics of the chronic form, but merely repeats the above-
mentioned appearances and must be regarded as reJapsing acute

Univertal Acute &gema.

This rare variety attacks at the same time the skiu of the whole
body, from the scalp to the feet, and will in general be marked by
redness, swelling, vesication, and desquamation. But these appear-
ances are modified in certain regions. Thus, on the scalp, the
skin at first appears covered with numerous scales, which are pre-
vented from falling ofi" by the hair. Afterwards the moisture from
the vesicles will mat the hairs together and in the course of decompo-
sition give rise among other products to fatty acids (as caproic and
caprylic), which may be detected by their peculiar smell. In the face
will be observed the redness and swelling, with (edema of the eye-
lids, lips and cars, which was described above. The skiu of tlie
trunk and limbs will present an appearance similar to that of ery-
thema or scarlatina, especiaUy in the desquamative stage; while on
the bend of joints, as the axilla, the elbows, groin and ham, and
ou the neck and genitals, vesicles will show themselves more ]>]ainly,
and lead, by their subsequent rupture, to the formation of weeping
surfaces. The skin of the hands and feet will, in consetjuence of its
thick epidermis, exhibit the most numerous and perfectly-formed
vesicles.

It will be readily understood tliat any single case of general acute
a may present many varieties by the appeuraiioe of scattered
I of vesicles, cicoriations, iiuslnltw, nr crusts, and these may
a rise to the description! by older writers of " ignis aacer,"
my'a, or St. Ignatius'i fire {JLXfumvp).

CHEONtC ECZEMA.

A universBl eczema of this kind runs its cooree in seveial weeks,
and very readily leads, when irritants are applied, to a chionic
eczema of parts, if not of the whole, of the body.

The participation of the whole system in the effects of general
acute eczema is shown by loss of sleep, and a constant feeling of
chiUineas which accompanies each freah outbreak of vesicles, even
when the patient is in a warm room or in bed. This feeling never
lasts long, and generally ceases when their formation is complete ; but
the patient remains so sensible to the least change of temperature,
that when he uncovers any part of the body, even for a short time, and
in a warm room or during summer, the feeling of cold returns, and
may even lead to trembling. At tiie same time the pulse is not in-
creased in frequency, nor is the actual t«mperature of the skin
altered. The urine and fseces continue healthy, and the appetite
and digestion are unaffected. Pain, tension, and itching succeed
each other aa the swelling at the outset of the disorder is suc-
ceeded by fresh eruption and vesicles, and they in turn by
desquamation. An attack of this kind easily recurs, especially
nnder tlie iuQuence of even the sliglitcat cutaneous irritants, and iu
such cases these may include oidiiiaiy fat, aud oils, and soaps, or
even simple water.

Chronic Sesema.

, The appearances observed in the chronic form of the disease

agree in general with those already described, uamely, papules or
pustules, crusts, aud exteusive, red, weeping or scaly surfaces. But

I the persistence of the affection, and the frequent relapses by which

^^^Hn acute eczema may become chronic, the numerous external in-
^^^^Beuces actmg upon the parts attacked, and the local peculiarities
^^^^B the regions most frequently affected, combine to produce modifica*
^^^^Bnis which will now be described at length.

^^^^K In proportion to the duration of on attack of eczema, its peculiar

^^^Hienomcna are increased in intensity as well as in extent. Thus we

I obaerve in protracted cases an increased secretion of that albuminous

fluid which we will call distinctively " eczematous,'" and also a more

I A]lliougli I give this special name (^Setfmfluidum) to tbo secretion wbicli
Gila the rcsiclrs of eczema, uid after their rupture and dt«appear*DCc is seea
upoQ tbo BUrface, I sm well awste that it might with equal proprielj bo
termed Plasma or so-called Inler-oelluUr fluid. And I do not inl«nd to

9» CUKONIC KCZEMA.

markeil sweUing and thickening of the true skin, so as in many cases
to produce a gradual enlargement of tbe papiilie, and great increase of
the connective tissue forming the cutis. We also observe a constant
extension of the affection, not only to parts adjacent but in course of
time to those conaiderably removed from its original seat. Dally
experience teaches that eczema may be propagated botli/^er coniinuum
and per contiguiim, and spreading thus from the originally affected
spot, may gradually extend even over the whole surface of the body.

Of the external iuflucDces which modify the appearance of chronic
eczema, the most important is the scratching of the patient. The
violent itching which accompanies every attack and increases with
ita duration impels him to rub and scratch the affected parts, and
thus fresh injury is done. The layers of epidermis which cover the
vesicles are destroyed, and these being opened gire rise to the
appearance which may be regarded as characteristic of eczema, and
has -been described as "weeping" {S. madidana). With repetition
of this injury by contmued scratchmg, the deeper layers of the
cuticle are gradtiaily laid bare, and the secretion so much increased
that, coming in contact with the linen, it stains it as the semen,
liquor amnii, or any other albuminous fluid would. Nor is this
all : the patient often cannot overcome the intolerable itching till
hia nails have readied to tbe surface of the subjacent papiUte itself,
and thus caused blood to exnJe, which, mingling with the eczematous
secretion, dries up into a dark brown crust.

Various articles of clothmg, and especially those which are in
immediate contact with the akin, exercise a similar influeuce botli in
producing eczema and in aggravating it when already present. So
again, certain irritants produce each so peculiar a form of eczema
that one may ofkn delerminc the nature of tbe irritant from the
form of tbe eruption -. thus, eczema produced by croton oil haa a
ditfercnt appearance from tliut caused by sulphur. Moreover,
another pecuharity of this malady is the result of tbe constant contact
of similarly affected parts, as in tbe axiUa and genitals, but most of
all under the mamma, between Ihe nates, and on the opposed surfacn

coarejr the iinpreuion Uut it is pccaJisr to eMenu, or repreieats in any MDM
a special pathalogiul proilaot. a malma feeauu ,- for it ii well known that tho
le fluid wiiicb l!lU Ilia vpsielcs of prirmii forms tliose also o( raricpUaiU '
herpn, nnd tlic bulk of iiDiapliigiu, uncliaugeil iu ib Buntom; uud oliomiilrjr
I Iborcfoio ciiooso tliis term aen\j u a oonreuicnt ono tQ denoto iho "
, the ucreUon of eczema.

ITS LOCAL VARIE'rlKS.

^f the liiigers and toes. Lnslly, the stimulus of the external aii
[Upon parts usually uncovered produces, when they are affected witli
na, a modification of its aspect. The secretion dries up into
tcruats of various colour and thickness, according as it was of purely
eczcmatous character, or had already become purulent or mixed with
blood. Whenever n transparent fluid dries, the scabs thus formed
are flat and brown : when more or less purulent they acquire n
yellow or greenish colour, and when blood is present it gives them
a darker hue. The Loney-like or gummy character of crust which led
Alibert to give eczema the name of melitagra is most often observed
when the erujition is on the scalp or face, and appears to depend on
llie admixture of sebaceous secretion.

When crusts of this kind form upon parts which are frequently

retched and relaxed by the action of the subjacent muscles, such as

a neighbourhood of the joints, and especially those of the fingers

rud toes, chaps and fissures are caused which are sometimes limited

to the crusts, but may also extend beyond the crust into the derma,

and thus produce excessive pain and also hiemorrbage. Sucli crocks

{rkagad^) also occur when in the course of E. squamotum, the skin

u covered with more or less thick epidermis, but has, by the con-

louBuce of the disease, becooLe brittle. It is in these cases that we

r^ohservc the whole eczcmatous surface cut up into Utile spaces by

a large number of cracks and cross-lines {eezeme /endilU) , so as

curiously to modify its aspect, but not materially to obscure the

diagnosis.

Although there ia no spot on the whole surface of the body which
is Dot capable of becoming the seat of chronic eczema, yet this disease
a more often observed in some re^ons than in others, and does not
ibow the same characters in each. The reason of this local variety
f aspect is partly the anatomical peculiarity of the skin in different
Igioni (especially the abundance of sebaceous glands and hair
Jlicle^ in some parts, and their absence in others), partly certain
^lUtcral conditions, as the different length and thickness of the hair,
e presence of certain articles of dress, the greater or less attentions
bven to the skin and its appendages, and certain habits and occupa-
In fact, the diversity of appearances exhibited by eczema in
Efferent parts of the body has been nevef overlooked, but, on tlie
bntiary, bait led to the erroneous opinion that these varieties did
ong to one and the same disease, but were distinct nffcctionp,
i distinct species, Thus eczema of the scalp was called

100

CUBONIC ECZEMA

Tinea or Porrigo, that of the face Crnsta lactea, and onlj that
observed on the trunk was allowed its correct name. I have
already entered fully into tliia question, and shall now describe these
local varieties as simply modiEcaiions of ecisema.

Chronic Ectema of the Scalp (E. eapUHtii).

Although, when the disease uuder consideration attacks the scalp,
it has no other effect of itself than on other parts, yet its ordioary
character is greatly moditied by the presence of hair, by the
varioQS modes of dressing it wliich habit or fashion dictate, and by
the Btiil more extraordinary customs which continue to prevail in
out-of-the way places. A proof of this ia furnished by cases occur-
ring in persons who are bald, and also by those in wldch eczema of
the scalp spreads to the foreliead and other parts free from hair.
An unprejudiced and accurate examination of an eczematons scalp
will teach us that here as elsewhere the disease i)reseuls itself
partly in the vesicular but chiefly in the moist form, and that the prin-
cipal peeuliarity of this local variety depends upon the eczcmatous
fluid matting the hair together as it dries up, and quickly forming
considerable crusts which are more adherent than usual from the
firm attachment afforded by the separate hairs.

Former writers were led to divide eczema of the scalp into seveTal

Bub-speeies, from the circumstance that sometitues only single and

separate parts are affected {in which case, when scabbing takas place

I the crusts are seen separated by intervals of healthy skin), wtiiie lu

other instances the entire scalp is attacked, and with it even the

I odjucent parts uncovered by hair. 'ITins the form in which the

[ primary eruption and the crusts formed from it both remain

I discrete, was designated Impetigo, Porrigo or Achor, with ibo

I sddilion of " f^ranulalvi" while the second form, occupying Ihe

I entire scalp, was quahfied by the adjeccivc mucota ». mucifiua,

I considered lo be E. impeti/^inoiium. I may refer, as an

I example of the inaccuracy of this separation, to the occurrence

I of eczema on the head of infanta with little or no huir : its origin

I in single spota and subsequent cxt^n^ion over the whole scalp and

■ (ace may he then clearly followed. The same takes place in ecxcms

of the scalp in adults, modified only by iho above- m<-ntioncd

oaoiirj dep»id«iit on the length, the thickiiBas, and the mode at

Mbg tliB hair. A pr<>fu—i' ^■-■-t-—' ■^■-.^i;,-, }-:^<-\r\'\

OV THE SCALP.

101

iiiaU

cons

I than

very different aspect when occurring in a pcrsoa with hair

>perly cut and combed nnd brushed, from that seen in one

rboso scalp is covered witli long and tliickly-growing Imir, ill-

idcd or quite neglected. In the former case the liuirs which

e matted together are constantly separated and reduced to

and llie adhering morbid products can \k readily removed :

the latter, the eczcmntous fluid continually exudiug, a langled

of hair several inches long is formed, and at last produces

compact and illicitly felted covering, tlirongh which the rest of

uncombed hnir appears to grow. This matting together of the

hair is increased by the patient's scratching, not only by the act

itself, iiut also by the more profuse secretion thus excited. It ia a

condition most often observed in female patients, who in these cases,

instead of combing, brushing, and disentangling their hair, keep it

constantly covered with a cap or handkerchief. Whether want of

tune and opportunity from the necessities of the patient, or the

uf the doctor, or habit, or superstition be to blame, the result

the disease ia the same; and, therefore, the same appearance amy

observed in rich and poor, on the baults of the Danube and on

ise of the Vistula (Weichsel). It is only the name given to the

■ttse which varies. A.I one time it has been called Kup/jrinJ, at

lothur WekiMliopf (I'licA polonica), without any other authority

than that of popular usage.'

We have, however, by no means exhausted the account of eczema
of the scalp. It must be remembered that the skin of the head ia
Tcry rich in sebaceous follicles, which mingle their secretion with
the cczematoua fluid during the progress of the eruption, and both
together collect on the surface of tli« skin and among the hair : hero
leceasarily decompose, and by the liberation of fatty acids
ipart their well-known and disgusting odour to the products of
We must also remember that if neglect of the hair, even in
ilthy persona, may fovour the development of pediciili, this will be
far more frequent result when there is an ecitema of the scalp,
" irding material to support myriads of lice, which, undisturbed by

I do not mUQ to m; that ever; case which is popalarl; called Weichsel- nr
el'EOpC on the TiiltiU must be regarded as ens of eczema. I am well
that aaj disease nlTnetiiig the teolp, without eiception — seboTrh<Ea oft£D,
fnTai, syphilitic ulccra — is Sicribcd lo the "Wichtel." But that this disease
is very often a lioiple fcwmn I am convinced by repeated obieirBtions, uot
only at Vienna but at Cracow, Warsaw, and other pUces in Poland iteclf.

102

CQEOKIC ECZKMA

the comb, ftoorish and multiply id a feaifol manner.' In one case
1 noticed even the Urx'ie of flies npron the scalp, and on separating the
rlosely felted hair, the disgusting- sight was presented of namWrteas
white maggots crawling lo and fro, as if disturbed in their

: enjoyment.

If we now inquTrc into the progress of a more or less severe
eczema of the scalp, wc shall Uad by experience that this also may
undergo spontaneous involution, often, however, after lasting for
years, and rarely until uftvr several months. Durio'; its course
different symptoms will he observed, correqionding with the severity
of Ike original disease. In cases, for instance, of aa eczema

, presenting the characters of PHca poloniea, the young Lairs will, of
course, not be matted together when the eczemntons fluid is no longer
accreted, and in a few months will Iiave reached sucli a length aa to
push before ihem the muss of hair felted together during the

I eruption, and thus to produce the appearance wliich the followcn
of the Plica poloniea theory bavp explained aa the "growing off"
(aiiffacisen) of the Weichselzopf, aud to allow of its being
removed by the scissors.

In other cases, especially when Ihc hair i.t short, after the crusts
have fallen off and eczcmatous ilnid no longer exudes, the appear-
ance of E. tquamoittm with a ted and scaly surface ensues, oud
lasts for some time, with continual exfoliation of epidermic scales.

Togethir with these symptoms we often liiid, accompanying eases
of eczema of tlie scnip, more or less considerable swelling of tlie

L posterior cervical glands, and not infrequently a loss of hair ; this,

I however, after the complete cure of the eczema, or even before its
last symptoms have disappeared, begins to grow agnin ; so that it la

I only in rare eases that eczema ia accompanied by an incurable

I dffiutium eapillorum.

Cirotiic Eczema of tie Face.

The frequent oecurrcnce of eczema in tho face lias always
I nttnoted tlio attention of physicians; but its numerous fonns have
I nut been always n-cogni>ed as part? of a single malady, hot, aa
I in too many otlier instAnccs, designated Porrigo larvalii. Impetigo

' Or llie relatioii uty bo reverMd : ttie irritation oanuil by pciHcnU may
« riM lo rccema of Ibo scalp.

OP THE FACB.

103

hftir.

i rubm, Tinea faciei, Melilagra flavescciis or nigricans, Crasta

:tea, Crusta serpiginosa, &e. Although, as I have already re-

itedly remarked, these different names have been bestowed merely

consequence of changes in the appearance of the same disease, yet

various parts of the face when attacked by eczema present each a

lotlifiention of its general character. I therefore think it advisable

describe particularly each individual region as affected by this

lease ; and lastly, to consider those cases in which the skin of the

itire face, and even of the whole head, becomes its seat.

or these two subdivisions, the former — E, faciei partiale —

may affect cither the smooth parts of the face, or those clothed with

hftir. Whnn the skin covered mtli the long, thick, and deeply

floured hair of the beard is attacked, the conditions are similar to

of eczema of Ihe scalp; but, iiiasuiuch as all affertions of the

re better attended to, even by the lower classes, than those of

icr parts, and since no superstition has influenced their habits in

this case, it is but seldom that the disease aLlniiis here that

development from neglect which T described as frequent when it

affects the scalp. Wo usually find that the cczematoua fluid, as it

up, forms yellow, greenish, or brown crusts whicli adhere to the

lir, and after removal leave behiTid a red and either moi^it or scaly

irface. The oidy variation from the common type of the disorder

that in cases of long duration the morbid process extends deeper

id affects the hair follicles in the same way as the disease called

'cosis.

In such cases beside the red, moist or scaly pat<'hes there may be
ilieed sub-epidermic abscesses (pustules) of pretty uniform size and
ipcarance, and each one perforated by n single hair. These
rise but slightly above the surface of the skin, and
'ards dry up to form greenish -jcllow crusts, for the most part
; beneath these the formation of pus ceases, while it begins
other points, and thus the well-known appearance of sycosis Js
iduccd. These symptoms may be observed on all parts of the
furnished with strong and thick hair, not only where the heard
1, but on the eyebrows, on the edges of the eyelids, and on the
tcous membrane of the nostrils, where it is provided with vibrisste.
transformation of eczema into sycosis is marked in its
progress not only by the appearances peculiar to the latter
bat also by its obstmacy and its perraoneni effects on the
;- Iw while in ordinutj eczema, of however long duration.

lat

CHEONIC ECZEMA

there is never any permnnent loss of Iiair or formalion of scnrs, in
those cases in which it has gone on to sycosis we find both.

The following names have been given to chronic eczema, as it
affects the different porta of the face famished with hair. H. faciei
iarbaia simplex, rabrum or impeltginotum (called by Schonldn
"Achor barbatus" (!), by Hardy, Impetigo sycosiforme, and by
Devergie, Sycosis impetigineui) ; E. rcgionit aupcrciliorum, E. mar'
ffinis eiliarii palptbrarum (Tinea cUiorum of authors. Acne ciliaris,
Blepharitis ciliaris of Stellwag] ; and E. tnembrana mucota nariunt
mbritsu veiHla. Of these four varieties tie last two have been
hitherto httle noticed, and call for special remark.

Eczema of the eyehishes has not been recognised as a local variety
of this disease, but. commonly confounded with infiainmation of
the Meibomian glands (blcpharoacleuitis), and regarded as a peciilinr
affection, or as a kind of tinea, or aa a form of acne produced by
certain condiUons, such as scrophulosis, or as impetigo, but never as
a true eczema which has simply extended deeper than usual. It is,
however, easy to convince oneself that ecuema of the edge of the
eyehds presents the same ap|)earancea in its origin and profpcas as
any other eruption occurring on the hairy parts of the face, which
has been recognised as eczematons by authors ; and the simultaneous
outbreak of the same disorder in all these regions is an additional
proof of its identity. It is the participation of the glandular appa-
ratus and hair follicles of the eyelids which gives this form of the
disease the character we have described above as thyt of E. syewii/orme.
The edges of the eyelids become red and swollen, and sometimes
excoriated, especially close to Ihe eyelashes, sometimes covered with
purulent exudation which dries up inlo grey or yellowish-grey crusts
and causes the lashes to stick together. Itching is never absent,
and a continuance of this morbid process leads to partial or even
complete loss of the eyelashes.

The characters of eczema affecting the entrance of tlie nostrils are
slight inflammatory redness and swelling of the mucous mem-
brane with formation of pustules, cacli of which ta perforated by a
hair; and when several of tliese liave united, and their couteuts
run together and formed a tolerably thick crust, this may in-
crease until it stops up the opening of tho nostril. T)ie purulent
fluid coutiniiidly secreted under this scab, causes uot only jncmued
L swelling of the mucous membrnnc, but also of the «kin of tho nose,
Land may even, in aome cases, go on to well-marked inflammation.

OP THE FACE.

105

ten
ex<

with all the characteristics of erysipelas. This form of eczema is
uBually accompaoicd by a similar aPTectioii of the Schneiderian mem-
brane in its whole extent.

Eczema of the smooth parts of the face has the same characters
as we have just described, but the absence of hair renders them
much more obvious. It may affect the whole of the face, or only
certain parts of it; and I may here make the general remark that
we usudly observe this form of eczema occupying both sides of the
face in equal extent and intensity. Hence it is rare to see only one
car, or eyelid, or side of the nose attacked, and when the disease
has fastened on the forehead, nose, lips or chiu, it usually ex-
tends equally from the median line on each side. That there are
exceptions to this rule is not to be wondered at, and they arc
the mort' explicable when wc remember that the exciting causes
<Df eczema often affect only one side of the face.

Of the parts of the face uncovered by hair, the ears are those
rhich exhibit most markedly the general symptoms of eczema, to-
ithcr with some special characters in addition. The skin, as is
'ell-known, invests the cartilage of the ear pretty closely, and thus
reproduces its peculiar conformation ; moreover, it forma folds as
it passes from the side of the head to the auricle, and from this to
the cheek, and both these peculiarities modify the appearances of
eczema when it invades this region. We must also bear in mind
that the lobule of the ear is formed of a single fold of skin without
ftny cartilage, and that the external meatus is lined by a continu-
ation of the integument as far as the membrana tympani, so that
ibis may also be involved in the affection of the outer ear. Eczeni.-k
mmy either attack the whole auricle or may be localised on certain
.parts of it. Thus it is often represented only by a red, raw, and moist
'flssure of the skin (rAoffas) at the bottom of the hoUow between the
ear and the mastoid process. Again, in some cases we see only the
posterior surface of the ear red and weeping, or covered witli crusts,
while in others the lobule alone is affected {especially after it has
been pierced for the insertion of earrings), or the skin of the concha
or other parts, with or without participation of the meatus. Tiie
peculiarities of eczema iu this region are, chieily, that in severe
an excessive swelling of the skin appears, so as to cliangc the
'hole shape of the ear, and to draw it forwards and away from ihe
and also that in proportiua to the small extent of surface
rect«d the secretion of eczematous fluid reaobes an almost in-

106

CnRONIC ECZEMA

L credible ainouut : constantly accumulating in Orops a« if from n
I squeeaed sponge, it runs together, spreads over the adjacent in-
I teguments, and, drying up, forma scabs, not only over the ear,
I but on the lobulej where they increase to long stalactiform
I crosfs {Darke stalactiforme of Alibert). Even in slighter cases the
1 patient complains of an impaired sense of hearing, and this is in-
I creased when the skin of the meatna ia implicated. As it swells,
I the passage is of necessity narrowed, and the secretion of the nume-
I rous ccraminons glands portly unites with the eczematoua Uuid, and

80 causes an otorrhoea, partly dries up, and may thus entirely stop
' up the meatus, and produce complete deafness. As this process often
I wis in only when the affection of the outer ear has begun to im-

prove, or is already cured, we can understand how our predecessors
I imagined that eczema of the ear should not be too quickly healed,
I lest temporary deafness at least should result by a metastasis lo the
I sense of hearing.

Eczema of the forehead is rarely seen alone, except when the
I result of some local cause, as the wearing of certain articles of

dress, and is usually combined with the same ajfection of the cheeks,

These parts are particularly liable to be nlfect«d in children with that
I form of impetiginous eczema which has been called Crasta taeUa
J (Milchschorf, Gourmes). It offers little variation from the ordinaiy
I symptoma of the disease — rcdncs?, swelling, moisture, and formation

of crusts ; but it is on the cheeks that the clear yellow crusts, like
1 dried houcy, or the gum cxude<l from a cherry-tree, are frequently
[ observed, and tliis it waa which led Alibert to the description of a
I Bpecial disorder under the name of Melitagra fiaveicettt. These
I crusts, after a time, acquire a darker olive hue, or even become
I black, cIiieBy from the addition t>f blood, and the disease was then
I called by Alibert Medtagra nigricans. Other fanciful writers have
I compared them with the skin which forms upon hot or ecaldcd milk,
I and named the affection the milk crust (Mdchborke). Eczema in
1 these regions usuidjy itches severely at intervals, and in consequence
I the scabs are loosened and the akin wounded by scratching. Ex-
I eept, however, the blackness of the crusts from the dried up blood,
I tliia does no permanent harm, and never produces scars ; so tliat
1 it is mere crndty to prevent the patient, and eapecinlty an infnnl,
I from relie\'iug the violent irrilntion by scratching or rubbing.

Eczema appears on the eyelids, and chiefly on the upper one,
Q the squamous form, often presenting red scaly [tatehes, tniiiivenocl

OP THE FACR.

107

single moist iissiire, wluch is the result of Ihe movements of the
III other cases the whole of the eyelid ia infiltrated, reddened,
nd covered with numerous red moist specks, which secrete a coa-
iderable quantity of fluid. This, as it dries, forms a thin, brown-
ioh ctUBt over the whole lid, and interferes so much with its move-
ments, that the patient can scarce open his eyes. This local variety
of the disease is usually the result of previous attacks in the neigh-
'iouring parts, but sometimes occors independently. It is often
Bcoropauied by an iiilhimmation of the conjunctiva (ophthalmia
ntarrhosn), probably by extension from the skin to the mucous
perabranc.
The skin of the nose from the glabella to its tip, together with
ut covering the alee nasi, often shares in an eczema of the fore-
i anil cheeks ; but it may be independently affected, and exhibit
1 varieties of the disease from its simple papular and squamous
9 io E. rubrum and B. impeliginomm. Just ss crusts may form
V. icicles upon the ear-lobulcs, so they may he observed on the tip
r aliD of the nose in cases of profuaely-aecreting eczema {Dartre
talae/ifi/rme). Moreover, the disease may extend from the integu-
iciit to the mucous membrane of the nostrib, and at List ntTect it
1 its whole extent. In such cases its ordinary characters arc modi-
1, the secretion being of a mucous chnractcr, and so abundant, as
I rcsctnblo tliat of an ordinary catarrh ; from this, however, it
iffcrs by iu great tendency to dry up, and thus to occlude the
ostrils. Beneath the crusts thus formed, there is frequently con-
ierable suppuration, which, though it contiimes superficial, and so
8 not destroy the mucous membrane, may, by absorption of the
s (or rather of a dwomposing puriform detritus) through veins and
lymphatics, produce inflammation of the checks and other neiglihour-
ing [lorts — an inflammation produced, as I have shown before (vol.
i, p. 340} by the local effects of pus.

Eczema of the lips is often confined to their red part, while in
rtber cases the skin is more widely affected, and frequently in cor-
Bliondenee with the estent of the orbicularis muscle. In the
r case the disease assumes either the form of E. iquamoaum, by
c constant ilesquamntioa of whitish or brownish fragments, some-
\ large as lentils, or that of E. madidam or rubrum, with
innatiou of numerous little drop? of fluid continually renewed upon
e lips. When this process is from time Io time interrupted, the
retion forma a yellow or brownish akin of varying thickness, and

108

CHRONIC BCZEUA

so closely adherent to the lips as to hinder their moveraeuts. In
obstinate cases the skin swells so much us to cnase both the lips to
pout (AmilSlptiHff) and thus increase the discomfort of the patient.
Eczema of this region presents, besides the ordinary phenomena of
vesication, secretion and scabbing, the peculiarity of numerous fis-
sures of varying depth, which c-onverge towards the mouth, and
become excessively painful when it is opened in speaking or eating.
It not unfrequently happens that during the continued rest of these
parte in sleep, the crusts accumulate in such abundance, that the
month cannot be opened in the morning until they have been re-
moved, cither directly or by the application of suitable emollients.

Eczema of the chin and neck offers no special peculiarities, and
we have only to remark that it often affects the nape of the neck
by spreading from the scalp, and then extends several fingera'-
brcadtbs below the hair. But since here the hair is neither long
nor thick, the disease is at once seen, and this may lead to the mis-
take of overlooking its original seat : careful observation will of
course show that the scalp is also affected.

Chroitic Eczema of lie Trunk.

Eczema may attack any part of the trunk, and presents the gene-
ral characters which I have already several times described. It is
only when it affects the nipples or the navel that peculiarities become
noticeable.

In the former case we may first remark that it is rare for one
nipple only to be attacked. Kloreover, the disease constantly
appears in the form of a disk, of which the nipple is the centre.
According to the extent and intensity and duration of the aiTection,
we find its further appearances to vary. The slightest form is
known under the name of "sore nipples" [wunde Bruiiaarcm),
and is a frequent occnnence during suckling. The nipple is
seen lo be deprived of its epidermis, and the cutis laid bare,
very red, swollen, moist, and excessively sensitive. If a sufficient
period of rest can be obt&ined, it becomcii gradually covered by
a crust, at first thin nnd brownish, afterwards tliieker, formed from
the dried up exudation, beneath which normal layers of epidermis
form, so that when the stab falls off, a heall.liy sarface is exposed to
view. But in other ch»« the secretion continues to form under the
crust, BO ae to break it into aeveral cracks and Essores, and, oozing

I cczcu

^^^ form!

I shape

I fuQCt

OP THE TRUNK AND GENITALS. 109

hrough these, to ptodace severe itching and pain. The disc&se

F often extends to the base of the aipple, and is accompanied b; a

I greater or less swelling of the surrounding skin, so that the nipple

iippears to be flattened or almost obliterated: and the raw and swollen

eczcmatons patch may spread over this adjacent part, as a disk

raised some Uoes above the surface. Here also the exuding fluid,

together with the pus here and there mixed with it, forms yellow

or brown scabs, covering these inflamed patches. This kind of

I may persist for a long time, in one or other of the above

. forms, and undoubtedly belongs to the most obstinate of its local

nriettcs. It nevertheless undergoes a complete retrogression,

|dtber spontaneously or by help of rational treatment, so that

Ttitilutianoi in iniegmm the nipple regains its previous

■hape, size and permeability, and becomes again litted for its

functions.

Eixemu of tho umbilicus takes a precisely similar course : often in
the ordinary form of E. rubruia or impetiginosum, without notable
swcUing of the skiu, while iu other cases the normally depressed in-
tegument of the navel swells until it may reach the size of a walnut,
and presents a convex tumour, raw, moist, and sometimes covered
with a crust, llie extension of the disease also follows the same
course as in the case of the nipple, although occasiouatly the disk
thus formed is not perfectly symmetrical, aud so the navel becomes
eccentric. As soon as the eczematous process has ceased, the swelling
^^^cradually disappears with the other symptomt, and the skiu of the
^^^Enbilicus returns to its original form.

^^^V Chronic Eczema of the GenitaU,

^^^K This form of the disease is very different in the two sexes ; we will
^^HlKrefore first confine our attention to it as it occurs in the male.
^^^ Here, as in acute eczema of the same parls,^ the penis and scro-
tum may be affected together, or either separately.

Chronic eczema of the penis rarely extends equally over the whole
surface of the organ, bat generally attacks the transverse folds of the
skin upon the dorsum. This may be demonstrated by drawing the
prt^puce forward, when the raised and red eczematous lines appear,
about a line in breadth and transverse in direction. 0[i relaxing
the tension, tlie skin resumes its former condition, and thus the

1 Cf., p. Si.

(HRONIC ECZEMA

;/,<Tmat»ui itrcukji come iuto contact and form au apjiarently coiili-
nutiui Korfncc On iho uhJlt surface of tlie petiis, we do not observe
thti pcauliarity ; the vrhole of the skin ia there red and inoisl, and
tki» (!tiQ(litioii usually extends as far forward as the fold of the pre-
((iicitit I have Dover seen a case in which a chronic eczema has
inrolved cither the inner burfacc of the prepuce or the glans. Not-
wlthttwiding tlie violent itching, and the consequent scratching!
■nil stiiunatmt, thi* variety is not marked by profuse secretion —
« )i>u-iillArity in which it ditfcrs from that affecting the scrotum.

Ktvcjiin of the iorotiim is remarkable for the changes of appcar-
mm it untltifgoei during a lengthened coarse. Thus the entire
•ilii may he deprived of epidermis, without much infiltration,
ttlillo ill (urfacu is covered with a profuse, more or less sticky, and
iilTniiiivo secretion. As the disease continues, it assumes the
churacters of eczema of the pema ; the natural promiuencea of the
ikiii being most all'ectcd, and appearing, when the scrotum is
ten*e, as irregular raised and fissured folds. Lastly, in aggravated
eases which have lasted for years, the whole skin of the scrotum
becomes thick and dense, and so increased m volume that only
tlie glans, or a part of it, is visible, the rest of the penis being
hidden, as in the case of au extensive scrotal hernia, or of Elephas
{Elephantiatii Arabum). In both the last-mentioned conditions
there is considerable moisture present, and this, as it dries up, may
no doubt produce an unpleasant odour of fatty acids ; but it never
assumes a milky character, as Fnchs seems to have believed Irom his
naming this form of eczema, Pachydermia scroti lactifua.

The same disease of the female genitals usually appears in the
form of E. rubram, and either attacks the tubia majora only, or
extends from them to the nymphce and vaginal mucous membrane.
It produces redness and swelling of the vulva, and hence patency
of the orifice, while the violent itching it occasions leads to fre-
quent scratching and numerous excoriations. In certain oases the
malady extends from tlie vulva to the adjacent parts of the tbigh)i,
and thence, either over the mons Veneris as high as the umbi-
licus, or down the inside of the thigh as far as the knee. Such
an extensive eczema presents an unusual aspect, especially wh«n
the skin It much infiltrated, and, at Jirst sight, might seem In
the inexperienced eye to be au affection of ijuite a different nature.

~ "1 the disease take a direction inwards, the iiymphn, B« wril
f lead to Ibo li.-il>lt of muturbatian, especisllj hi obUdreo.

Oe TUE TRUKK AND GEKITAL8.

Ill

co:
I un

^^m no

^ evi
I wit]

I per

k oftei

the labia majora, become swollen and prominent, and the mucous
membrane of the vagina is red, infiltrated, and covered with an
abundant secretion which resembles that of an ordinary BlenoTThira
vagina imotu. I must not omit to mention that this affection is often
miataiken for one of venereal or syphilitic nature, and that it may be
confounded, especially when slight in degree, with Prurilus vuIicf,
uncomplicated with eczema. Keeping, however, to the above positive

"icalions, and reaieiabering that neither syphilis nor any other
form of venereal disease can produce eczema, while, on the other
band, the latter may, by its extension from the skin to the
mucous membranes, give rise to excessive secretion, we shall have
no difBcuIty in cases of undoubted £. vulva in ascribing the con-
comitant blenorrhiea to the same cause; unless, indeed, there is
evideDce of its having arisen from a specific source of infection.
Nor will it be difficult to distinguish tbe symptomatic itching
without obvious affection of the ekin, which usually accompanies

iorders of the uterus and ovaries, from that which is produced
ly tbe infiltration of the skin in eczema.

An allied local variety of the disease is that which nffeda the
penmeum and anus {E, perinaale, E. hiemorrhoidale) : it does not
differ from the general type of eczema, is usually found associated
with the preceding form, and specially affects the fold of skin which
stretclies along the raph^ between the genitals and the anus, When
the akin immediately around the anus, which is normally drawn in
numerous folds by the action of the sphincter, becomes red and
swollen, deep fissures [fhagadea) are formed, which reach through
the epidermis to the subjacent cutis, and resemble those observed
in cci^cma of the lips or hands. A considerable amount of
secretion exudes from these cracks, and causes not only pain,
but such excessive and intolerable irritation, that the patient is
compelled to rub and scratch the affected part, aud even the
mucous membrane of the rectum.

In severe cases, the anus assumes the form of a more or less
prominent tumour and the mucous membrane becoming exposed,
there ensues a partial prolapsis ani. The extruded parts may
further become cedematous and hypcrtrophied, and exude a large
amount of fluid, which dries into scabs and covers the affected
region to a greater or leas extent. Here again it may not be sujwr-
fluous to repeat the remark made above, that these parts also ore
often affected with simple pruritus without eczema, as a result of

112

CHRONIC ECZBMA,

disorders of the urethra, the bladder, the uterus, or the rectum.

So that ire muat not assume &1I itching of the periuKuiu and anus
li'pend upon eczema, but only admit it when a careful eiami-
I nation of the aifected parts has shotru the existence of its cbarac-
j teristic lesions.

Circumscribed Eczema, £. marffinaium.

I apply this name to a peculiar form of Eczema, which i» distin-
guished from all others by its constant localization on the inner
surface of the thighs, the pubea and the buttocks; by its centri-
fugal progress and simultaneous involution in the centre ; by its
well-defined raised border eshibiting the moat marked appearances
of the eruption ; and lastly, by its almost exclusive occurrence in
the male sex, and especially in shoemakers.

Observation of the conrse of this malady teaches us that it always
begins on the inner side of that tliigh, with which the scrotum comes
in contact, and hence most frequently on the left. Here there ap-
pears first a red, raised and circular patch of nearly the size of a
sixpence ; it itches, and is scratched, and thus becomes covered
with minute punctiform excoriations. Soon after the centre becomea
pale, and only the periphery retains the above characters. Here we
observe, in succession, papules, vesicles, excoriations, and after-
wards small brown or black scabs, formed by the dried up exudation
and the blood which has oose^ from the scratches. While tlic
centre heals the circumference s|)reads, so that the original patch
I will reach the size of a crown-piece, or even of the palm of the
hnrnl. It then becomes obvious that the central parts have become
darker in colour, eo as to contrast both with the surrounding red
circle of eczema, and with the healthy skin beyond. ^V^e may ob-
serve here and there single minute pomts of fresh eruption, even
in this central pigmented region; but the chief signs of eczema
are limited to the outermost margin, and the further the centri-
fugal extension of the disease ia carried, the more completely are
the}' limited to this narrow advancing edge. It is rare t« find only
a single patch of this form of e«zema on the thigh : there com-
monly appear fresh outbreaks close to the first, which run a pre-
. cisely similar course; or the same affection appears upon the
[ corresponding surface of the other thigh, so that both become
I gradually and synunetrically covered with uuineious circle* of

K. MARGINATCM.

118

Bzi'tna of various sizCj which extend in all directions over the
rent and back of the thighs, towards the putcs and the Vne^.
Kionld Lho progress of the disease continue uuchecked, the ad-
tncing circles may at last meet in the hypogastric region, and
leh fla high a* the umbilicus, while they nnitc again belund o»cr
e buttocks.

It may be observed from the first, that the separate circles, as
Ptiieir gradual extension brings them into contact, coalesce at theae
[ {mints. And here we see the uppliciition of the general law we
have frequently had occasion to obsen-c," that when cutaneous
diseases spread centrifugally from sc-veral points, the effects they pro-
duce disappear as soon as they touch one another, and give place to
a healthy surface, or to one only marked by increased pigment. In
' nisequence of this check to development, the eczematous circles
only extend when they do not meet with others, and thus
I serpentine margin is formed, composed of as many segments
circles ns there were patches at first. ^Vhcn a double £.
utyinaium has spread until both sides join above the pnbes in
font and over the buttocks behind, a similar coiJcseence will take
place at these points, nod so a great circle will be formed which
may be thus traced : beginuiug at the umbilicus, wc find it passing
over the hypogastric and inguinal regions to the front of the tlitgh,
I running down two-thirds of its length, and lh«n turning to its inner
jface, ascending to the gluteal region, and hnally completing the
■ (orcle over the sacrum, by joining tlic corresponding eruption of the
[ opposite side.

When a patient thoa affected hes with both thighs abducted and

' flexed, the whole extent of the disease is visibh; at a glance, and it

!s then seen how remarkably exempt the penis and scrotum remaio.

When E. narpnaima has lasted for some time, fresh eruptions

of quite simikr character appear in other regions, and first on the

(sfadomcn or thigh, or over the sacrum, near the parts originally

ittackeil. But I have remarked afterwards, and often not until

I has healed, the same form of disease in the most vcirious

^rts, tba back, the breasts, the back of the neck, and (in one

utance, uccurtmg in a woman] the extremities. In these ca.'sea

c malady preserved its distinctive marks, an eczematous border of

piiform breadth (about a line) and n darkly coloured surface within

: while in those of the longest duration and greatest extent there

' Cf., vol. i, p. 387 i u, p. 7.

114

CHRONIC ECZEMA

were never added to these any further changes, such ns formation of
pustules or of ulcers. When a euro is effected, either without
interference or by the aid of suitable treatment, ail the sj-mptoms
entirely disappear, and only leave behind at first tt slight increajse of
pigment, wliich gradually subsides ootil there remains no trace of
the malady — no scars, no thickeniug, no bleaching of the skin.
Nor is this malady more pronn to relapses than other forms of
eczema; and, indeed, rarely returns when the causes which
originally produced it have been removed. I was long in doubt
whether the name Eczema should be here applied; and after I
became convinced that this is the most advisable title, I was still for
a time undecided whether syphilis was not the cause of the peculiar
characters of this variety, in which case its full description would
be E. gyjihiliiicum. But 1 am now fully convinced that neither
this nor any other form of eczema owes its origin to syphilis, that
there is, in fact, no such thing as a syphilitic eczema. In speak-
ing of the etiology of eczema I shall have occasion to treat this
question more fuUy.

Ectema oftke lend ofJ)»nU {E. articvlorum) .

It is well known that many cutaneous diseases appear at the same
time on symmetrical parts of the body, but the explanation of the fact
has not been discovered. We often see psoriasis, for example,
occupy the kuees and elbows, and sypliilitic affections the palms and
Boks, while the rest of the body remains exempt. We must view in
the same light the occurrence of eczema Umited to the llexor aur^ea
either of all the jomts or of a few, and those usually on both sides of
the body. Thus it is rare for this disorder to attack the akin of one
axilla without that of the other participating in the process. When
it invades the bend of the elbows, the hollow of the knees is
frc(iuently found affected as well, and so with the wrists and aiiklcs.
The only eiception to this rule is the skin of the groin, which doca
not, in relation to eczema, correspond with the ficxor surfaces of
other joints, but rather with the adjacent i)arts of the genitals and

\ thigh.

One of the peculiarities of this form of ecjiema is diminished b

1 uf the adccted joint, which is generally held slightly Hexed J|
patient, and that so tirmly and constantly that it cannot he t\

or THE JOINTS.

IIB

I vilhout great jiaiii, ot is even completely immovable. In cases of

peczctna of the hams the patients never walk upright, but always

■irith the knees bent at a more or less acute angle ; and in the same

f UTection of the elbows we observe a similar position of the arm and

forearm, especially when the secretion has dried up into crusts, or

tlie skin ilself has become considerably infiltrated by the progrt^ss

of the disease. This immoblhty increases of course with the

L duration of the malady, but most when it spreads from the flexor

mto the cjitcnsor surface of the knee or elbow, and thus compels the

' patient to avoid bending aa well aa straightening the alTccted hmbs :

ihis condition may often be mistaken by an inexperienced observer for

nkylosis.

The natural etTect of the painful movements which must of

L necessity be made in these cases is to produce cracks and chaps,

issurea and rhogadcs, wliich always preserve the direction of the

'lines and furrows observed ia the healthy state of the affected

joints. These Essures will correspond in deptii with the seventy of

the attack, sometimes only dividiiig the cuticle, sometimea reaching

to the true skin. In the former case they appear as red shining

I streaks, out of which the eczematons fluid exudes, while in the

I latter blood is mingled with it and dries up into dark-red or blackish

^«iusts.

These peculiar characters have induced French authors to apply

■ the name JCczh/m /'cntlilU (nssuie-d eczema) to this variety. 1 do

l&ot, however, see the necessity of using a special name, since the

■peculiarity of its form is suQicietitly explained by the onatomicul

lations of the parts.

Eczema o/f/m hands and feet {E. manuum, pedum et di^itorum).

Eczema of the fingers and toes presents characters similar to
« just detailed. Here again vc meet with fissures of greater or
csa dqith which run across the joints of the phalanges on both the
flexor and extensor surface, and also over those of the metacarpus
and of the wrist. While eczema affecting the larger joinla occasions
severe pain and limits the mobility of the limbs, the same effect is
~ idoced to a much greater extent in the case of the hands and fingers,
i their power of movement is reduced lu a minimum. These
GS, however, ore not the only elTectfi of ecscma upon the

CHRONIC KCZEMA OF THE LEGS.

I Rtid feet, and we shall here again be able to observe its
1, and those of a very pronounced kind. Tlina, for
!, B. siinjilex sen vesiculotum will be represented by a great
Wei of well developed, t«nsely-filled vesicles, which either spread
over the whole palm, or are limited to the fingers, or even to smaller
parts, as to the tips or sides of the fingers, to the flexures of their
joints, or the back of the hand, and so form such sub-varieties as
E. diffii&rum, E. palma manus, E. dorsi mania, &c. The thick cuticle
of the palms and soles allows exudation to collect beneath it for a
long time, and hence favours its transformation into pus. Accord-
ingly, the first result is the development of pustules, which in their
turn lead, on the one hand, to swelling of the skui and lymphatic
iuflaramation, and, on the other, to the formation of thick crusts.
While we find E. implex and E. mpetiffinosum represented by Ihwe
forms, successive attacks of the disorder produce the aivpearanees
proper to E. ru&rum t. madidani, and afterwnrds \a E. s^iamomnt,
according as the red and weeping surface of the former, or the red
infiltrated and desquamating patches of the latter present them-
f selves.

Eczema of the feet and toes pcoduces the same appearances as
Kthat of the hands, which it usually accompanies, and when at all
1 levere renders it impossible to walk or even to wear stockings.

Eczema of the Ugt {E. crurum ». ertfemitatwn).

A pecuhar importance has been always ascribed to eczema of the

I, and both its symptoms and causes have been held to distinguish

t from the other forma. A special and weL-known name has been

3 given it, that of Eluxtu lalinxa. And, allbough I do not ugree

a viewing eczema of the legs as a peculiar mabdy, but must regard

t as essentially the same in its etiolofiy and its characters with the

1 varieties of this disease, 1 still a<Iinit the propriety of consider-

tog it under ft special heading. For not only does the locality

reduce certain modifications in the general appearniiccs of eczema.

But it frt'fjuently occurs here in consoquenct- of olbiT and more

tensive diseases of the »kin ; it may thus |ml on the chnracton fl

I peculiar malady, and conceal those which on accurate obscrv

HcteTmiue it to be an eczema ojtfima formte. 1'bc Rrst jiccal

D be uotioed is that the skin of the lower limb? tv fn-mnn

D1A0N0SI8 OF ECZEMA.

117

tn conseqnence of varicose veins, either with clironic dermalilis,
vith infiltration of its tissuesj or ivilU ulceration, and, aa results of
these, witli cicatrices or with patches of dark pigment. i''rom the
■Bine cause may ensue transitory or ^lersisteut itdemu, aud the skin
and subcutaneous tissue wiU in time become thick nud tough. Now,
when eczema attacks a part already altered in oue of these waya, it is
not suqirising to find it characterised at one time hj excess of
pigment, and at another b/ a peripheral distribution around the acar
of an old varieo»e ulcer, a form which is often excited by the
applicalion of strips of plaster. Then, agniu, the increased size of
the limb produced by cedcma anJ pachydermia, give an apparently
increased extent to an attack of eczema, of which it ajipears the
result rather than the antecedent.

Some would fain make these variously modified appearances servo
to form so many stages of this fonu of eczema. But although many
degrees of infiltration may be observed, there is no such strict line to
be drawn between ihem as would j ustity us in laying down a deEmte
number of gradations. Nor do 1 think such a subdivision woald he
of prncticiil advantage, the important fact for t'lc dermetologiat and
practicsl physician to understand, being the great thickening of the
skin which accompanies eczema of the legs and distinguishes it from
other local varieties. Any one who is familiar with ec/ema i(«clf
and knows its gnuhttioua from £. simple^: seu veskulosum to E,
intfetiginosum and E. squataomm, w:tl be able to recognise it on the
lower extremities as easily as on many other parts, such as the bauds
or the elbows, and more so, because of the very pronounced character
it here commonly assumes.

Diagnosis. — I- follows from the description above given of the
coorso of eczema (hat its appearance is not at all times the same, and
we must thcrefoio take in a conaiderable number of symptoms as
diagnostic characters. In one case a number of vesicles either
discrete or collected in heaps (in Uaufen) — never in groups — denote
an E. nmpUx, while E. papuhium ». lichenoides is characterised
by papules, mingled with vesicles or alone, separated from one
■mother or heajied together, of the size of millet seeds, with shining
furface and fluid contents.

E. rubrum, ogain, is denoted by its red and weeping surface of greater

less extent, or by its numerous miliary deep red and moist spots,

may eithtr be regarded as the bases of previous vesicles, or as

dementaiy stage of E. riArum io its more extended form ; for

[ this appears to consist of n great number of snch minme
I moiBt points coming into contact. Iiiasmnch ns the contents of the
vesicles of E. simplex or the papules of E. papuhiim, and tlic
exiided fluid of E. -ntbrum, become in course of time purulent, and
the pus dries up into crusts, we most regard E. impetiginotum ns a
result of tbe above-Tuentioned forms, and ehall find it usnally
associated with one or all of tbein. When scabbing lias taken pluce,
a diagnosis of impetiginous eczema cannot be made unless there
neither appear the papules and vesicles of the other forms around
the crusts, nor the red and moiat surface of E. rubrmn, on their
removal.

Lastly, it is very ea^ to distinguish E. aquavwmm {Pifyriatis
ruira) with its red, slightly infiltrated and extensive surface covered
with minute scales, from other cutaneous diseases, as psoriasis and
lichen, which resemble it.

All these varieties of eczema are accompanied by more or less
escoriation ; that is to say, the cuticle ts torn off by the violent
scratching to nhicli the severe irritation of the disease leads. But
all attacks of eczema do nut itch alike, and the irritatiou varies from
Ume to time even in tbe course of the same attacks, sometimes alto-
gether disappearing for several days : hence tbe results of scratching
will also present every gradation, from the slightest white, dusty
I line to a wound deep enough to lay bare the cborium.

In order, however, ia make more clear the resemblance between
these forms of eczema and certain other affections, we oifer a brief
sketch of their differential diagnosis.

To avoid confounding E. timplex «. vetieulogitm with kerjia, we
must bear in mind the peculiar grouping and locality of the latter
eruption, its acute and regular (tjpiach) course, the absence of
itcliing and tbe burning pain. Monrover, herpes does not recur, or
at least only after long inl«rval», as in the ease of //. ins, and this
usually does not return until a year has elapsed.

In considering the distinction between eczema and mtliaiy ve»icU»
we roust remember that wc have only to deal with the form described
nbovc fvol, i, p. 384} as Miliaria crgtfallina, since the so<caIlcd
M. nthra ei alba have nothing in common witJi this affection, nnd
mu*t, in fact, be regarded simply as varieties of ttczemo. True
miliaria is sufficiently distingnwhed from eczema by its affecting
i special parts of ttie body (tbe breast ot abdomen), nnd that in
I pronps, white ecacmntous vesicle:* usually occur in gr.^it . :■ ..'.■

DIFFERENTIAL ItlAONORIS.

119

. A small surfiicc, ami are Uius crowded iuto hcnps; by loiliary
\ ernptions bring niiattciided by the cbaracteristic itcliing of eczema, or
I by any other uiijiIeaEant sensation; by the former afiectiott being
} almost alvays associiitcd with some febrile coudition, and by its short
h course, iu contrast with the absence of constitutional disturbance and
the long continuance observed in eczema.

Aa to tcabiei, it is well known that vesicles, wLich are not in
themselves distinguishable from those of eczema, occur where the
young acari lie, and beside the burrows of the females. But since
several acari do not burrow side by side, we never observe heaps of
vesicles tonehing each other, and thus their separation and their
appearance on the favorite haunts of the parasite {tbe hands ond
feet) serve, if not as characterisfica of Bcabics, at least as an
Argument for its presence rather (liau for that of eczema.

The papular form of eczema, often called lichen, will bo readily

enough dislinguialied from the ad'ection I n^urd as lichen, if the

point insisfcd upon in its definition above (p. 52) be steadily kept

in view. The chief characteristic of the papules of true liclicn is

Hint in their entire course they undei^ no tniusformation to

vericles, pustules or orustfl, but from first lo last preserve the papular

form unchanged. In the case of eczema, on the contrary, we see ita

papules always filled with fluid, many even while they still appear

hard elevations not bigger than millet-seeds; so that they readily

become ordinary vesicles aa their epidennic covering becomes

thiuner. Further, we observe that lichenous papules are from their

cbrouic course always covered more or less tliickly with scales, while

those of eczema have a smooth and shining surface; because,

depending upon the sub-epidermic moisture, they cither dry up when

the malady goes back or become vesicles when it continaes its

course. Lastly, it must not be overlooked that the vesicles of

I eczema rarely occur alone, being usually associated with other

' eczematous products, while the characteristic papules of lichen are

only accompanied by others of the same kind. The forms of lichen

j described by Willan as L. auntie and tropicus (prickly heat) must

I evidently rank as varieties of my JV. papuloaum : indeed tbey have

1 been regarded both by earlier am! by more recent writers as rather

[ Badamina or eczema than lichen.

ruirum ten madidatm can scarcely be confounded wilh any

r malady at the present day, if its characteristic appearances be

~. But tbe old notion of an " ulcer" of the skin, as we find

ISO

ECZEMA.

that leaion described and figured in a work of Dr. J, N. Bust, vhich
appeared at Berlin as late aa i9+2, and aa it is still employed by
some living practitioners, makea it necessary to lay stress upon the
great difference between a moist eczema and a tecreting euCaneout
[ nicer. While in the latter case a loss of substance is always observed
which ia only slowly repaired, there is no such thing ui eczema; the
cltorium is intact and only hypencmic, while the cuticle aUine is ill-
■ developol. Accordingly i.'. rulirum produces neither depression nor
I marked elevation of the affected part, but only swelling of the cutis;
while every ulcer of the skin must, by the loss of cliorium, cause
more or less deep depressions, or in other cases raise its surface above
tliat of the surrounding skin \>y eKuberont granulations. Careful
observation of the part also shows that in every case oT £. rubrtm
there appear numerous, pnnotiform, intensely red spots from which
minute drops of moisture exude (these spots, in fact, Jjeing the
bases of vesicles which liave burst or been oilierwisc destroyed),
i whereas the floor of an ulcer is either uniform or uneven and
granular, but never presents the appearance just described. More-
over, £. rabTUm iichas violently, and thus leads to scrateiiing
and excorifltions, while this sensation is replaced by pain in the cose
I of ulcers. And if, lastly, we renjember that eczema heals without
i leaving a scar, while tiiceration ia never followed by complete
regenerafion of the cutis, wo shall surely have adduced sufficieot
marks of rJitTcrence between the two diseases.

On the other hiuid M. imprfi'ipn»9«7ii cannot be distinguished from
J Inpeligo of nuliiors, ejjpccialiy from those forms which begin with
I Bcborous and psydracious pnstulps, I have therefore preferred to
1 consider as really identical with the impctigiiious form of eczema the
I following of its rivob ; viz. — Wiilau's Porrigo favona (plate 4a),
I J". AireJfl/i> of the face (pi. 41), P. larvalU (pi, ^-j). Impetigo actiidda
J (pl- 36). I- tparta (pi. 39), /. figurata (pi. 3,1) ; Alibcrt's Tdgne
I granulee (|)lanche a), T. vinqueuse (pi, 5), VuHre cruti^cee tlalaetu
^/orm (pi. 17); Wilson's Impetigo faciei (fasciculus 11}; and lastJy,
the several forma of disease described as different species of im-
petigo by Biett, Caaeuavc and Scliodel, and by mo»t living French,
English and German dermatologists. Althooxh the jiit<tilication
of this view haa been more tliaa once already bniught forward in this
work, I may yet n-pcat here that any observer may eonvinci^ him-
«df of the identity of these M-callcdvsrietics of impetigo with impcti-

DIFFERENTIAL DIAGNOSIS. 121

ginous eczema by removing t.he yellow or green gummy crusts/
when the subjacent red and moist surface will be at once recognised
as the characteristic appearance of E. rubntm ; aud if the process be
further watched, the secretion which accumulates on the exposed part
will be seen to form puriform layerSj which at last dry into crusts
like those at first removed, and thus reproduce the appearance of
impetigo or E, impetiginoaum.

The form of disease which may be rightiy called PUyriaais rubra,
but which I have for the first time named E. squamoium, demands
special notice here to justify my view of its nature, aod to distinguish it
From conditions wJiich resemble it. Referring to p. 69 for my general
remarks on Pilyriaah rubra, 1 may here adduce the well-known fact
that the early stages of an attack of eczema which afterwards goes
through the regular process of vesiculation, weeping, pustulation, and
acabbiug, are frequently marked by merely a red, slightly inlillrated
oonditiou of the skin, accompanied by minute desquamation. And

. what is still more instructive, we may often observe, as the last stage
of an intense eczema, after the scabs have fallen off and the moisture
disappeared, a red and desquamating surface. It is obviously much
better to regard these appearances at Ibe beginning and end of an

f eczcmatous erupiion, wiiieh c'early form part of the whole process,

I Bs bemg forms of eczema, ratner than to say, as our forefathers did,
that an eczema developed itself out of PU^riaaia rubra, and that

I after this bad run its course Pii^riaaia rubra occurred again as the

I final stage of the attack.

If, then, my definition may be regarded as well established, the

I question remains how we are to distinguish cases of E. aquamosvm
from those of Pttoriasis, Lichen, Lupus erythematoaua, &c. Attention
to the characteristic marks of lichen aud psoriasis will prevent all
chance of confounding them with eczema when they occupy extensive
regions; but in a few cases it becomes really difficult to decide
whether a localised affection is a case of E. aquamogum or no, and
most of all when it is confined to tlie scalp or to the hauda or feet.
The points to be looked for are the vesicles, crusts and moist patches,

I which rarely fail to accompany true eczema, to however small an extent,
and the peculiar and sharply defined eruptions of psoriasis and hchen.
.:;

■ Tbe formation of tbese crusts mast ilill be in progress ; for if it hu ceased,
rtlieir removal nrill onl; expose tlie sahjacent skia ia the condilioQ or £.

F-CZEMA.

Moreover, a comparison of tlie slight swelling and deBqiiamation of
t B. sqitamotum with the intense swelling anil redness, and profaso
I fonnation of scales seen in [jsoriasis and lichen, and of the continual
I changes of appearance in eczema with the uniformity of psoriasis,
I will rarcl/ fail to clear up any do«hts as to diagnosis in course of
I extended observation, if not at the 6rst glance.

PnoGNOSis. — We may in general expect a much more favorable
I resnlt in eczema than in many other chronic diseases of the skin ;
I for although relapses frequently occur, they are not so regularly
observed as after psoriasis, prurigo and lichen. The varieties of eczema,
however, differ among themselves in this parlicniar, Tlius acute
eczema (if this title be merited) will return perliaps twice or thrice,
but after this will nsnally either disappear entirely, or at least be
I absent for many years. In the chronic form much depends upon
\ the region affected. Eczema of the scalp, or of any otlier part
provided with hair, is certainly as a nile peculiarly obstinate, but
when once got rid of it rarely comes again. Eczema of the face in
children (Cnisla lactea] runs in most cases if not an acnte, no very
chronic course, and is mostly over in the space of a few weeks,
without recurring for the rest of the patient's life. "When, how-
ever, it has lasted some months, the character of the disease is
sliown to be peculiarly obstinate, and it then commonly returns at
diiferent times. When eczema appears for the first time in an adult
it usually assumes the impetiginous form, and rarely lasts longer than
a few weeks, disappearing, however, only to return on the slightest
I provocation. The disease is especially tedious when it affects the
I lips, the eyelids or the ears ; and upon the trunk a similar obstinacy
I and tendency to relapse are observed in ec/ema of the nipples, the
navel, the genitals and the anus. E. manjinalum belongs to the
I more easily cured and less frequently relapsing forms of the
I disease. When the flexures of joints are attacked, suitable ttent-
I ment is as a rule successful in a short time, but the malmly will fre-
I quently recur ; on the other hand, eczema of the legs needs a longer
course of treatment, but when properly carried out, and when
external influences do not continue to act injuriously, its return is
quite the exception. Of all varieties of eczema, the most obstinate
and lUfGcult to cure is that which attacks the fingers, and here it is
I also peeiiliiirly prone to recur. Of course eczema wliich is the result
Lof external causes, such as beat and cold, soap and other irritants,
tiction of clotlie* and pressure of ligatures, will the more readily

PROGNOSIS. 123

bpse the less able the patient is to avoid tliese conditions;

"lenoBe tliere is no fear of the affection returning of itself.

There carij naturally, be no certain prognosis of eczema whicli is

wntaneous, — that is to say, arising from causes of which we are

piornnt. Observation shows that many such cases are ended with a

igie outbreak, wbile others return from time to time during many

ears, or even for the rest of the patient's life.

I can by no means support from my experience the theory so often

maintained, that the cases which occur in scrofulous, rhacliitic, tuber-

■ colar, and otherwise unhealthy patients, are distinguished from those

iiich occur spontaneously or from external injuries by the persistence

( their course in spite of remediesj and by their liability to return ;

I have sometimes seen, in children as well as in grown persons, an

. a healthy subject exeeediugly obstinate, and the same in a

J case recovering with rapidity. We must, however, not

jet what has been already mentioned more tlian onco in these

es, (hat when a patient snfferiug from eczema is attacked by a

t and violent disorder, whether or not accompanied by fever,

! result is often that the original affection is subdued or even

y cured. Tlie converse is never true : the healing of an old

tabliiibed eczema never lends to other maladies, So that the

fStcmation which has been described between eczematous and

ptber diseases only occurs when an eczema disappears at the

hvDsion of an acute attack of another kind and returns when

t is [last ; the first term of the scries is always the appearance of

cw malady, never the cure of Ihe old one. If some physicians, as

uneya, have not the courage to treat an eczema locally, when an

betinate ophthalmia, a chronic dyspepsia, or any other important

rder has disapjwnred since its occurrence, because such eczemas

L^ apparrn/ltf vicarious to the former diseases," I would by no

s encourage them to do so, since any subjective opinion should

espectcd, I may however be allowed, depending solely upon

n exi>erience, to assure with certainty any one who has not

■ formed subjective opinions, that neither ophthalmia, nor

ronic dyspepsia, nor any other important disorder has ever been

1 by a chronic eczema, whether spontaneous or artificially pro-

I have, in fact, made this remarkable observation, that physicians

e talked of metastases to internal organs, of alternations, and of

r of curing chronic diseases of the skin, eo long as the

means of curiDg eczema were iinknown to lliem. Aa soon na they
could convince themaelvea of the suceesa of any nnti-eczematoua
treatment, they were the first to ahaudon tbeir former doctrine, and
became my most zealons discipl«s. It is not more iinpossible to
mitigatej to remove or (as it has been expressed) to bring out by
derivation, a disease of the brain, the lungs or the abdomen by help
of irritating applications to the skin, than it is to produce an iutemnl
disease by curing au eczema. All that has been taught to the
contrary is pure imagination, the result of inaccurate observation and
false views of the natural processes of the human body. When it is
brought forward in alleged proof of the derivation theory that in
variola the fever subsides as soon as the eruption appears upon the
skin, or that acute symptoms ore relieved by the appearance of
herpes, or that true raetatastic deposits in the skin in form of boila
and abscesses are regarded as favorable crises, we must in tlic first
jilace remember the difference tlicre is between such spontaneous
eruptions or deposits and those artiliciaily produced ; and again, it
must not be overlooked that the cutaneous eruptions of variola and
heri)es may well be regarded as only parts of the general process,
and not as being evacuations of a materia peccaaa — oUierwise we
should desire an abundant rather tiiau a scanty eruption, whereas
practical experience teaclies precisely the reverse. In the same way
tiie assertion that in curing long established eczema it is necessary to
employ purgatives, " so as not suddenly to break ofl" the excretion to
which nature has become accustomed, but to replace it by another
artificial excretion," may be disposed of aa an ungrounded theory,
and an arbitrary explanation of physiological processes. Thus we
may finally return to the statement t'lat every attack of eczema may
and sliould be cured as quickly and as well as possible, and Liiat not
tbe slightest injury will ever result. If we have anything to regret, it
is that our remedies are still too slow in operation, and that we are
not always able to prevent recurrence of the disease.

Akatomy. — The changes produced in the skin by the eczcmatous

process vary in accordance with its length. When its coarse is acute

I in character and short in duration, swelling of the cj)idermic cells is

more lOArked Uian serous infiltrnuiou of the oiioriumj and thus wc

observe a large development of papules and vesicles, and subaeqncnt

exposure of the rete mucosum by destruction of thii aupcr{ici;il layrrs

I of cuticle, while icdenin of the cutis is but slight. £nch of the

kveaides is formed by a drop of fluid situated between the layers of

ETIOLOoy. 125

'- epidermis, so that their formation ia only possible when at the begin-
ning of tlie mdady there are enough of these layers to resist the
preasure of the fluid. But when the eruption of vesicles has lasted for
. Mrae timeand one layerafteranotherhaa been washed away,the fresh
fluid meets with no homy covering, and after breaking
rough the delicate newly formed layers of e]iiUermia can reach the
rface without hindrance. The minute red points often observed in
a of E. rudrum are the representatives of vesicles wHch have thus
plost their epidermic covering.

When eczema has lasted longer, changes of another kind gradually
appear in the whole of the slin ; the cuticle becomes darker in tint,
its lines and furrows are deeper, and the ridges between tiiem harder
and more prominent ; it feels rough, dry and crisp, while the |>apilln!
are enlarged so as to become visible to the naked eye, and the cutis
appears harder, more close in texture, and often hyperlrophied until it
reaches. several inches in thickness. In this way the integument
of the lower limbs may often become so thick during the course of
ehrottic eczema that the appearance results which is known under
the name of Pachydermia or ElephanliaaU Amlum,

Microscopic investigation has n»t yielded either to myself or to
Iflther observers, among whom I may again refer particularly to Gustav
Ifiimon, more results than have been already mentioned in describing
pthe contents of vesicles generally (vol. i. p. i i). The opinion that has
L liere and there appeared that amyloid degeneration lies at the root of
K^ronJc eczema may, 1 do not deny, hold for the cases adduced in
' iUustration, but cannot be allowed to apply to what may be univer-
' inlly looked for.

Etiology. — ^The method which our predecessors and contemporn-

I ries have adopted in investigating the causes of disease has in no way

tnswered the just demands of science in this particular. The

Iriraslom is aniversally sanctioned for the physician to apply to the

Mtient or his friends and ask of them to inform liim how the iUness

tame about. The tirsl step in the investigation is to find out the

(lustory ; the doctor informs himself of the patient's temperament,

I former illnesses, his virtues and vices, his age and religion ;

rashes the same inquiries hack to his parents and grandparents, and

flB finally satisfied to draw his conclusion as to the cause of the

disorder from the information he has thus obtained. Now though I

would nut maintain that every statement of a patient must be abso-

lotdy antrue and worthless, and should therefore never be believed.

126

ECZIUA.

1 1 am coavioceJ that ve can onl^ oae the conclusiom of a patient
when, and in bo far as, they rest opon &sceitaiDabIe facts, and do not
contradict other experience and observation. We must ncTcr forget
that every patient, even the most educated, is so stronglj influenced
by his own pre-conceived opinions, his traditional wrong views and the
prejudices of the country he lives in, by hia friends and by the im-
pressions of early education, that all these pbty a much greater poirl
in what he tells as than do liis own Beusations.

This explains how it is that patients in telling their story always
mix up their pains and aches with the remedies which have been
used, the supposed causes of the malady and the opinions of otlier
doctors and of their acqoaiutane** ; and it is very difficult to con-
struct out of this confused narrative a coDsecutive and logical state-
ment of facta. If this is tlie case, it cannot be denied that the
assertions of a single patient must be of very subordinate value to
the observant and scientific physician ; and that the concurrent
testimony of many similarly affected persons, in combination with
accurate and prolonged observations of years, can alone lead us to a
really scientific etiology.

This result we can only reach by aid of esact statistics; we must
inquire under what conditions certain diseases cotutantlif appear, and
what are those which, on the contrary, exclude them. Nest should
come observations of the conditions whicli only render the occurrence
of a certain disease possible, bat do not, like the first, make it a
necessary consequence. We must add to this the results uf experience
as to the concurrence of several morbid conditions wliich, by their
freqnently simultaneous appeanmce, render some mutual rehttion
probable, although we may not yet be able to supply the intermediate
steps between cause and effect.

The necessity for such an investigation of long*continaed observa-
tion and extensive experience, founded on sufficiently large materials,
is quite obvious; but freedom &om prejudice and love of tnitb
arc scarcely less important quaUtiea in weighing the result of
statistica.

The materials I have at my disposal for working at the etiology of

eczema consist of more than 6000 cases ; the yearly number of

^patient) treated for this disease in the general hospital uf Tiouia

bg officially ilatexl at more than 300.

Jt oci:urs inure oftcu in uiaks tlnm in females in Uie proportion of
I to one, my 600a patienta compraing 400Q uea utd 3000

ETIOl-OOY.

127

women. Aa children are not admitted into the hospital under four
jrears old, there are none of the 6000 cases below this age ; but every
other period of hfe, even the very advanced, ia well represented. It
is from tLe conscientious use of these materials as well as from the
experience I have acquired during more than twenty years in other
hospitals and in private practice, that I have arrived at the following
conclusions as to the etiology of eczema which I will now detail.

The influences which produce eczema may be divided into the
kuown and the unknown. The former are either ( 1 } those which are
external to the body and produce the disease by direct local action,
i. e. idiopathicalty ' ; or (2) those which have their seat in the
organism itself, and frequently, if not constantly, give rise to tiie
same disease.

Of external agents, some produce eczema by tlieir chemical com-
position, some by their temperature, same by their mechanical
action, and others by a combination of these. All of them cause au
eruption of eczema, more or less, under all circumstances j that is to
say, witbont fail, if only allowed to act on the skin long enough and
intensely enough.

The chemical trritantt especially alter the nutrition of the
tissues of the skin at the spot on which they work, and cause collec-
tions of fluid under the cuticle and HweUing of the sebaceous glands.
To this class belong several substances, chiefly used medicinally,
which were formerly often applied {and too much so even now) for the
iittainment of certain objects by the revulsive method of cure.
Such are croton oil, tincture of cantharides, blisters, tartar emetic in
solution and in ointment (fny. AuleHritthi), mezereuui, oil of
turpentine, ointments containing turpentine or other irritiint oleo>
resins, white and black hellebore, mustard [pleum sinapu), caustic
alkahes, sulphur (especially as a fumigation) and certain of its pre-
)>&ratious, and lastly, those of mercury. To these must be added leys,
soap, dilute acids, various dyes, and other materials brought frequently
and unavoidably into contact with the skin in the practice of ci-rtain
trades. These substances, when employed in a concentrated form,
produce, as before stated, in every ease a more or less severe attack of
eczema, but not always in the B.imc time or as the same variety. Most

> The word ii tued bcrc, u usually bj Geimaa vrilon, lo denote an affBolion
whicb is not a mcic tjinptom of tome ulcrUBl dueue. Tlirongbout Ibe preseol
work the ineanin|;coaimuDlj attached to the nord in thii country of depccdcnoe
on •omCDakaown CAntc is ciprcued bj "' »[iiiulBncoM."— En.

128 £CZ£MA,

of those first mentioned, whicli belong to the class of vegetable, irri-
taata, usually produce their effect on the skin in a short time iu tbe
form of vesicles and bullce, and thus give rise to the vesicular form of
eczemQ ; the others, taken from the mineral kingdom, only cause
changes in the skin after amore lengthened emjiloyraeiit, their effect
being in the first instance a production of papules, and afterwards
partly vesication partly the appearance known as E. mbrum.

Great importance has been ascribed to the form of the disease
produced by mercury, and a special name invented for it, viz.
mereuriak s. Hydrargyria. It b described as an affection
inning in the shape of red papules, of vesicles or of small

, pustules, which usually multiply to a Inrge extent and close to
one another; and it is asserted to be the result of the internal
use of mercurial preparations, as well as of thar direct opplica.
tion to the skin. As far as my own experience goes on this last
point, I can only admit the occurrence of liydra^yrin from the local
use of mercury, and may assert with confidence that no affection
of the integument has ever been caused by the internal exhibition of
aJiy kind of mercurial drugj. E. merciiriale is most fref|uently
observed afler inunction of grey ointment, whether id the case of a
heallliy or diseased subject. The remedy may have been used to
kill pediculi pitiis or to cure syphilis, its effects are precisely the
same. This form of eczema has no cliarBCt«ristic symptoms, for
precisely similar results follow the employment of other cutoneoaa
irritants, especially that of sulphar and sulphate of copper; and it
behaves in nil respects like any other artificial eczema.

The following agents are less certain in their effect than those
already mentioned, producing the disease only under favorable condi-
tions, or on certain individuals : such is the irritntion caused by
unusual l«inpersture and by the action of water or of sweat, the
mechanical injury of pressure, robbing and scratching, and the
pnseiice of certain epiz.oa.

The [lowcr of ^ttil and cold ta produce eczema is well known:
that of heat especially has been always acknowledged and is indicated

I by Biicli names as £. tolare (Willnti) — " prickly heal" of the English,

I calori of the Italians — sudamina, Ptoriaint pitloria, or baker's

r ilcU {Gale lien houlangcn, Bikkcrkriilae).

We must particularly insist ujKtu the fact that the same absolute
temperature is not necessary for tlic production of ecaeuia by means
of heat, and also that tltosc who may often expose their skin to a

ETIOLOOV. 129

t certain degree of warmth without injury, are at other times so

I alfcctcd by the verysamv heat as to suffer from an attack of tliis disease.

[ For instance, many persons can bear the heat of the sun very well,

J and at the utmost find redness, pigmentation and desquamation

I -follow expoBiire to it ; and yet in other cases, under apparently tlic

; conditions, there result vesicles, or even buUif, with more or

less considerable awellliig of the sib. The same discrepancies may

be observed in the case of blacksmiths, locksmiths, tinmen, cooks

and others whose occupations expose them (o a high temperature,

Any persons, whether sick or in health, who have been for some
time in a state of profuse pertjii ration, without removing the accumu-
lated sweat from the skin, are liable to un eruption of minut« puncti-
forra papules and vesicles, varying in number and occupying mostly
the chest and back. This corresponds fully with the appearance of
f ordinary eczema, especially in its papular form, but has, notwith-
l atanding, been regarded as forming a separate malady and received
I ft variety of names. Thus, when occurring in healthy persona from
I violent sweating, it is called sutlamina ; when observed in the course
of fevers, and most of all where, as in Italy, a peculiar " miliary
fever" is recognised, it is named Sliliaria rubra el alba ; when tliis
eczematous eruption has been observed to be the eifcct of heat with
or without sweats, in southern climates, it bns received the name of
I calori, or as it is called by English writers who have seen it in the
I tropics, prickly heat {Lickm Iroplcui) .

Lastly, I may mention certain varieties of eczema which ore the

result of excessive perspiration in special parls of the body, as in the

neigbbouihood of the armpits, the cheat of women where in contact

with large and dependent breasts, the groins, the genitals, and

I especially the scrotum and adjacent part of tlie thighs, the buttocks

I wliere in contact, especially in the case of fat persons, and the sides

I of the toea when the feet sweat profusely. This kind of eruption is

I Darned Eczema iiitertrigo.

But not only must & high degree of temperature be recognised as a
Icause of this disease, but also eoM. Experience shows that the
■ same exposure to cold, which in many persona causes chilblains
l'(/)*mM«»M),wiIl, in the case of others, produce an eruption of eczema
a the same parts of the body. Tiiis, like chilblains, lasts only so
s a low tem^ierature prevails, and hence usually lasts during
iantuma snd winter and disappears in spring. If we consider that
diilblams an nearly related in their pathology to cczematons crup-

130 ECZEMA.

lions, since in both cases an exudation inflltTfites the skin — deeper
in the former, superficial or sub-epidermic in the latter — it is not
suiprising that the same cause should at one time produce chUbbuns,
at another eczema.

The action of water in exciting this disorder is everywhere acknow-
ledged, though the eruptions caused by warm or cold baths, or
wasliing, have been erroneously regarded as critical evacuations
instead of artificial eczema. Even at the present day we hear iu
every wat«ring-place from physicians as well as others, that the
eczeruatous eruption which is produced by the use of the waters
(Ptydracia thermalit, as our fathers called it), is the proof of thdi
beneficial action. In consequence of this theory, the opinion is
widely spread that when the eruption occurs the use of the waters
most not be relinquished, but persevered in until it has disappeared.
In the same way " hydropatliiBte" pretend that eruptions, which
result chiefly from their bandages but also from the packing, the cold
baths and the douches, are to be regarded as " crises," and that when
they appear these manipulations must be continued all the more
zealously so as not to paralyse the good effects of such hydropathic
tieatmeat. What has been already advanced renders it nnnecessair
to state further how untenable these opinions become so soon aa
cutaneous diseases begin to be studied with the least attention, and
how widely my own views differ from those of hydropathists and
watering-place doctors.

The remarks jnat made on warm and cold baths apply equally to the
Boaaian vapour-baths, which combine both effects ; for when the skin
ia acted on by water varying from lai" to 45'5° Fahr., eczema i« a
hequeut result, and all the more when douches are added which &tll
from a considerable height. The efficacy of the wat£r in producing
ecxema is moreover naturally increased when combined with materials
capable of causing it themselves, such as sulphur and chloride of
sodium. Hence the eruptions bo frequently observed in watering-
places supplied by springs containing thesi! substances.

Mechanical Irrilanta of all kinds are a frequent cause of eczema
both in the sick and healthy, hat chieffy in the former. Some of
these are univeraally recognised, and thdr effects are not denied by
any one ; but othpn am not prDperly appreciated, and it does not
therefore appear superfluous to refer to them. Thus «c may
obserre all fortos of qg^gpa, from the Bquaujmi^ tlir inipctigmous

I the rtault of i

I, gartcrv

ETIOLOOV. 131

earrings hikI bracelets, antl any articles of dress worn too tight — stajs,
waistbands, caps, hate, braces, &c. Moreover, the pressure produced
by the tools used in many handicrafts, by carrying loads and other-
wise, may so irritate the skin as to cause an attack of any variety
of eczema. Nay, the mere compression of the skin between tlie
tuberosities of the ischium and a bard seat, in persons engaged
in sedentary occupations, or that caused by long confinement to bed,

I is quite sufficient to call it fortli, especially when the persona in

I question are in bad licaltb, and most of all when the skin is

I previously in an unsound state.

Anotiier cause of eczema which has hitherto been entirely overlooked
uid rii^Iected is the patient's scratching. Those who are tormented

[ by violent itching of the skin, whether from epizoa, as lice, acari,
bugs, gnats, or in consequence of various iuterual disorders, present
to the observer (he symptoms of every variety of the disease, from
E. fiopulotum to E, impett^inosum.

Wlien this fact is once understood, it is easy to see how an eczema

[ originally confined to a small spot may, in consequence of the itching
and scratching it has itself produced, spread to parts which were at
first unattacked. Thus, for example, we see in the case of eczema of
the legs, originating in a varicose state of the veins, that the eruption
gradually extends to other parts, where the long streaks it assumes
show ttint it is no longer the consequence of veuous congestion, but

J of mechanical irritation by scratching. This las been long observed

' by physicians and by patients, but its explanation has never been
onderstood. Thus a popular notion is that the act of scratching
brings the eczematous fluid from tlie diseased to a sound part, and so
occasions an extension of the malady by contagion. That this is not
the fact is certain, for the fluid secreted in eczema has no contagious
properties.

The fact that an eczenu already existing may be aggravated by
repeated scratching has been already referred to, and, indeed, follows
from what lias been stated.

1 must, lastly, not omit lo mention that many patients are not
contented to scratch with their 6nger-nails in order to abate the
eiccsaive irritAlioii, but make use of other instruments, such us curry-
combs, strigils, borseliair gloves, and even brushes : with these they
tear pitilessly at their skin, and not only scratch the cuticle away
mechaDically, but by continual irritation cause hypenemia of the
■luoiand exudation under th« epidermis \a the form of an eczematoui

1S3

ECZEUA.

eruption. The eczema wliicli has been thus produced may bu
readily diatinguished from that which results from scratcluug with the
nails by the form assumed by the eruption, which always corresponds
with the character of the instrament employed.

Of the cases of eczema produced by internal causes, some are the
results of certain well-known constitutional disorders, while others
appear without our being able to find the smallest basis on which to
found a theory of their origin. Thus we observe in cases of great
varicoae dilittation of tnhctitaneona veinx, moat often those of the leg,
but also of the rectum, that eczema may occur \a it* various forms :
these aa a rule become more and more distinct, and bring with them
B greater or less inlUtration or degeneration of the tissues of the skin,
especially of the cuticle and the papillte, a thickening of the chorium
and diatensiou of the ducts of the sebaceous glands and hair
follidea. Such attacks of eczema are known as " fluxus salinus "
when they affect the lower extremities, and have been ascribed to a
gouty diathesis {" arthritis ") ; while when the anus, perineal raph^,
and parts adjacent are attacked, they are called htemorrhoidal, aiid
attributed to the existence of piles. In my judgment it ia needless
to seek for an explanation of these maladies beyond the extent of the
skin and subcutaneous fascia, for there are abundant instances of the
occurrence of eczema in these places simply from the retarded
circulation which is the result of varicose veins. Venous congestion,
it is well known, is very quickly followed by serous exudation and
infiltration into the subcutaneous connective tissue; and if, as
experiments have proved, pressure on a vein for a very short time, as
iu the case of bandaging before venesection, is enough to cause
peripheral serous infiltration, we can easily understand how venous
congestion, that bas lasted for months and years, may end by
producing infiltration into the cutis, under the culicle and at last
upon its surface, and thus cause an eczema. If this explanation is
satisfactory for the cutaneous veins of the leg, it will in like manner
apply to congestion of those of the rectum, and the consequent
appearance of eczema about the perineum and anna, without resorting
to the supposition of u peculiar crasis or diathesis.

Again, eczema is often observed as the nianlt uf impairetl iK-

getlion. Ityspeptic patients exhibit morv tlmn .my others that

peculiar tint of akin which .slands midwn ■ . ...m and

ictATUs, and may bo coni|Hircd with Ihat [jlcxiMi |

1 wliicb has been long known as "earthy" or ■ ■ i i? *Jll» i

I tliis sallow, vhitish-yellow colour of the skin, tliere ia a relaiation of

I its teiture, numerous wrinkles apjicar, and the muscular tissue loses

I its tone. The patient complains of heartburn or violent eructation,

of a feeling of repletion and distension of t!ie abdomen, with loss of

appetite ; while in many instances diarrhtea continues for a lengtti of

time. EcKcma in such cases settles mostly upon the hand?, the face,

and about tlie anus, nud is accounted a proof of the existence of piles,

I especially in the last case.

When such eruptions occur, there ia no disappearance of the pre-
I vious internal maladies, so that it cannot be admitted that there is here
a alternation between eczema ami disonlers of ;iutritton. Moreover,
wc may observe that even after all the symptoms of the affection
\ of the stomach or bowels have ceased, the ec>;ematous eruption
I will still persist, and will not iletinitely disappear until digestion
I has been normally carried on for s considerable time.

Rachitic also frequently appears in company with eczema, especially
in clutdreu, without, however, our being able to assign this diathesis
s the cause of every case of the cutaneous affection at this age. A
I much more frequent coincidence is that of eczema in girls at the age
, of puberty with liiwrikred mensCrualion, with cMorotU, and with
tluit countless host of morbid phenomena which baa becD named
h^tieria, including hemicrania, globus hystericus, clavus, saliva-
tion, pyrosis, pains in the hypogastrium, the ovaries, the uterus,
or aacrum, a sense of weiglit and dragging in the genitalia,
leucorrhusa IJJuor albu»), pains in the course of the sciatic and
anterior crural nerves, rheumatic affections, and so on. When
eczema occurs in these cases it mostly affects the scalp, the face, and
particularly tlie lips.

The instances in which this malady appears either in the course of

pregnancy or after laclaiicm has been completed, depend, perhaps,

I upon causes similar to those at work in the instances just mentioned.

It often happens that women are attacked by eczema, generally on the

haniL", at u definite period of their pregnancy — commonly in one of

the early months — and continue to suffer from it in spite of all

I remedies, until after their confinement. Cases have been observed

, by others as well as by myself, of women who during several

[ sacccssive pregrutucies were otlncked by eczema of the hands always

' at the same period, so that in the later ones they could be more

' tertain of having conceived from the appearance of this disease, than

from the cessation of the meiisca ur the movements of the child.

ECZEMA.

Still more frequent are instances of girla who suffered from eczema
! of the face or scalp, wh3e the subjects of chlorosis, and were again
' attacked in the same plocc« after their first confinement or, if thej
suckled the infant, afttp it Lad been weaned. In some of IJiese cases
there is merely d^uvinm capilhrum with sh'ght seborrhoia, in others
the malady may allain considerable infenaity and duration, bat
always disappears as soon as a fresh conception takes place. When
however, eczema attncks sterfle women in conjunction with hysteria,
it may be cured while the sterility remains. Lastly, when women
have reached the climacteric period we see the same affection of the
scalp, the face, and also of ihe trunk and extremities as oecurs in
cases of chlorosis and pregnancy. In fact It may bo asserted gene-
rally that all derangementt if tAe utenit — tamours, hyperlropliy,
' congestion, infarctus, involution and atrophy — predispose to
eczematous eruptions upon the scalp and face, although no one has
yet succeeded in explaining the reason of this singular combination.
I therefore simply take note of the fact as one which is supported
by numerous observations ; and leave it to the future and to the
advancing investigations of my medical brethren to clear up the
precise connection of these coincident symjitoms.

After thus enumemting the few conditions of the oi^nism wliich

are known to me as being frequently followed by eczema, I must

T frankly confess that quite as large a number of cnses occur

whose causes are completely unknown. For I have no liking for the

commonplaces which are so often brought forward by medical writers

1 discussing the etiology of disease, as favorit« Dei ex macMu^ to

explain the origin of the most (liverso maladies. I seek, on the

contrary, to conline ray statements as nmcli as possible to the

regiou of ccrtamty. Accordingly a great number of the causes

I vhich are set forth at length ns well ascertained facts by other

I writers, appear to me to be of but little etiological value. Bnt

though thus unable to state much positively as to the causation of

I eczema, it will not, perhaps, be aseless if I enumerate other

supposed I'redisposing causes and dispute their reality by the

rt'sultfl of cjiperiencc.

French physicians have always laid great stress upon the iempera-
I menU, and, without entirely cxcJuding the others, have nscrihrd to tlio
I lymphatic a great tendency towards eezematons eruptions. Nay,
1 >»me, as Cazenave, go so far as to recommimd m I^ bcrt mumiii of
aiaiafimtsthiiiii w..'L nu

ETIOLOGT. 130

f Uie opposite teraperamcnt (P) to that of the child she is to suckle.
The slender basis on which this etiological theory rests i»t11 be at
once apparent to eiverybody, and I may therefore spare the reader
any extended rofutation of it.

As great abuse is made of the teething of children as of
their temperaments, and just as every coagh, every colic, fever,
I dinrTl<ea, cramp, or (it, in an infant is put down to teething,
I BO eczema is ascribed to the same caua? when it occurs at this period.
1 Now, although I by no means ignore the influence which this
I; physiological proci-ss is capable of exerting upon the whole of the
L organs and functions of an infnnt, yet I cannot admit it to be a
t cause of eej^cma; because any conscientious and accurate observer

■ may convince himself that this malady occurs just as much before &s
I during the period of dentition, and oirers the same smptoms, the same
lintensity, and the same extent, without being in the least affected by
Bthe completion or the delay of the eruption of the teeth.

I Witli regard to age il has been staled that eczema is disposed
llo affect the head by preference during childhood, the trunk in adult

■ Bfe, and the lower extrt^mities in old age. This statement also 1
K cannot agree with ; since I have bad occasion to observe eczema of
I the trunk and limbs in children, and of the head in adults and aged
p persons, just as often as the reverse.

Again it is commonly asserted that this disease is more frequent
among iromfn than among men; but two thirds of thti cases
L observed by myself occurred in the male sex, only one third m
LOic female.

I Haiils of life and the use of certain articles of food liave been
■flso assumed to have the power of producing eczema. Of the latter,
■game, lobsters and other shell-fisli, cheese, sausages, herrings, and
wtaXi provisions generally, arc regarded as the most injurious ; nay, it
■lias even been asserted that the longings of pregnant women for
■ligbly seasoned dishes may be the cause of eczema in the new-boni
Knfant I Other writers, agiun, have maintained, and popular opinion
Bias followed them, that excessive use of spirituous liquors, esjiecially
K>f brandy, will produce a tendency to eczema, or will aggravate the
^pisfttsc when already present. But I must once more directly opjiuse
■heae long-ertabliahed prejudices ; for I have seen, on the one hand,
BQiosc who lived Ihe most respectable, regular and temperate lives,
K^hlren and l.-ulics who seldom or never took highly seasoned food or
Ktcoliolic drinks, attacked by this disease ; while, again, I know those

186 EC7.EMA.

who have lived in exactly the opposite way, bonvivants grown grey iu
glattony, and yet free from the slightest blemish. I can, therefore,
assert that the poor and the rich, the temperate and the Insurious,
the abstemious and the self-indulgent, are found in equal numbers
among the suiferers from this malady. So that I am justified in
maintaming that, for those who are otherwise in good health and with
good digestion, neither the kind nor the amount of their food has the
least effect in producing eczema.

How far different occiijtaiioni may be looked upon as leading to
this malady I have abeady considered iu speaking of the effects of
local irritation, and need only add here that 1 know of no trade
which can produce such an internal change as to lead to the de-
velopment of eczema.

Once more, writers have attributed an excessive importance to
chAfi^es of weather and of seasons in the etiology of this disease.
Intense cold and intense heat have been already adduced and acknow-
ledged as efficient causes. Butwhen it is asserled that the beginm'ng
of spring and the end of aulumn are marked by such eruptions, I
can only regard this as an empty supposition ; one indeed that has
been applied, not only to other kinds of cutaneous disease, but to
almost every malady with whose real cause we are unacquainted. If
any weight is to be laid upon the time of year, it is in this respect ;
that an eczema which has lasted the whole winter, unaffected by any
mode of treatment, has disappeared with the approach of spring.
So that, from my own experience, I should rather look upon a
severe winter or a hot summer, than on spring and autumn, as tlie
Benson most injurious to the skin.

Upon what clinical observations the aaaertion may be based that
diaordem of the mind, and menial emotions, especially those of a
depressing kind, often result in eczema, I cannot at all decide from
my own experience, for I have seen but few cases of such connection.
But since 1 have neither seen myself, nor read, nor heard from
physicians who have charge of lunatics, that cutaneous affections
are particularly common in such cases, it is not, I think, too much
to assert that this connection of the two as cause and effect, which
appears as an axiom in almost cnrery book on the subject, is a mere
fancy thrown out at random.

Ki ti'T i\\f. geographical diftnbvHon of ecKema, I am acquainted
with no quarter of the globe, no country where it may not be met
with abuadantly ; und there ate uo grounds for believing it lo be

reqnent ia the south than in the north. Indeed, my own
impressioD ia thnt the contrary is the fact, those cases being of
course excluded which result directly from excess of either cold op
heat.

A favourite explitnation of the occurrence of cutaneous diseases in
genera], and of eczema in particular, has been that of hereditary
lran»mUaion. I cannot coincide with this view, for I have seen many
women who, either while unmarried or as mothers, have repeatedly
sufTercd from eczema, sometimes during their pregnancies, and yet
their children have never been attacked by it. I can even adduce
the case of those who have been eczematous for years, and have
given birth during that time to seven, eight, nine, or ten children,
all entirely free from this malady. The fact that in a few cases
whole families may be found affected with it must be viewed aa
exceptional when contrasted with the general results of experience,
and can, at the utmost, only prove that eczema in parents does
not exclude its occurrence in their children.

This disorder is never contagious ; for, neither by close contact,
nor by inoculation, can it be transmitted from one individual to
another. It is true that both doctors and laymen imagine that a
patient may, by scratching, " draw out " the eczematous fluid, and
then spread it from one place to another, thus producing extension
of the disease by its influence on the healthy skin. We have,
however, sufficiently shown hefor« (p. 131) that this ia not the case,
the progress of the disease depending not on the virus of the
secretion, but on the mechanical irritation of scratching.

That attacks of eczema may take their origin from certain dgs.
eraaia has been assumed as a demonstrated fact, both by patients
and physicianti. Thus, when the disease occurs in children, it is
ascribed by some to a manifest or else a lurking scrofulosis,
by others, especially if it attacks the legs in the form of E. rubrum,
to a gouty diathesis, and in a third case to urinary metastasis, or to
syphilis; while, when none of these hypotheses will apply, a psoric,
or herpetic dyscrasia is called in aid . When we consider the want
of clear notions of the nature of these so-called dyscraaicc, and the
arbitmry and elastic de6nitions of the blood-diseEkscs, for which so
many names have been invented, a scientific scepticism as to their
vnlne will not be deemed unoeceasarT.

I cannot indeed enter here upon a criticism of the accuracy of the
theory of siu:h dyscrasis in the science of medicine generally. But

138

ECZ EHA.

from my own point of view, that of a dermatologist, I must remark
tliat only thosu skin affections can be ascribed to a blood-disease or
general dyscrasia, which present such peculi.tr characters as to
decide thi?ir origin of thcmselvea, without reference to the pecu-
liarities of the patient. In the case of syphilitic eruptions, for
instance, we are able to identify them in every cas*, without
uiquiring into Ihe history or the diathesis of the patient. Now,
we can not do the same with eczema, since this disease is the same
in form and course, whether it occur in a healthy or in an unhealthy
person, whether by artificial irritation or spontaneousiy : moreover,
when eczema occurs in persons who offer the most marked symp-
toms of so-cnllcd scrofula, namely swelling and ulceration of
glands and caries of bones, we observe it to run precisely tlie same
course as in other cases. I cannot, therefore, admit that thJa
diathesitt modifies eczema, far less produces it ; and so must deny
the existence of a scrofulous form of eczema, though admitting
its occurrence in scrofulous patieuts.

The same reasoning applies to other dyscrasiro, as syphilis and
gout. Even in the case of chlorosis, which we have discussed before,
this condition can only he regarded as favoorable to eczema, for
there are cases enough of chlorosis without the least sign of cu-
taneous affection ; so that all we can say is, that the two conditions
are often coincident. Since the itch-insect was discovered, we have
ceased to hear of a dynoratia ptorica, or, if still met with, it is only
among the disciples of Hahnemann. Lastly, the ciistenee of a
herpetic dyscrasia,' the mother of all sorts of cutaneous eruptions,
ban been disproved by the more thorongh investigation of their
pathology, and we may at all events regard it as defunct, until its
defenders succeed in expressing it by a. chemical formula.

These hypotheses furnisb, in my opinion, a far more forced and

difficult esplanation of the occurrence of eczema than the following

, theory, which is based partly ontheresulls of direct experiment,

' partly on observation of the diseases which arc usually followed by

I this eruption. Since we know (i) that eczema may ho caused by

uiechanical and other irritanls, and (2) that it frequently results from

varicose cutaneous veins, it is not n very rash supposition tlut the

I immediate cause of the disease is disturbanw! of the circulation in

I the capillaries and the smaller arteries ntid veins, producing capillary

V congestion. Whether this be ilsolf the result of an nlTeotiou of the

' Virus ilnrlrmx — Diathf'M dsrtteuat;,

_ for ir

BTIOLOOT. 139

or of the vossels, is of leas interest for my present purpose, and
ranst be left for the solution of professed physiologists. It is enough
for me that both from cutaneous irrilnnta and from changes in the
louB system, there may ensue congestion and other disturbances of
circulation. Further, I believe thnt this congestion leads to
excesssivc exudation of liquor sa»ffiiitii», that it cannot be
ipletely used up in supplying loss ; and thus a certain qoantity
lemains over, which inliltrates itself among the elements of tlie
alTectcd tissue— in this case among the qndcrmic cells.

In the first slage of the disorder, while only a small quantity of

as exudation is present, it will pnali before it the sound cuticle,

llect in the deeper layers, and so produce vesicles. When this

icess has lusted longer, mid the exuded fluid has increased in

lantity, it will burst through its epidermic covering and appear on

surface, thus producing all the phenomena which have been

idy fully dctiiilcd.

So that we need not, for the explanation of an attack of eczema,

ippose a disease of the blood, or a materia peccant, which is ori-

inlly iiieor]wrated with the blood, and thence expends itself on the

as an ammonia tangvinii. For we know that we can produce

na in perfectly hrailhy persons, by the application of irritants,

and find no other elements in the exudation thus called forth

than iu that which oecnrs in a spontaneous attack. But, to avoid

misunderstanding, I must add, thai every case of this disease is not

the result of 'local irritation, but that it may be caused by affcctiuno

the rest of the body; even in these instances, however, the

ucbance of cutaneous circulation may be explained by the con-

\tui nervorum, just ns well aa by the assumption hitherto current,

the presence of some morbid product in the blood.

Even the itching, which so constantly accorapanii^ this malady,

more easily explained by an original affection of the nervous sys-

than by the old theory of acrimonies ; because experience shows

in true dyscrasite, as, for example, syphilis or exanthems, the

irbid products deposited ui the skin cause no itching, while

the case of scabies (the local character of which is now acknow-

Iged), the presence of tlie acarus is qnite suDicient to explain the

isation from wbich the disease derives its vulgar name.

Lastly, the symmetrical character of an eczematons eruption is

ire simply accounted for by an original participntion of the nerves,

by the supposed excretion of impurity in the btuod. And since

140 ECZEMA.

the advance of knowledge of diseases of the skin has shown that the
distribution of the cutaneous nerves ploys the chief part in determining
their form {as, for instance, we observe in the case of zoster, variola
and syphilis), it is no vexy bold assmnption to suppose that in eczema
also it is faulty innervation, which is the most important element in
iU production. The further question as to the cause of this change
iu the nervous system must be at present left unanswered, since we
have no trustworthy observations to direct us on this point.

Treatment. — As my views differ from those of my predecessors
and contemporaries on the nature and etiology of eczema, so also
my experience has led me to look upon their methods of treatment
as imperfect and fallacious.

Although my own researches have not yet enabled me to cure
all cases of this disease " into, cila H Jucundf," yet I think I may,
without boasting and with a good conscience, assert of my own plan
of treatment, that it will cure tiie great majorily, will cause groat
alleviation in all, and will do harm in none. Before, however, I
succeeded in devising the mode of treatment which I now employ, I
had made good proof of the plans recommended by other jihysicians,
both past and present : and a criticism of these methods will not
perhaps be useless, if only to preserve their memory for the
future.

Starting with the assumption that cutaneous diseases in general,
and particularly those accompanied by secretion and exudation of
.purulent or other fluids, were to be regarded as wholesome deposi-
tions of injurious material, it ia not surprismg that physicians ex-
horted their patients to put up with their eczema, and consoled
them with the notion that some more serious internal complaint was
thus averted. On the same principle we can understand why almost
all authorities warned their disciples of the danger of bringing on
severe internal maladies, or even death itself, by the sudden and
rapid cure of an eczema. Now I am unfortunately obliged to
confess my ignorance of any remedy which can produce such a sud-
den and rapid cure. Indeed, I can only repeat what I s»id in the
year 1846 : ' " that it has been my most anient wish, the stimulus
of all my studies, to cure clirooic cutaneous diseases aa qaiddy aa
possible, and yet, to my most eincere sorrow, I have never succeeded
in spite of Ihe use of all possiUe mtuos, intenial and cxtcninl, in

p. j5«-

' Zeitoi^irirt det k. k. OMellsolufl det Aecrto in Viiea,' 3rd m

GENERAL TREATMENT. 141

wing such & disease suddenly, or even very quickly," And, wliilo
y experience has since only confirmed this, it is partieularly true
1 the case of eczema,

I I have already more than once had occasion to remark, the
s writers have expressed of the metastasis of this disease
T core by certain means unknown to me) can only be explaiucd
" c accidental cobcidence of an acute febrile attack with the cni-
Uoyment of some supposed remedy for eczema; so that the appearance
f the (ever has been ascribed to this treatment. For instance, a
, before in good health, has extensive eczema of the face,
body and the limbs, and the only symptoms are violent
, nitli the consequent restlessness and want of sleep. The
ictor is called in, and orders some placebo, such as deeoctum
ttlfiea. But suppose the child is between seven and ten months
Id, going through the process of teething; from this or some
■ cause it suddenly falls ill, becomes feverish, shivers, and,
I the eczema which nas fully out the day before bus disap-
arcd ; the skin, before red and swollen, is now pale and flaccid,
r moist patches are dried up and covered with thin yellow
I Kales, the violent irritation has vanished, and the anxious
I parents and inexperienced physician impute all these eyuiptoms
Lto tbc inert medicine which was prescribed. Of course this view
bia only confirmed when, a few days later, the fever, the rigors, the
bdiarrlicea, or whatever acute symptoms there were, have disappeared,
r and the skin has again become red, and irritable, and moist, pre-
senting in fact all the previous eczematous symptoms. Here it is
obvious that the abatement or disappearance of the cutaneoos
diBease depends not on a metastasis to internal oi^ans, but on
anicmia of tlie integument caused by tiie acute febrile or other
attack ; and as this effect has been already fully explained, we need
only refer to the passage in question (vol, i, p. 70).

We will now mention in order some of the modes of treating
t-czema, formerly extensively in use and not yet entirely abandoned,
but which appear to me to be undeserving of adoption,

And first of all, venesection, leeching, cupping, scarititation, and the
nsxint and ingenious Baunsc he id t- treatment.' All tliese modes of
abstracting blood are admitted by the majority of writers to bo use-
less in the treatment of ecaema, and tliere are now probably very few

' Thii is RD elaborate melbod of acupunctare.

tio

142 ECZEMA.

praclitioncrs who would defend them. In no case are they of the
slightest use, while theymay, in very manjj cause permanent injury.

As to the " deriventia," which are often appUed near the eczema-
tous patch of skin, such as blisters, croton oil or even setons, I
need only remind my readers that Eiett himself warned against Ihem
as very likely to enlarge instead of diminishing the affected area.
In those cases even in which such an attack has passed off of
itaelf or under suitable treatment, I would strongly advise that
aetons he not used; for they are just as litely to do mischief after
the malady is cured as durmg its course, and can never in the least
prevent its return.

One mode of treating eczema (and all other chronic affections of the
skin) has been to try to eliminate by repeated jD«rj)»^ the supposed
materia peccans. Unfortunately, moreover, we must add that not
only in past times, but at present also, this error is common ; and
Bpecialists, as well as clinical physicians and those engaged in ordi-
nary practice, still defend this " evacuating method" for cutaneous
diseases generally, and for eczema in particular. One set of doctors
and patients extoi the benefit of simple neutral salts, and of the
mineral waters which owe their celebrity to these compounds —
Glauber's salts, Epsom salts, cream of tartar, seidlitz powder, sal
Seignetti,^ and the springs of Saidschiitz, Friedrichshall, Ofen,
Iv^nda, Fiillna, Marienbad, Karlsbad, Kissingen, &c. Others look
for the cure of ecaema from more powerful remedies, as senna, jalap,
Bcammonj, gamboge, colocynth, and most of all from calomel.
These drugs are ordered not only occasionally, and when constipa-
tion is present, but for many months continuously : and from such
practice success is anticipated. I am, however, obhged simply to
oppose to the supporters of this plan of treatment mj own experience,
that in cases of chronic eczema purgatives taken alone are never of
any use, and are often injurious. The mistaken view which ascribes
to such drugs the power of curing chronic cutaneous diseases can
only be explained by the fact that those who hold it prescribe at the
same time baths, lotions, ointments and other local applications,
and imagine that the good eiFects really due to these were caused by
the aperients they exhibited. If they had made the experiment, as
I have, of prescribing in one case purgatives without local applica-
tions and in another external treatment without purgatives, they
would very soon have become convinced of their mistake, and would
' Sulplmte of soda end miigncsm.

OENEaAL TREATMENT. 113

no longer lave atttibated to laxative medicines, or indeed to internal
retnediea at all, effecta which they uever have possessed and never
wiU.

I iQust confess the same conviction of the useleasness of the woody
decoctions which are called purijier» of the blood, on the action of
which I had occasion to speak at length when discussing the treat-
ment of psoriasis. I will only add to what was there said these
words of Ahbert : — " The force of habit malies every one trust to
the efBcacy of these drugs upon his neighbour's testimony."

The same remarks apply to the more active remedies mentioned
above (p. 2i); such as antimony, manganese, baryta, graphite,
anthraco-kali ; and to these may be added the fuligo-kali, prepared
by M. Desehamps, an apothecary of Avalon, and recommended by
him for both internal and external use as superior even to anthiaco-
kali.'

The iliuretic medicina which have been often recommended have
all proved useless, and one of them, tincture of cantharides, when
employed for a long time or in considerable doses, cannot be counted
as iiidiSerent, for it injures the patient without curing his eczema.
Camphor, which Erasmus Wilson recommends, is not at all more
efficient than the preparations of iodine and mercury preferred by
other authorities; and cod-tivtr oil, although of the greatest service
as a local application, is quite useless when given internally. I
cannot even concede to araenie the undefined blood- purifying and
eciemo-curing powers which are attributed to it by English and
French physicians. Let the experiment be only tried of treating
two similar cases of the disease, one mth arsenic alone, the other
with external applications only, and the local plan of treatment will
undoubtedly bear the palm. Indeed, I must repeat what was said
of purgatives, that it is only the undesirable plan of combining

■ Tlie mode of praparing fuligo-kali ia u followi ;— A icniple of caustic
potasb is boiled wjtb fire scruples of soot {Fuligo ipUadni) in as mach water
Biwill disiolre the potash; after an bour it ia allowed to cool, Cllered and
evaporated to diTtiess. The fuligo-kali titen appears in Ihc form ofacoles, and
mutt be kept in well-stoppered bottles in a dry place. Beside this, a nul-
phuretled preparation ia prescribed, whicb is made bj heating 4 parts ofsuljiliur
with 14 of caustic potash io water, and after it is all dissolTed, aJdiog da parts
of wot. The miiture is then evaporated and the residue preserved as before.
Gibert and Erumu Wilson have both repettedij tried tbew preparation* and
Hud ibem niekaa ; bo Uiat tUej arc only nicatloned here for the sake of oom-

141 ECZEMA.

internal and external medication in cases of tcr.emn, which has led to
the erroneous doctrine of the great value of arsenical preparations in
this disease. Nevertheless, I admit that if drugs are to be given
internally, arsenic is so far eligible as it undoubtedly docs exert an
influence upon the formation of epidermis. Bnt at least let this
medicine be only used in cases of obstinate and universal chronic
eczema, — cases always complicated by weakness of digestive power
and loss of appetite, and in which one is obliged in practice to pre-
scribe sometliing internally, if only to satisfy the patient and hia
friends. The best preparations and mode of exhibiting this drug I
have discussed at length already (pp. 27 et seqq,).

In passing to the consideration of the local treatment of eczema, I
cannot resist quoting what I wrote as early as the year 184(1.' "The
insufficiency of the so-called specifics in the treatment of chronic
diseases of the skiu, and not any spirit of opposition or desire for
novelty, obhged me to devise other means of arriving at the desired
end." For since I was never able to cure eczema by means of the
internal remedies recommended by my predecessors and contempora-
ries exhibited aione, and since many eases came before me which
had been previously treated in all the countries of Europe by the
moat celebrated physicians and in the most varied ways without
result, it was not an unnatural conclusion to come to, that a
successful therapeutic of eczema would never be reached by the path
hitherto followed.

It was an eqimlly natural result of this observation for me to try
other means, and above all to try each one by itself, never in combi-
nation with others, in order to arrive at length at n correct estimate
of the several remedies for eczema. And from the first I began to
see from these experiments in therapeutics that it was possible to
attain one's object by local applications alone, — that is, to get rid
of cases of this disease thereby, which had witbstood internal ttcat-
meut for yean. Thns encouraged, I have fuUowed this path of in-
vestigation constantly, and at the same time have not fulled to try
every mode of treatment recommended by others, whether external
or internal. It remains for me to lay before the reader the rcsolta
of thcM observations, which have now been continued for mom
tlao twenty years.
^^Bttu begin, as in the case of psoriasis, with an account of the

^^^^■B artick cutitlcd " Dermatol ogical Sketches," whidi ap[>eAied lu the
^^^^Blft del k. k. Oet. d. Aente.' jn] teriM, td. i, p. 346.

TBBATMENT.

145

tarative action of waU-r. Its most important (lualily in this respect
p its harditess, or the character of the salts it holds in solution.
uij experience teaches that many jKrsoas, and especially ladies with
y delicate ekiii, acquire a rough aod dry epidermis by washing their
p^dnds and faces in hard spring-water j chaps and fissures may appear,
J « even, after prolonged u§b of such water, eczematous eruptions.
fcTTie Earae effects are observed to result in even a greater degree
a the use of cold baths supplied by hard water. It is true that
Irhen any cold water has been long used in treatment, symptoms
r artificial eczema will ensue, as already stated; but the rapidity
lad degree of its development will depend, ctrlerit parHitt, upon the
fcnality of the water. When the physician and the patient can choose
firhat is to be used for water-dressing or lotions or baths, rain-
water, distilled water or water from large rivers shoidd always be
preferred. But since this can often not be obtained, or only at great
expense, the best means of rendering other water suitable must be
borne iji mind. It is welt known that when water has been boiled
and allowed to cool, it dejmsits a great part of its salts, and thus
becomes better titled for therapeutical purposra; and it is further
improved by the addition of a mucilaginous substance. The best
plan, therefore, to prepare hard water to be used in the treattnent of
cntoneouB diseases is to pour it l>oiling upon bruised almonds or
flour, and then allow it to cool. We may explnin in this way the
action of the decoctions and infuaians employed by ladies to improve
their complexion, such as Dee. atthe^, mallow and pansy water ; none
of which have any Wrtue in themseJvea, but serve to make the water
soft. Such prepared water maybe applied either warm or cold, and,
if thought desirable, can be reduced to a low temperature by the
easel containing it being immersed in one filled with ice.' In
applying it to an eczematous surface, care should be taken that it
^oes not act on more than the affected part; and to ensure this
e limbs should not be rolled in wet bandages, bat a thickly folded
Sompress should be accurately and firmly applied to the precise
!i upon which the water ii* to act.
If it be desirable to avoid fre(|Ucnt changing, and the patient lin<l
p tow temperalure agreeable, the best plan is to fasten upon the
pompress a bladder or caoutchouc bag, lialf full of ice ; the dressing

> I must liere give a cauliuu agiiiuBl Ilia ute of melted ic« itielf, brciusc
t it rrequenll; not free from tlia saliae compouoils it conUineil before bciag
1, iod morcovw is orten pnrpOMly miud with common tall.

146 £CZBHA.

Deed then only be changed as often as the eczcmatous socretion
readers it necessary. But it is qait« improper to um oU-skin or
gutta-percha in sach caries, since a temperature is soon produced
beneath them eijual to that of the body, and thus the cold appli-
cation is tnmed into a warm one, and the object in view is defeated, i
For the water ought not to soften and macerate the cuticle, but l
chiefly to work upon the distal nervous system, so as tn mitigat«
or do away with the sensation of itching; and this can only be
accomplished by cold. Aa soon as the dressing becomes warm the
irritation returns, and often in an aggravated degree.

It is upon the qualities of cold water above mentioned, its
softness and temperature, that the action of some mineral springa
depends which are succeasfdly employed in the treatment of
eczema; and hence those are most useful which are chemically
as nearly inert as possible, and possess a temperature of from 68*^
to 88*2° Fahr. The eczema which is artificially produced in
hydropathic establishments (Kaitwasserheilamtalten) often disap-
pears under the continuance of the water-dressing, especially
when it is applied in the way just recommended, and often clianged
BO as not to become warm. Even when it is not so judiciously
used, the apparently good effecls of the water treatment arc eanty
explained, from the skin, which was at first irritated, losing its
susceptibility and so experiencing no reaction. Other cases, bi
which the continued apphcation of cold water docs not cure I
the eczema it at first produced, but leaves such a violent itching
when intermitted that the patient is driven to it again, rau^ be i
regarded as instances of irritability not overcome, but only ti-
nted to the production of fresh eczematous eruptions. Kvcn
when cold water is constantly end carefully applied from the firet,
there will be aomc eases which, instead of being cured, will only be
Eomcwhat reheved so long as the tiMtment is kept up, while tl>c ,
emption spreads all the time, and exhibits more active symptoms
than ever as soon as tlic wet apphcation is left off. It will be nere9-
aary in such cases to turn to a different plan of treatment, gencmlty I
to the employment of pitch in forms which will be detailed bi the {
following pag«a.

Vapwr and akiiieer balht wilt also be found very useful in many I
coses of eczema, and especially when It is localised upon the scalp or I
other parts covered with hair ; for it is then scarcely jiossiblc to ctuure I
the thoroui^li application of water to the atfected surface in any othit ]

TREATMENT.

147

_ lo S(

ly. The vapour-bath, however, must not be of too high a tempe-
rature, nor last any longer than is ncceasary for its purpose, namt'ly
lo soften the eczematoiis products aiiil prepare the patient to receive
Bubserjuent douche with pleasure ; for it is the latter, anil not
vapour-hath, whieh is effectuul iu the cure of the disease. The

iter should be in considerable qnanlity, and the douche should he

lely divided and fall from only a slight elevation. My ovm cxpe-
ice is, thai contrivances for directing the water from the side or
n from below, and the hcll-apparutus ouce so much used under

le title Auloteloutron, are not only useless toys, but otherwise
ondesirable. All that is wanted is for the wat«rto pour down from
a sieve above, so as to irrigate the patient's akin. This sieve should
have a diameter of fourteen inches and a half. It should be per-
forated with numerous minute holes, and not be more than one
foot above the patient's head. Increased height and a more undivided
streiun of water only does mischief, for the skin is thus mechanically
injured, aud the way prepared for inflammatory swellings and boils —
results which no reasonable observer can regard as crises, but as dis-
agreeable interruptions which only complicate and delay the cure.
In fact, I cannot comprehend how medical men can, even now, regard
troublesome pustules and boUa as critical metastases, and I only
regret that the dictum of persons utterly unacquainted with our art
should he so generally accepted by those who ought to know better.
Shower-baths, when used in the treatment of cutaneous diseases,
must be taken three or four times a day, and for not less than
five or more than fifteen minutes at a time. In order to prevent
the water entering the nose and mouth, the patient should put the
tips of his four fingers together, and then, by placing the index
firmly on each side of the nose, and the corresponding thumb upon
the angle of the jaw, a kind of roof will be formed by his two hands'
which will protect the nose and mouth from the water, aud yet allow
of free respiration. The water should be turned on first, and tlii'
patient should then step into the bath, thus avoiding the unpleasant
feeling caused by a gradually augmenting stream. When be has
become accustomed to the shower-bath, he will be able to use hi<
bands freely, and will find it agreeable to rub himself with them ;
indeed, he should then be advised to move about while under the
'he.

It matters little what time of day is chosen. The most com*
.able arrangement is to take the fin>t on risii^ in the morning.

148

EC/.KMA.

the seconil in the course of the forenoon (lo-iajy
tKe afttrnoon (3-j), and the last before going to bed. But what-
ever time is selected, the patient should always manage to sjKMid at
lea:^ lialf an hour after the bath in walking, citbtr out of doors or
under cover; and should never go straight to bed, as reaction is
then very slow and imperfect. Moreover, the douche shonld not be 1
talien in a dark, cold, isolated chamber ; but in summer, if possible,
in the open air, and during winter in a warm and comfortable bed-
By means of water thus ertiplojed, iu the shape of lotions and
various kinds of baths, and continued for several months, it is pos-
sible either to cure ccxcma, or to help forward its successful treat-
ment by other methods, or at k-iist greatly to mitigate the sufierings I
of the patient, and especially the intolerable itching ; while in I
no case will this jilan be productive of the slightest injury.

Faltg and oleagiitoai suistnnces play almost us important a part as 1
water in the treatment of eczema. The choice of one or anotfai? I
depends, not so much upon its chemical quality or composition, as upon ]
its more or less solid or Buid consistence, and the odorous prindples I
which it contain* ; for while ouc form will be agreeable from its ]
want of smell, another, though equally efficacious, is less applicable |
by reason of its evil odour. As long as the fatty substance is
applied in suitable quantity and in the proper way, the purely the»a-
pcutical effects will be just the sauie whether we prefer almond oil,
olive, linseed, or even walnut oil, cod-iivcr oil, milk (whey, curds, I
cream), pig's lard, mutton suet, spermaceti, or iho-w ointmeols I
which contain only an indifferent colouring matter, such as UKg. I
linaria, Ung. althetr, cr^me cfleste, cold cream, Uitg. ealadula, '
Unf. fcpu/fntu, Ung. e^uilii^nt, Axuiu/ia pectinit.

Since tho applicatiou of any of these suhstanccs is iutended to I
soften the scales, scabs and other products of eczema, and since, while I
the disease lasts, tlicre is continually secrrU-d moislure which tends as I
it dries to renew these products, it ia tnanifestly not suffidmt to I
smear an ecy,rniatous part from time to time with an oily or fatt^i' f
substance, or, after the common ]da&, (o rub il in once every hour I
or two. It is absolutely nccestary to keep tho oleaginous nnttcr I
in continual contact with (he atTitt..! .un
drying of ibesccrrled nioistun- ti
dipped in oil should tbmfore '

■ i>r«-2.-l.m uf iL,' .-mlti

upou the hair, ami after it has been rubbed ia sliould be kept from
rapid evaporutiou by beiug covered with flnnncl, or with aome other
woollen fabric not easily penetrated by oil. The very general
prejudice that woollen cSuthing has a bad effect upon the skin, and
especially upon a diseased surface^ is quite uiirooudcdj and ought not
to hinder its use in preference to linen when, as in this case, recom-
mended by enperieiice. My own practice usually is to anoint the
sculp, in cases of E, capitU, with about an ounce of oil, at least
twice a day, and immediately aflerwards to cover the head with a
close-fitting Hannel cap. When the face is affected, 1 accomplish
the same end by moans of flannel bandages, or, if necessary, by it
mask of the same material, made so as to fit closely ; and tho same
plan of treatment is readily adapl:ed to other local varieties of the
disease. In cases of universal eczema I make the patient wear next
the akin a tightly- fitting jacket and drawers, made of flannel or other
close woollen material ; or, when the horizontal position cannot be
avoided, I let him lie naked between two bhinkets, and after rubbing
him well with some suitable ointment several times a day, pack
hira tightly up between them.

£vcn Itayer said, in his uft-iiuoteil work, ' Exposition dea Mak-
diea de la Pean,' — "The good elFcet of ointments composed of nine
and calomel doubtless depends to a great extent upon the fat which
they contain, for their active iugredieut^ arc often very small."
This opinion 1 would almost completely endorse; for enpericncc
teaches that a great many ointments, and those which do not
contain caustic ingredients, may be used with etjual success. In
practice, however, where, as we well know, the medical man has
Dot only the disease but the patient to treat, and very often needs to
vary his applications less for a strictly therapeutical reason than to
produce a moral effect upon the latter, he must have at his disposal
a larj^c number of medicines differing if only in colour, so as to adapt
them to the changpabtc wishes of his patient, or, in many cases, to
carry oat some special therapeutical object.

With a view to these requirements, I will therefore enumerate
tlic most valuable and commonly uscil of the salves and ointments
Tecommended by different authors. Tlicy are ;

Ung. album simplex, containing five parts of washed lard, one
simple leaiU pi aster, and three of finely -powdered while lead —

vrwiae railed Vug. ccrtutiP or white lead ointment : Vng^futcuw

Carat»M fittcwm, made by heating one pound of dincliylon plaster

150 BCZRMA.

until it becomes brown, adding to it four ounces of ydlow wax, foor
of mutton snet and six of lard, and thmi pooring the whole into
moulds: Ung. IMar^ri (Ung. plumbi aeetiei, Ung. salmnmum),
composed of one poond of lard, four ounces of white wax, and two
drachms of acetate of lead : lastly Ung. ealaw^dano* (3j ad |]), and
Ung. zinci (of the same sizength) ; which last has been praised as a
specific for eczema.^

I have for some years used an ointment in the treatment of eaema
which I at first applied for the cure of sweating of the feet ; in fiMt,
ever since a patient, who suffered from both complaints at once,
found both equally cured by its use. This unguent may be prepared
by melting ordinary diachylon plaster over a gentle fiie until it has
become fiuid and hom(^neous, and then adding an equal quantity
by weight of linseed oil and allowing the mixture to cool; but a
more elegant preparation is obtained by using olive-oil instead of
lard in compounding the diachylon. Dr. St^nhauser, the director
of the Imperial Drug Manufactory in Vienna, has furnished the
following formula for this ointment : —

9^ Olei oliTinim optimi, ^xv ;
Lithargyri, Jiij, 513.

Coque. Dein adde
Olei layandali, 5ij.
M. ft. nng.

I may add as further details of its preparation, that the olive oil

' A peculiar mode of preparing zinc ointment is giTen bj Mx. Erasmus
Wilson, who prescribes it as follows (1. c., pp. 86, 87, 771) :

1. BelPt formula (Ung. Oxjdi Zinci benzoatom) :

9: Adipis prap., 3vj ;

Gummi Benzoini pulv., 5j ;

Liquefac cum leni calore per horas xxIt in vase clauso, dein
cola per linteum et adde
Oxjdi Zinci purificati, Jj.

Misce bene et per linteum exprime.

2. Wilson* s formula :

^ Ung. Oxjdi Zinci benzoati, Jij ;
Sp. Vini rect., 5ij ;
M. nt fiat ung.

ohol, spirits of camphor, gljcerine, liquor plumbi diaoetatis,
or preparations of tar may be added to the benzoated zinc
proportion of a drachm to an ounce.

TREATMENT. 151

' should be first mised with two pounds of water and heated : then,
wliile fresh water is coiistaiitl_» iMjuretl in and the mixture stirred,
Treshly sifted litharge should be gradualljr added. The whole
shoold be kept in motion until it bus cookd, and lastl; the
lavender oil sliouli] be ndiled. In cold weather, au extra ounce
of olive oil should be .tllowed for every pound of Hie oint-
inent. I have called this preparation t%. diacA^li, and pre-
scribe it either alone, or in combination with balsam of Peru
or one of the other materials to be presently mentioned, wliieh may
be adapted to the case under treatment. It ia either applied by
tneana of the Soger, or rubbed in with balls of cliurpic, from once
Kto three times n day ; or, if it he desirable to increase it^ effect,
u piece of linen or Haimel of suitable size ia spread with the
uinlment, and laid on to the alTcctciI surface like a plaster. It
n obvious that this last method ensures a much more thorough
Boperation of the ointment than simplt' inunction; for white in the
tiUter case the greater part of it must be soon lost by evaporation
lor by friction from the clothes and other objects, the application of
h compress covered with the ointment keeps the therapeutical agent
■Id constant and direct contact with the affected part, and thus greatly
Fincrcases its efficacy.

I Another set of unguents, much used in former times in the treat.
I neut of eczema, and not yet entirely abandoned, contain more or less
K-of caustic compounds, and thus do not depend entirely upon their
UBtty constituents for their effect, Such are those known under the
Htames Utiff. WerlkoJIi { Vng. pracljp. alU v. it/dmrg. bichlor. amtno-
wmittli)^ and citrine ointment {Vug. h^dr. nilrafU), and those which
Montaiu Iljfdr, iod. Jlavtim (proUodide of mercury), or Ilydr. iod.
Wrvlit'tiiit (deuiiodide of mercury}, ot Merc, orj/dalut niber (deutoxide
mat mercury) '. These prepamtions aic most useful when the skin has
Fbeeu for a, long time greatly infiltrated, without any excoriation from
destruction of the epidermis, i. e. in the forms of the disease which
I have de.'tcribed as E. papulotum and E. tquainotum. But their
slightly caustic character docs not allow of their application by
bieans of compresses; tbcy should be sbijily rubbed into the alfccted
Barts once or twice every day.
■ The next class of external remedies for eczema consists of those

I ' UiigucDluui Uj^rtirptriaiiiRiODiBtiof tlte Briliib PhftnnflCo[i<xia, iWIy.
m* UngueDtum H^drnrgjri uilrira-oiidi of Ihe London Phammcopixii,
Ktogutotnin HydrargjTi oiidi rubri (B. t.). ,

ECZEMA.

wtiich are employed in aqueoos or alcoholic solations; and
some are best applied as lotions, or by means of liueo bandages, vbile
others, especially when concentrated, arc too caustic to be used in
this way. Of the former, I may mention aolutioas of sijphatc of
zinc (gr. v ad 3j), of corrosive sublimate (gr. i ad 5j), of borax
(3ij ad 3j), and of caustic potash (gr. j-v ad 3j). Lotions of
this strength may be best applied wlien the crusts of an impetiginoua
eczema have been already removed by other means, or when they have
not yet formed : in other words, they are most useful in dealing with
circumscribed patches of E. rvirviii, or with an impetiginous form,
when it is desired to destroy the pustules and to soften the cuticle.
These same lotions acquire cauatie properties when they are less
diluted, in the proportion of dvo grains of corrosive sublimate to the
ounce, or one part of potash to two of water — the most concen-
trated solution possible. This last lotion which I used to employ
frequently, and always with the best results, b al present only my
ultimum Tefugium in the most obstinate kinds of eczema ; for though
it cures everj' case without exeeption, the pain it causes is very
severe. The reason therefore for my not using it as I once did,
is simply that I have succeeded by constant trials in obtaining
remedies equally efficacious without being painful ; moreover, this
panacsB has the additional disadvantage of easily doing mischief in
inexperienced hands. The exact mode of application of the con-
centrated liqvor polat»ee is the following : After the accumulated
masses of dead epidermis in th« form uf scales, crusts &c. have
been removed by appropriate means, so ns to expose the subjacent
red, inliltrated, mobt surface, the solution is applied with a
charpie-brusb, passed quickly and evenly backwards and forwards
over tlie affected part in every direction; then the hand, or u
piece of flannel, is to be dipped in water, and with it the lotion
spread still more equally over the whole surface. A white froth, not
unlike soapsuds, will soon be observed to form on the eczematous
patch; and this only occnrs when water is thus rubbed in after
application of the caustic solution.

When this part of the process has been thus finished, a con-
siderable quantity of fluid exudes in drops upon the surface. To
alliiy the pain, and to prevent the formation of .icabs, rags dipped in
cold water Hhonld be apjilied, and frrciuently changed daring the
day. ITic patient need not be disturbed in the nighl, if care bn
lakin that the rags arc kept wet, and this is best dune by help of

f oil-silk or gutta pMcBa^Tra^ater-dressing has been thus coii-
I atantly appiied for n week, ihc minute raw places of greater or less
deptb, which the caustic sppUcatiou has here and there produced,
I will have recovered their epidermis, and the itching, which had
quite ceased during this time, will again become troublesome.
' Moreover, it will be soon observed that red spots reappear here
and there, and vesicles are seen : this should lead to a repetition of
Ihe former procedure. When t\, water-dressing has entirely re-
moved tlie traces of the second caustic application, n third should
follow, and this weekly course of treatment should be repeated
, as often as the symptoms just mentioned return. It is scarcely
I ever necessary for the solution of potash to be used more than
i twelve times, even in the most severe cases ; for even if after this a
[ few small places should show a disposition to relapse, some more
I gentle txeatment will suffice to prevent it.

As I mentioned above, it is but rarely, and only in pressing cases,

that I now avail myself of this most energetic and effectual but

[ cqaolly painfui procedure, and I much more often employ potash

I eoap, and the " spirit of soap" prepared from it.' ITae soap may be

I used in several ways: by rubbing it into the whole body, and then

wrapping the patient in blankets, as described in the chapter on

psoriasis, or by partial inunction, or in the form of plaster. The first

njetbod has already been fully detailed.' For the partial application

of the soap, 1 spread a piece oi it as big as a walnut upon a flannel

J rag and rub it into the eczematous part for several minutes, prnting

\jirml^ all the tirnr, and dipping it from time to time in water

\ to make il lather better. Water is then applied, or, if this cannot

I he, one of the above-mentioned oils or unguents is smeared over the

place. The soop must be rubbed in at least twice every day, so

I long as any excoriated points a|>]iear after its application. 1 may

[ add, that soap rubbed iuto hfafthg skin will not leave any such

r rlTects behind it ; the part feeling clean, smooth and comfortable

I after the soap has been washed off with water. The contrast this

[ offers to the eczematous parts is very striking, the latter presenting

s mtensely red, raw and moist spots. These are all caused

I Vy the layers of cuticle which were before undermined by the ecKC-

I matous fluid, so as to form the coverings of vesicles, hoving

I become softened and at last destroyed by the action of the soap;

I nnd thus each of them represents the floor of a vesicle, thr roof of

' '^A PP 35. Jf>- ' '''* PP- 37. 38.

154

ECZEUA.

which is gone. The appearance of these red shining moist points
after the first inunction, looks, to the ineipericnced eye, as if the
malady had been aggravated ; hut they bccume less in number after
each application, until at last they entirely disappear, aud then the
I formerly eczematoua surface is no more affected by the soft soap
[ than is the surroundmg healthy skin.

When this soap is used in the form of a plaster, it has n
very powerful and persistent influence upon the parts with which
it comes in contact. In many forms of cutaneous disease besides
ma, and even iu those which depend upon hypertrophy of
I connective tissue, in ichthyosis aud in lupus, I have succeeded in
softening and destroying the new formed material. In such
cases I spread the soft soap evenly over a piece of flannel to the
I thickness of the back of a knife, aud then lay it directly on the
I affected ]iart. With eczema such an application has, of course,
a caustic effect, and cau therefore be kept on without interrup-
tion for only a few days at most; but with the more severe diseases
I have spoken of, it may be cooLinued for weeks, and eveu months,
before the destruction of the morbid growth is accomplished.
[ Accordingly, in treating eczema, or any other malady, by this
I soft-soap plasti'r {"caustic plaster"), wo must desist as soon
I 88 any considerable excoriations have formed — and tlicse are usually
very painful — and not apply it again until the results of its prc-
^ vious action have disappeared; ^. t^. until the raw places arc again
covered with skin-
When eczema occurs on the scalp, or when it is desirable to
avoid the unjilcasant smell of soft soap, I am accustomed to use
the " 8p. tajionalux alkaliimt" which is a])pbed in precisely tie
ame manner as the soap itself.
Iu no cutaneous disease have the preparations of lar proved
I BO advantageous as iji eczema ; for tbey diuunieb the irritation,
I ojid either completely stop further secretion, or at least reduce
I it to a tniniuium. The remarks made in a former part of this work '
I on ihc history of the use of tar, on its various preparations, the
I mode of their employment, and the cautions nccefsary iu its use, all
1 find their application in the case of eczema, I need only remind the
I reader that the tar must, as in other eases, be brought into immedinte
I contact with the affected skin, and that, consequently, nl] morbid pro-
Iducts, such as scales and crusts, must be Grst jfot rid of, either by
' P. 40.

TltKATMENT.

155

e oily preparations already described, or by the action of lotions or
plaiters.

The use of some preparation of tar is particularly indicated

" I those cases of eczema which, from the slight infiltration and

bscnc£ of moisture they j)re3eiit, come under the description of

a-called E. s^iamoatm. But in tliosc also in which tluid is

Bcreted over only part of the afl'ected surface, and which correspond

"ore with Ji. rubrum, tar will often be found of great advan-

There are cases, however, in which the result is exactly the

I opposite of thut desired ; for instead of the moisture, itching, red-

l^ncss aud thickening of the skiu disappearing after tar has been

■ applied, tha amount of secretion rapidly iucreoses, and the irritiilioii

ttecomes quite intolerable. It is therefore advisable whenever a case

Kof E. ruifrum is to be treated with tar, to rub it at first into a small

■ipart only of the afiected surface, in order to test the susccplibthty of

1 the patient. Should he bear the first inunction well, and without

any symptoms of reaction, the whole surface may be rubbed without

further scruple or any doubt of a good result. In cosea of E. papu-

tosum the tar treatment ia especially indicated, and it must be very

rare for this form not to bear its action. When such exceptional

cases occur, the effect of the tar is to increase the ocsematoos papules

till they become wheals, and such violent itchuig results, that the

. remedy tamiot be continued. On the otiier hand, tar is counter-in-

[ dicated in all cases of acute eczema, and whenever there is great

1 serous infiltration of the skin, with a pufly and swollen surface,

(Edema, intense redness, aud elevation of temperature: also when

au enormous number of small vesicles are rapidly developed, or

when the secreted tluid quickly dries into the yellow gummy crusts

Lof £. impel iginoium [Porrij/o lurvalit, or Melitagra flacfscena) .

The manner of applying the preparations of tnr does not in the
I least differ in principle from what 1 have expounded in treating of
Ipsoriasis (p. 44, note). It may bii observed, however, that at first the
Itffected part should be painted with tar at least twice a day, because
I the appUcation is so often washed away by the subsequent eczc-
Ltnatou^ secretion, that until the moisture has diminished it will not
Igct a firm hold of the surface. The rule should thirerorc lie lu
iJceep on applying the tar, when it is well borne, unlil the layer htid
1 on last keeps its hold and is no longer washed away by the cczeroatous
I fluid. This practice ia almost indicated by the fact that the tar,
f vhich soon disappears from the aOectvd parts, readily sticks to the

156 ECZKUA.

sound skin ; and the more it holds on to the former, tlie better is
the sign of improvement. When at lust the part origioally diseased is
covered by as thick a coiit of lar as the hcnlthy surface which sur-
rounds it, nothing more shouhl be done until the natural process of
growth of the cuticle has laid bare tlie whole surface by detachiog
tlic tar. Ttie former ecKemntous part will then always look redder
than the rest. But when il appears otherwise healthy, and the
patieut no longer scratches or complains of itching, no further appli-
cation is necessary : for this redness does not de})end upon con-
gestion or exudation, but is only caused by the epidermis not being
yet so thick and hard as that of the snrrouuding jiarts. If, on the
contrary, after the mask of tar has fallen off, the redness appeals
more intense, and accompanied by slight swelling and very cousi-
di^rable desquamation, or if vesicles or weeping points or excoriations
are here and there observed, or if the patient complains of itching —
these, or any of them, are phenomena which point ta a relapse. In
such cases the tar must be again applied, and repeated until the
signs of recovery appear.

When discussing the treatment of psoriasis I mentioned the
products of distillation of tar described by Pereira, namely restnon,
resiiieon, and re^iinein. Since the publication of that part of
the German edition, I have obtained siJccimens of those prepa-
rations and have made experiineuts with them on different patients.
I will therefore state here the re-sult*, as far as they go, though the
short time for observation does not allow me to form a definite
judgment upon their efticacy. On the whole, these products act
like lar itself, but with a more caustic effect, and their odour is not
at all more agreeable, while it is much more penetrating. So that
they will be best used in cases of psoriasis, E.nqu-iimosum, E.nArum,
Lichen ej-«u<hfipue ruber, or other affections attended with but little
swelling or inllammation, and with patients who are but tittle sus-
ceptible of the action of cutaneous irritants. Ou the other hand,
carbolic acid' is, if not more active, at least a very convenient pre-
paration in practice ; for it is sold iu transparent crystals, which are
soluble iu boiling water, alcohol and glycerine; and, moreover, its
scent, though not exactly pleasant, ia less penetrating than that of
tar. Hence it is particularly applicable to the treatment of eczemn
of llic face and hands, or of other parts which arc usually uncovered.

■ OlhenriM called Plieulo Aoid, HO,CuB,,0, or HC,n.«.— £o.

^H TREATJUKNT. lo7

^fltis the custom in London to prescribe carbolic acid iis a latum
^M under the following form :

^M p. Aoidi Catbolici, ^as ;

^H Gljccriiti,

^H Sp. Vioi rectir, aft ^u ;

^B Aq. destill., ^vj. M.

I have frequently use<l this lotion, but have titways found it too
weak ; und even when the treatment hcts a good result, it laats mueh
longer than when other forms of tar are used. T liave therefore

H^ emjiloyed & more concentrated solution, omitting tlie water ; so thai

^M the formula is —

^H IJ. Acidi CrirbolioL, ^ij ;

^M Gljoeriai,

H .£tlieri&, flft ^ ;

H Sp, Vini redif., Jrj. M.

^H Even this lotion is not caustic, und is by no means so efficient as

^m pure lluile de Cade, or Oleum msci ; nevertheless its vnluc is oft«n

^H aceu in cases of £. squamosum or E. ruOrutn afTeeting the face.

^M Sulp&vr and its prepamtious, including Bulphurous waters, have

^B obtained great reputation in the treatment of eexcma. It is bard to

H find a hook on diseases of the skin, it is rare to talk with a physi-

^K dun will) treats or a pnlient who suffers from eczemn, without

^B hearing the old assertion that sulphur is a specific against cutaneous

^P diseases in general and this in particular : indeed, when we con>

" sider how often this opinion is acted on, it is really surprising

that, in spite of such an accredited and ancient medicine, there arc

still so many old and uncured cases uf eczema to be met year after

year at the most fnsliionable sulphur springs. I nm very sorry to

find myself so little in accord wilb standard wcrks, with doctors and

with patients ; but I am obliged to ascribe a very subordinate value

Ilo sulphur in the treatment of even the most fnvorable eases of this
disease, while in many it is of do use at all, and in not a fewactnally
does harm. I found this judgment partly upon my own eiperi*
nients und the observations of many years, partly upon the testimony
of unprejudiced jihysicians, who from their official position or from
residence at sulphurous watcring-[)tace3 had opportunity of observing
the effect of the baths, and partly upon the admission of many
patients, who, in spite of long-continued use of sulphur in all ito
forms, never got rid of their obstinate eczema. This remedy is par-
ticularly mischievous in nil acute forms of the disease, in £ rulrvm

156

ECZZIU.

' cr umpet^imMmm with profuse ncnticni, and in all veskBlar n
It if of no tue at all in milder forms of E. iqiiamonm mp^alonm,
KMBc c>M» of viucfa nuT get well under mlphur, but whboat snr
proof that it ii b}^ meaju of solphnr. I havp seen it tt>ost useful in
cases of E. margimaiMM, and in other raiirties of the auUad; wh«l
conpticaled with scabies and prorigo ; um) it is pmbablj^ Ilie sl^liter
cases of tba kind vtocili have gives rise to the repatation of
snlpbor for ecxcnu generally. Por the form of the disease wfaidi
aocompBtiies scabies and prurigo is stnpljr produced by the patient's
flcntchtngj and this of course depends upon the iiritation of the
Bcarus or of the papules of prurigo. Isow, since solphui kills the
itch-insect, and prevents the forniBtioa of prariginoaa papnlea, it
removes the itching % and as soon as the patient ceases to scratdi,
the eczema gets veil of itself.

But even in these cases modem expcnenoe bas gireo us better
remedies : and this is fortunate, for sulphur and its preparatiocu
are, it is well known, so irritating to the akin, that thet often
produce fresh outbreaks of eczema in places before free trom
and this explains the fact that sometimes sulphoroDs baths an

, found to aggravate instead of curing the disease. On the wholr,
therefore, I wonld fain see sulphur expunged from the list of medi-
cines fur eczema, without at the same time wishing to dispute its
Weil-earned reputation in the treatment of psoriasis, of prurigo, and

[ of scabies.

The great variety of eczematous affections and the difference iu
tlieir coarse make a few other applications occasionallj useful ; either
such as simpl; protect the surface from the air, like eol/odim, or
those which absorb the secretion, such as lycopodjum dost, starch,
jwwdcred lice or asbestos, pulvii tatci Feneti, pu/v. lapufis baptiala
(holystone), carbonate of magnesia, and oxide of zinc. Moreover,

I when an expectant treatment is indicated, but something must be

I prescribe^l to please the pntleut, these powders may be used «ritli

' great sdvantsgc. Or they may be employed when the eczona-
ton* ]iarts have been covered with ointment or tar, to prevent it

[ b<:ing nibbed off by the clothes and help its adheaioa to the skin.

X beUevc that all the means in use against eczema have bees now
linlly di»cus!teil, but it may be of practical interest to add
arks, based OD actual trials, upon the best mode of cbousiug
Itlcd for each form of the diaease.

TREATMENT.

15U

For acttle attacks experience sliows that any very active treatcociit

does harm rather than good. More especially warm and cold baths,

DDguents, tar, soft sonp, sulphur, make matters worse by increasing

I the inflanimntion of the skin, without rclievmg, at least for long, the

I anpleaaant feelings of itching, pain or burning. On the contrary,

Ithe expectant or "homoeopathic " method of treatment has proved

' the best adiipted lo such cases. Let an acute eczema, then, be

treated with indifferent applications, and the patient be sattsHed witli

Deeoct. altkea or Ej:lr. graminit, while the skin is either left

, quite undisturbed, or dusted with some such powder as the fol-

I lowing:

9> 2iuci Oxidi ;

FuN. Alu minis plamusi ;
Piilv. rad, Iridia &ims, M jj -,
Pdr. Amjli, jij. M,

In many cases it is admissible to allay the burning and irritation
by applying rags dipped in colJ water, or in Jcelum UfAar^yrl
[liquor plumbi sub-acetatis. — B.P.] . But even this sometimes rather
increases than mends the evil ; so that it is well lo prescribe these
lotions only conditiomdly, and first to try whether they are well
borne or no. In the desquamating singe of an acute attack, such
ointments as the I'ng. timjiht (with or without oxide of zinc),
diachylon, or ordinary white lead salve do good service by softening
the harsh cuticle, and so preventing the formation of cracks.

When we have to deal with the ehronk form of eczema, our
tre-atment must vary according to its locality, its duration anil iuten-

' sity, and the individnal peculiarities of the case. Above all, wc
mnst not forget, while ensuring every advantage to the patient, to
adapt the treatment so as to interfere as little as possible with his
ordinary habits. For there is a multitude of persons who dei)eud
upon their labour for their daily bread, and who cannot therefore
remain away from their vocations for days or weeks. If they were
Dsked to give up their whole time day and night to the treatment of
their malady, they could not undertake such a plan of therapeutics,
and would prefer to go about their work and keep their eczema
ntlier than to attend to it out of work. Whenever therefore we
con cure the disease without interfering with the patient's business,
there is no doubt we should do so.

No less when eczema attacks eiildren does their tender age

i demand careful attention ; ftnit e»ipecially so in the cose of infanta at

[160 ECZESIA.

I the bfpasl. Here we must make a great clifTercnce in the Ircat-
L meiit, according as the disease is coofine-d tu a small part of tli« skin
or is more widety spread. "When it involves the scalp and face
I (Porrigo, Milclischorfe, " Vierziger," Croflle de lait, Gourmc),
[ whether of healthy infants or of those affected with scrofula, rickets,
I aufeioia, or any other constitutional complaint, the treatment should
I always be strictly local; for experience has not yet given ns
I any internal medicine which is of the least use in these cases.
[ Indeed many physicians assert that tliia kind of eczema gete
I well of itself iii a short time without any treatment whatever, and
I hence believe interference to be uaeless, if not hurtful. As to this,
I I can only refer to what I have said on the subject when discussing
I the prognosis of eczema in general ; adding, however, that 1 will
I answer for the complete liarmlessness of the following treatment.
I Jlrst, all scales, scabs and other morbid products must be removed
from the head, by means of cod-bver or other oils, or by zinc or
lead ointment, not only rubbed into the skin, but, if possible, spread
on hnen or woollen rags (the latter is pre fe ruble), and so kept con-
stantly applied. Indeed, the best plan, when it can be followed, is
to keep these bandages on day and night without interruption, so as
I not only to get rid of the products of the disease, but to prevent
I the eczematous fluid from drying again by favouring iU abundant
I secretion. When matters are so far improved by tliis means, lliat
I tho surface appears no more moist, but oiJy red and scaly, the cure
I should be completed by applying in the same maimer white or red
I precipitate ointment, or, if practicable, 01. rusci {oil of birch),
I 01. cadini (juniiier oil), 01. faji (beech oil), or carbolic acid, as
above prescribed, or by simply washing with tar soap. This last plan
will be found most pmetically useful if, after the infent has been
well washed in a batli with a piece of flanue! smeared with the soap,
rags dipped in one of the oils just mentioned be at once applied.
, Older children may be treated in the same way; or the cold wat«r
I cure may be n-sorled to with great advantage, especially in casea of
I universal eczema, and this either to its full ext<:ut, or iu the form of
L water-dressing, or baths of ruin or river water. Some of the omt-
I ments or preparations of lar enumerated above may also be employed
I in combination witli this treatment.

I When eczema ntlncks the tcalp and face of adnlt«, the beirt plan
I is, after getting the crusts soft, thorongbty to dranse the skiti by
f rubbing in soft soap ; next to bathe it with cold water, in Ihc form

TBEATMENT.

161

Its!
^^ uaefi

^^* nece
she-
au{

I of I

uni

I npi

^^ «cc

of a douche or otherwise; and after continuing this for eeveral days,
to proceed at once to paint the parts with the spiritaons solution of tar.
It should be borac in mind that the treatment by tar is nowhere so
useful as in eczema of the seal]) ; that it may be employed just as
:ly on the long and thick bnir of women as on a bald scalp ; and
l&Bi it never affccta tho growth of the hair in the least. It is only
necessary that any application to a part covered with much hair
should not simply be rubbed in with the hand, but its direct
and thorough contact with the skin ensured by using cither a piece
of sponge, or a huir-broah, or a painter's brush with long bristles ;
unless the still better plan can be adopted of pouring it directly
npon the head. If the patient objects to tarry preparations on
Account of their colour or their smell, or if they are inadmissible on
lOther grounds, the same end will be obtained, though not so quickly,
the DSC of oleaginous materials.^

In cases of eczema of theyiictr, beside the means already described,
solutions of sulphate ot zinc or of caustic potash, in the proportion
of a dracbra to a pint of water, may be used as lotions, or the
surface may he painted with laudanum, or with tincture of Turkish
When the constant treatmeat of such cases of eczema on the
Itead and face is not possible, wc must be content to apply oleagi-
ioioua fomentations to the head and diachylon ointment to the face
during the night ; and in the morning, after properly cleansing tho
with 1^. taponii alk. and water, to smear them with solution of
bolic acid, or with white precipitate or Wilson's zinc ointment.
\Vhen the eart are affected with eczema, they should be wrapped
ry night in rags covered with a suitable ointment ; and cither this
itmcnt must be continued during the day, or, if this cannot be
done, zinc powder shiiuld be spriukltd over them, after removing
the rags iu the morning. Eczema of the parts of the face covered
with hair must be treated in the same manner ; remeraheriug, how-
rer, that it here readily passes into sycosis, and that as soon as the

I > I msj lierc remark that tbe practice of cutting o7 tbe hair mid Rhavuig
B hc»d in these caew ii quite unneeessary ; iudeeil I have ererj year treated
1 cured manj bundred cnsei of eczema of tlic scalp, bolb in cliiidren and m
ulti, bj Ibo method rccommeaded in tbe text, without being once obliged to
a Uie liair cut olT, Cases no doubt ocour in which ao eczema of llie scalp
e characters of ijcosis, nnJ llicn recotery is more rapid if each hair
bat pierces n pustule is pulled out. Itiil as tbia Tariety is alwajs coDfioed to
■Kfcw circumicribed spots, it is act absolutelj aecessarj even here to removo
la bair, but oaij to pluck out every daj all tLose nhich luu through jiuslulu.

193 ECZKUA.

characteristic nodules^ and pustules of this disease appear, it bcoomos
absolutely necessary to pluck out every bair that is aifected.

The treatment of ecaema of ihn trunk, incloding the ueck, must
be conducted on the genera] principles already fully explained : but
vhen the disease is situated in the nipples it is usually very ob-
stinate, so as to resist the action of oleaginous and alkaline aiid tarry
applications, and soouur or later to reader necessary the use of more
caustic remedies, such as solutioits of corrosive sublimate (gr. v ad
3j), or o£ potash (553 ad y). These may be used without any
fear of subsequent mischief : the excretory duets remain patent, anil
the mammilla is as fit for its function as before. On the other baud,
E, maTginatum of the inner surface of the thighs or any other part
is very amenable, not only to the more generally potent applications,
but also to sulphur, whether employed in the form of batlts, or of
Vlemingkx's, sulphur lime,^ or solution of ordinary liver of sulphur
(K S or Na S). In the treatment of eezema of the pcrmfeam and
anus, or of the scrotum, either one of the ointments or Bome tarry
preparation will be found most useful, with the caution that two
opposite surfaces must not he allowed to come in contact when
covered with tar : to prevent this, they should be dusted over with
some dry powder, or Imt [plumcuseaux) should be laid between them.

The very common variety of the disease which affecls the lower
extremilies, and often causes so much thickening of the skiu, will
generally yield to the use of diachylon ointment, followed by pitcli,
but may not unfrequently require the application of caustic potash
or soft soap, followed by water- dressing. Of course the latter treat-
ment can only be put in force when the patient can maintain a hori-
zontal position, while the former plan may he carried out when
be is obliged to go about his daily business. These cases illus-
trate the thoroughly practical value of diachylon ointment ; for it it
is spread on a narrow piece of linen, and then laid on the afTected
parts and covered by a flannel roller, the patient can be on lus legs

> In this and other passages I bavc trnnslntcd Knalrn. Knolehm, b; llieit
etjmologicsl enuivalcnts, "node*" or "nodules." Tuier is n term uow seldom
used, and tliR curresjiondiog dimiantivc, Mtreulmn, hu acquired sucb ■ v^a&e.
meaning, that 1 Tcaloro to think it would be well not to ute it al nil wliere h
re nnatomi»t dfsoriplicm ti iiil ended. We mlghl then epcxk of ijpiiililic
or lupous or Hniphuluui. or tulii-reuJar nodules or node), and oac source ul
I confusion would be rcmorcd. — [Ro-]

■ See the oocount of this preponliuu {tlven in tbe chapter on Fioriaait.

TREATMENT.

163

ud ubout liis business the whole dajr without suffcrmg from pain,
tching or any other trouble.

Nor does this treatment prove less elEcient in the case of
raema of the Jkxor mrf<Ket of joinlt. Whether the arm-pit, the
elbow, the groin or the ham i» the aeat of the disease, the
limb will regain its mobility immediately after the diachylon
ointment is applied, even when it could be neither bent nor
1 extended without causing the patient extreme pain. If this course
\ be continued until all scales, crusts, pustules, vesicles and moist
patches huve disappeared, and when the skin is only somewhat red
and furfuraceoQs pitch ointment be applied, such cases may often
be completely cured without at all interfering with the patient's
occupation.

£ut the most etrtkbg instance of the value of this treatment
is seen in the case of eczema of the fingert or tueit. Here,
from the brittlcness of the cuticle, aud the constant movement of
the parta, deep fissures arc formed, which quite prevent the use of
painful remeies like soft soap and solution of potash; but the
diachylon ointment alleviates the patient's previous Bufferings without
causing him fresh ones, and quickly restores the n»c of the parts.
Of course in such cases each finger or toe must be separately wrapped
in rags properly smeared over, and then a lai^ glove or stocking be
drawn over all. The ointment muut be renewed about every twelve
hours and then the epidermis which has become sortenetl should be
removed by hard rubbing, even though the skin may appear re<l or
loist after it. This is quite necessary, in order to prevent the
tohing which will otherwise ensue, as well as to get rid of the already
ioftcncd and dead cuticle, and thus to bring the remedy into more
F intimate contact with the afiected surface. I do not mean to assert
I that treatment with soft soap, alkaline lotions (a drachm of caustic
Mtash to a pint of water), corrosive -sublimate baths (gr. xij ad Oj),
I with preparations containing tar, when this ia indicated, may not
■wfully employed in these cases ; but the use of diachylon
faitmcnt has proved, and always will be less painful, and in every
faiy preferable.

I I would urge, in conclusion, that, whatever coarse be adopted

I treating chrouio eczema, constancy and persei-erance are of the

'utmost importance, tie who is nlu'.tya changing his plan of treat-

t mcnt is sure not to attam his object ao quickly aa one who steadily

d patieolly oppliet whatever remedy seems best suited to the ca

CHAPTEK XX.

HUtoty of ScaHea? — It is very probable that among tbe many
Israelites wlio are recorded to have been afflicted with leprosy,
(and Manetho speaks of 90,000 lopera as having existed at ODC
time among the Israelites in Egypt), a few only sufl"ered from the
"Elephantiasis Grtecorum," and that tbe majority were affected with
some other and contagious form of chronic cutaneous disease. For,
although the Greek word Lepra and the German word Aussatz
{leprosy) are used as being equivalent to the Hebrew term
Zaraath {njJi?) it can hardly be that this term really belonged
to that terrible malady, which still exists, and is now (as it was
then) generally adioitted to be incurable, to infect the wbple
organism, and to be hereditary, although not contagious. IF
this view were correct, surely no Israelite at the present day
would be free from the disease, since {as is well-known) the Jews,
instead of mixing with other nations, have alwnys intermarried
among themselves, and thus are the only people who, through a
|>eriod of thousands of years, have preserved a perfect purity of
race. Evidently, therefore, the word Zaraath must hove included
most, if not all, of those contagious or hereditary chronic skin
affectiona which disfigure those affected by them. Now these
affections all come under the heads of scabies and By[)hili9, and
consequently it is no very rash hyitotiiesis to suppose that what
was termed in Hebrew Zaraath was really, in many cases, (if not in
every case), one or other of these diseases. Arguments in favour
of this view may also be drawn from the rules for personal cleanli-

' Ilandbuvli der BUcbcrkuiirle filr tliu ii!t«rc MHicin,' vnr
Leipci)ti >94l. Koebel, 'LilteraritHchichta der ArenetkuDil> .
' VeUatfaidigv Uebcrticbt der GMcliiclito ilcr Ueilicin,* VDQ L' >

■ Niu

lUSTORY. 165

laid down by Moses, from the well-known liiatory of EHeha
and hia sen'ant Gehazi/ and from certain passages in the Bible, in
irbich leprosy is spoken of as affecting apparel, and even dwellings.
In the verses to irhich I refer, directions ore given that clothes
fhich had been worn by lepers should be washed before being
used, and that houses which had been inhabited by persons
Affected by the disease should be cleansed before being occupied by
others. Now in all these pnssngea it ia more natural to understand
the word Zaraatb in the sense which I attribute to it, than to
suppose that it refers to the Etitphantiasls Qracorum.

Bourguignon,' again, quotes, as evidence that scabies existed
among the chosen people, part of the fith verse of the ijjth
l<^pteT of Leviticus, which he n^ada ns follows ; — " Et die »eplimt>
\temjplabUur : ri oljscurior fuerit lepra {,^ tt non ereverit in cute,

In the Gfth cliapter of the second Book of Kings it is rfcorded that
NaaaiaD, captain of the host of tlio King of Syria, weut to Etiaha, in order lo
be onrcd of the " EBTaath." B; the advice of Ihe prophet he wuhed in Jordan
Mven times and wu cured. Elisba refused the present wliich was oiTered by
Numan and the Ulter deputed ; but Gchnzl, the scrrnnt of the prophet,
followed after NuiDan and askcil of him prGSUuts upou ■ fidae preteit ; suit
NsBiiian " bound t«o laleiitB of silver ia two bags, with two changes of
garments, and laid them upon two of his serrants, and they hare thorn before

bim; and when he came to the tower ho took Ihem from their hand "

And the prophet, receiring him with a rchuke, said, " The leprosy

therefore, of Naaman, sbsU cleave onto tliee, and unto thy seed for ever ; and
be went out from his presence a leper at white as snow." If, as I am inclined
to believe, this acoount ia lo be underslaod literally, and in a medical senjr,
Naaman's leprosy, which passed to Gehaei, muit have been, not Elephantiasis,
— for this has no contagions properties, — but scabies, which is commuoioable
by oontact, and by wearing the clothes of those affected willi it.

Moreover, it is cot easy lo understand bow the Elephanliasis Graxorum could
be removed by washing in Jordan, whereas it is quite explicable that scabies
should be cured in this way, for (he water contains sulphur (" Zur Bibel,"
naturhislorisch, medicioisch, antbropologiselie Fragmente von Friedreich,
Nuroberg, 1S48, Theil i, p. 339). In eiplanatton of this fact, and of the cir-
Oumstauce that bathing in Jordan was used for the cure of skin-diteaaei in
general, it must also be mentioned that the water of this river deposits a block
snhstance, containing resinous principles. It is probable that these ingredients
ars derived from the subterranean communications which exist between Jordan
and the Dead Sea. For in this Uke there is a Urge quantity of aaplialt,
and this tabitance oonlains sulphur, a wcU-kDown remedy for cutaneous

discHCs.

Traiti Eatomologiqne et Falholosiqae da h Oale do I'Qomns.' 1^151,

mundaiil eum, quia scabiei (/) esl ; lavabiiqw homo v\
et tnwtdua mV."'

■ I do not know from whti tmuUtion of the Hebrew origiaal t
iiBvt been tikcn. As I liave alread; slated, and ahall fnrtiier eiplnin
am stTODglj of opioioQ that tUo disea«e termed Znrutb n-oa not lepra, bot
scabies, and tliat the aamo term was also used to include, without distiaction, &U
kinds of ontaneoos affections. This, however, does not prevent mj pointing oat
that the application of the two words, lepra and scabies, in tiie passage 1 liavie
quoted above, is perfectlj arbitiaij. The word which in this passage is
translated Jf^ro is, ia the original, "Haoega" (VlSf), Now "N^;r" in Hebrew
iimplj means disease (mordui), as is evident from the second verse of the Mine
chapter, where we find the expression " Nega Zaraatb," which is clearlj nothing
more than " the rfuewe Zaraatb." In other parts of the Bible, too, Hie latne
word is employed to di^signate a corporeal, material pisgoe ; in fact, it la a
general term, meaning sootcthing " nnpteasant ;" and there is no ground what*
ever for translating it b; the word lepra.

Again, the expression which in the passage qooted bj Bourguignon is rendered
tabia is in the Hebrew original " Miiepacbatb" (rinp^'?)- What then is
the proper meaning of this term F Tbo words whieli begin the second rcna of
tbe same chapter are (iu the KogUsh version), "When a man shall have la the
skin of his fle&h a rising, a scab (Sai>achath, rinW, geueralljr translated Inlo
Oeruan bj the words iciai^lor ieiiippiff),oc bright spot, and it b« in tluialda
of liis flesh like the plague of leprosy (Zaraatb) "

Now " Sapachatii" is evident]; the aamo, both in spelling and in sound, u tJie
Arabian Sipabat or (per neltUhei'm) Saliaphatii but nnder tliis name tlie
Arabian writers, and Avicenua after them, described forms of disease, equiTa-
lent to Eaena eapitu or Crutfa laeUo, of wbicb the most striking charaoter
appeared to be the formation of oru.aU aod scaIgs, so long as the essential
nature of the processes bj which such orosls are proditeed was unknown.
Sapachstb, Iben, simplt means a erust or scale (Schnbc), as it indeed i
evident from tbe sixth verse of the same chapter, and from other pusagea |
betides I and it is only iu Ibis seone that tbe Hebrew term in question can ba |
oorrcctlj translated " scabies," a word iUclf derived from tlio Lilin " tcabcrc,**
to scrape (scbabco), and thereforo vtymologicaU; equivalent to "8clube''or
Kniaoi but in this use of (be word the "teaiiti " of modem medicina ta not
included.

1 wiU also take this opportiuiity of eiaminbg into the meaning of the term
Zuutb witb greater minuteness, in aupport of mj statement Uiat tlie distsM
in question cannot be true ifpraty. Throughout the Uurtcgulb cliapter of
liovitieui, when cutaneous afTeaious are being spoken of, tbe word Zaraatb ia
nsod 10 oRcn as a more severe form of disease is referred to. Hut it is not
easj to SOB how this could have been elcipbonliosis, for as oarl; ai tbe third
week, wlii:ii tlic jirkit li.i.Ls m (lie iiimi. lie iii^_v pniuoiunv tliMl he n dean, or,
iuolb.'i > ■

ofajni,:.
I ulccn. "-.. — :..c — --■

niSTOEV.

107

As is wei! known, the most ancient Qrtstk writers included nil

cutaneous diseases ander the names \p^pa, Mirpa, and \ti\{iv, bnt

without giving ttny occurato definitions of tliesc diiTerent terma. As a

r general rule, however, atlections wlucli were moist, pustulu, uloora-

tUve, or attended with the forination of scabs (grindige), were pltteed

I by them under the head of ipuipa, while scaly and tuberculur alTections

' verc respectively entitled Xtirpa and X(i\/fi>. Hippocrates is said to

have remarked to reference to such complaitils, that he looked on them

as ]]ollution3 rather than as diseases {tuni auUm taHa turjiitio magit,

quam wu>rbi\. Neither in I'nulus jEgiiicta, nor in Oribasius, do we

I find any passage which goes to ahow that cither of these writers

I possessed any accurate knowledge of scabies. The only writora

I whom we have any reason for supposing to have been acquainted

I with the disease in question are Aristotle, Galen, Actuarins, and

I tome others, who speak of confagioutneu as a property of the

if/wpa.

In a work of Aristotle's,^ we find the term axapi used to deBignat«

an animal. In another passage in tiie same book' mention is made

of ^Oilptc, and it is stated that tlic ticc in question live in small

L Tctriclcs which contain no pus (tovOoi fUKpat oiV t\ovnc tt^ov).

I Now the aniinnla which lee term lice do not live in vesicles, nnd, in*

I deed, do not even penetrate the skin, but are upizoa found among ibo

V hairs, or occupying the clothes. Hence it is at least iiossihle that

I Aristotle may have meant by the word fOtlfiic, not these animals,

* most eoticbuivilj in ver«es 34 to 19. ilUch conlnin directions eotieemiiig

banu (FeuervcrbreDnnngen). Wlien the oiarra ia auch cues itro ciposcd to

the sir, and to long a* ijiey app«sr oorored nilli teabs, it is Zutatb, and llie

patitnt b to ba pronounnd uqcIbkh ; but wlien tiiey do not enl (urthor, " Uie

J. priest shall pronounce him clean," It ii a scar of tlic burn {"cine Narbe dc*

wBrandnittls"}. [Tlic Euglith tcisioh, liowcvcr, has it, "an iuflamuiaUoa of

Btlie buroiDg." — En.]

This sbort digrcaiioD (which, for the furtlierance of tha tnith, I havelhonglit
kit riglil to make} sorely prove* (lint to Irautlate Zaraath by Icpn or elepbanliasia
LGnccorum is cotirclj incorrect. U wuuliitiavebeoafarbetlciiftbotcnniiiquus-
Btiou [as wcil as Scheehia, ISaclicrctli, nnd mao; other nnnics for diseases) bad
■iKcn incorporaled.in tlio trannlatioiiH of tlio text, it lieiug left for medical men to
■ ktic to these namcalfar-irproiicrmeauing:!. For Irepeat that instead of the word
KxaraalU being aappoaed to moan siin]ily eiepliaiitiatJs Grwcorum or " lopiti^,"
I it would be more correct to underatand by il soaietimea ncabies (II King),
cliap. v). EOmctimci ulcers of syphilitic and those of nou-syjiliibtic ongiD,
tometimu ecxeoAtous scd other aSectiona (Leviticus, chap. liii).
* 'HJstoria Auimaliuni' (£d. Schneider!), Li^tia, 1611, Lib.*, eap. a6.
~ I. cit., LngduniB!, 1590, Lib. t, cap. 31.

168 SCABIES.

tout the acari of scabies, which do reside beneath the epidermis,
find also give rise to small vesicles, near which they are foond.^

In the works of the Latin writers, Horace, Cicero, Ansonios, and
Juvenal, there are passages in which the word scabies is used meta-
phorically or ironically, being either applied to actions which are
ixnsuccessful or unseemly {Scribendi versus scabies, scabies lucri) or
employed in the same sense as the German " Kitzer' (Dichter-Kitzel,
Xl^ffschafts-Kitzel, &c.). Celsus^ gives a description of an affection
termed by him '' scabies,^' but this does not correspond with the dis-
ease which we know under that name. The passage runs as follows :
Scabies vero durities rubicundiar, ex qud pustultB oriuntur quadam
humidiores, quadam sieciores. The same writer speaks of a '^ scabies''
affecting sheep, and recommends a mixture of sulphur and tar for
the cure of this disease, as well as of that which occurs in the
human subject {ac si nihil aliud est, amaria ad teriiam partem
decocta, vel sulphur pici liquida mixtum, sicut in pecoribus proposui,
hotninibus quoque scabie laborantibus opitulantur).

The physicians of the Arabian school (Bhazes, Haly-Abbas,
Avicenna, and £bn-Zohr) mention the itch in much plainer terms.
They, in fact, describe a contagious disease, attended with itching,
and essentially characterised by the presence of an eruption, to the
individual elements of which they give the name of Botor, and
which distinguish the itch from prurigo, being absent in the last-
mentioned affection.

£bn-Zohr (Avenzoar, Ben-Sohr), too, speaks of an animal as
infesting the human subject. '^ There is formed,'' he says, "in
their bodies, on the exterior, something which the people call Soab,
and which exists within the skin. If the skin is removed, there
comes out of various parts of it a very small animal, which can
scarcely be seen," &c. It would, however, be very difficult to
make sure whether by the term Soab he means lice, or nits, or
creatures which resemble Uce, but reside within the skin. For in other
Arabian works of the same period, the word ^' soabe" is undoubtedly
applied to animals living in the hair, and removable by combing it,
as well as to others found in clothing and among the feathers of birds ;
and it is obvious that these must be lice, not itch-mites. The fol-
lowing passage is quoted by those who regard Ben-Sohr as the

^ ' Die Kratzmilben der Menschen und Thiere,' yon Furstenberg, Leipzig,
1861, p. 3.
' Op. cit., Lib. V, cap. 38.

niSTORY,

1G9

;discoverer of Ihe acarua scabiei : " S^ronM, inqu'd AlenxoaT, Aioahat
i Atoab dicti ttint pedicelli, subf-er manvum, crunim et pedum eutem
'pe»te», ei puituUu iiideta eieiiaHtei tiipia pleaag j fam parva
mimalcttla nt v'tx vim pcripicaci dUecrni vakantP In this sen-
tence, it 13 ui^cd, Ebn-Zohr could not have meant lice by his

ppedicclli, null must have been speaking of itch-animalcules. But,

Fin truth, the former of these animals, as veil as the latter, may
bo the cnusB of vesicles (pustulje aquQ plente], in consequence
of the irritation of the skin to wliich they give rise ; and those who
know this fact will hardly, I thinkj see in the passage above quoted
sufficient evidence that Ebn-Zohr was acquainted with the acarua
acabiei. All that it really proves is, that he was a mnch better
observer than many of the writers who followed him, particu-
larly those irlio invented the word Phtheiriasis, and defended its
nse.

The lirat indisputable reference to the acarua scabiei is in a work
entitled ' Physika,* written in the 1 2th century by Saint Ilildegard,
the Lady Superior of the Convent on the Ruperts-Berg, near
Bingen. In the first liook "De Plantis,' there ore two distinct

L'pBSsagce in whicli mention is made of remedies against the itch-
One of these passages ia to be found in the fifty-sixth
fchajitcr, headed " Se wyntza major*" This sentence is as follows :

fc" Alia myntza e*t qua tnagna eti, ealida magit nt quam frigida.
i3iA» confundaiur, ft vbi sukek ant snevelzen homintm eomedenda

miadunt, illud eirfa detuper ponattir ef panno ligetur ; el morienlur,

mpum Jngut efvtdem majorii mentha aliquati/alum amarutn esl, el
' ' V prtffaiot venuiculoi morlificat, qui in came iominit naxwifur."

FTfao other, in the iioth chapter, " Deliilta," says, " BiUa /riffida
«ti, ti moUit nhgque vtribue; et <?' quit earn, auf oleum ex granit
^vt/actvm, eomederef, mortt^enim venenum in illofaeeret. Sed »&i
turen in komine sun/, ita quod earttem ejut exiiecant, eodem loeo earn
ma lucco tere, et luren morientur."
It is evident from these two passages that itch-mitra were at that

piiuie called suren, or tuem. Indeed, up to the termination of the lajt
century they were popularly known by that name.

At the end of the 14th century, we find Guy de Cbauliac writing
in his 'Ghirurgia magna,' " Syronti tunt animxilia parva, fadenfia

^ft'df »iauota» corrodendo inltr cament el eufem, poliut in maniiua
ptiotorum." It wonld appear from this sentence that that observer
lot only wos acquainted with the acanis itself, but also knew in

170 SCABIES.

what part of the body to look for it. He did not, however, connect
its presence with scabies, although he was aware thst the disease in
question is contagious, for we Tead iu another place, " £»t eliam
teabiet de sgrifudinibKg cotiiagioait."

In a Herbarium written by "Wilheltn Qralap, which appeared in
1456, we find a passage which may be rendered as follows, "Jusqui-
amu3 or Caniculata (henbane] is called Bilsenkrot. And let him who
has siiren in his body, rub the parts where these exist with the juice

of this herb, so will the siiren disappear. Again, the othex

' myntz,' is called the great ' myutz ;' and let him who is affected

with siiren, which bit« and produce itching, take the herb and crash
it, and lay it over the siiren, and bind a cloth over it ; so will tliey
die."

Li a work published in 1 533 at Venice, by Alexander Benodictus,
who was a professor at Padua, there is a passage which shows that
he, too, was acquainted with the acarus ^cabiei. It is as follows :
"In faanibiit quidam exUit piilicellus Icnte minor] lub cnie terpit,
tton adiaodum Jre^ent in capite atih ciile pedtculnt infantia peoulian
(■odium. "

In the writings of Paracelsus, again, frequent mention is made of
Syrones. But he seems to have applied the term, not to the acarus,
but rather to some morbid change in the skin, possibly of a pustular
or ulcerative kind. In his 'Chirurgia magna,' for instance, he says,
"Sic mim vidimut SyroJtei in crurtdtii appanime, quot pro JEstJaa-
meni* quidam curare enitt »uni"

It does not appear from the writings of Joh. Arcuianns, Job.
de Vigo, Necker, and other contemporaries of Paracelsus, that they
were acquainted with the acarus scabiei, or, indeed, had any correct
knowledge of scabies. Por the detiuitions which they give of the
disease are scanty and inaccurate ; and chief among the cansea to
which they ascribe it are "mngttii adiitlu*, bUts, atra bilit, pituita
nnl-tKe." In fact the word acabi^ was not at that time applied ex-
clusively to cutaneous diseases, being sometimes used for an alTection
of the eyes, as in the following passage of Arculanus, " Srabiei ett
irgritvdo in mpe^fif, cum a*ptrilai4 et rubedine aiil pVJitulit im
' tnper^cie tnlrinieca palpebra cum pniritii." '

ISome writers, too, employed it to designate syphilitic diaeaM*.
The following passage, for instance, occur* in a work ' Do eura
tnorbi gallici,' by Joh. dc Vigo: "Omnt genns insvper tcabiei wlmt
nt tnalvm morttitm el atajikalt, S^c." Laatly, the Mime nomo w«i 1

HI8T0RT.

Applied to tUseaaes of the scalp. Of such an use of the word, we
(have an example in a work by Rioloiius, in which he says, " Tinea
ibies particii/arit propria capiiit,"
Of those who wrote towards the end of the i6th century, there
ime (fluch as Ambrose Pat^, Aldrovandus, Rabelais, Ingrusias
and Scaligcr) who displayed a knowledge far beyond that of their
contemporaries. The following passage, for instance, is itom
I Ambrose Par^ : " Lea elrotu tout peCiU anitnaiKt toueiiovrt cacAee
I tm» le cuir, tout le^uel iU te traineni, rampent, et U rongent petit
h petit, escUant ti»e fatcheuee d^vtangeaieon el gralelle. Ik sonl
/aits d'urte malice eeicAe, taquelle provteni du [decani de viicotitS,
et divii/e et aeparSe comma petid atome» vtvant*. Let ciront te
doiveat tlriT avec espinylei oit ai^uillet ; toute/hit il vast mieux let
L facr avee ongiient et d^coctioni faitet de choiet amirei et eaUet. . . .
t Le remade prompt ett le vitiaigre dans Uijiiel on aura fait lioiiillir dii
Bt-aphysaigre et eel comm'in." Again, we find Ingrassias stating pre-
cisely what parts of the body arc most commonly infested by Iho
acarus, and describing how the animal lives, and what etfects are
produced by its pri'sence in tlie skin. After Aristotle, he was
the first writer who spoke of the pustules of scabies, and connected
them with tlie bite of the itch-mite, which be supposed, howevM,
to be a kind of louse.

In his work 'De Subtilitate,' published in Paris, 15^7, and dedi-
cated to Ilieronymus Cardamua, Julius Ccesar Scaliger s[ieaks of the
Bcarns scabiei, andjdisplsys so complete a knowledge of the animal
I ttntt one cannot but feel surprised that its very existence should after-
I wards have been forgotten, In different places, itch-mites wer« at
tliat time called pedicelli, scin, and brigantes. Among the pasaagea
which refer to the acarua is one in wliich Scaliger says of it, " ita
tub nte iaiiiat, iit aclis miiicitli-t urat ; extriKtui acu, luper un^e
potif'Ht ita demum tete 'novel, li eolit colore adf'itvatur, altera uiffve
1 prettut hawl line »vno crepat, aqnaumqtie virut reddit."

The writings of Fullopius, imblished in 1584, in Frankfort, con-
[ lain in the chapter, ' De olceribus,' the following sentence, which
fcods a» if he were acquainted with the acarus scabiei : " Alitjuando
\ orifinliir quadam animalia in tnbttantia ciitii, minima atqua pir
tiailnlia,qui» illam exednnt, atque vetictu excitaiU: tcirones vocantur
a hartari*, pedicnhi no* vocantut," Agua, in 1592, his contempo-
rary, Qatiehnus Kondclct, in describing the varieties of pediculi,
meDtioiu the itch-mite as forming ' iMtim (genus), quod g

( 173 8CABIE3.

rulgo appellant, qui nunquam extra emmpunt, el aemper intra euf^tn
el eutkttlani latitant." In another place, tooj he says, " Mulierea
acu exlraivni, el tic aese aprurlta vindicant."

Lautentius Joubertus, in 1577, evinced a knowledge both of the
acari themselves, and of the method of extracting them with a
needle. "Alii" he says, " »unt cyrones dlcti, omnium minimi,
temper rub epitiermide Ulentei, sub qua aerpuitt,&c.;" and in another
cyronet peciiliariter vulgua acicula extraMt."

Lastly, I must mention Vidus Vidius, who, in his work ' De
curatione generatim,' published in 1586, speaks in the following
terms of "syrones" under the head of lice or phtheires, " lerlia
ipeciet esleornm quot reeeniiore» medici vocanl scirojies, vulgm pedi-
cellos, qui intra pelticulam el ciitem serpimt" &c.

In the year 1 600, Joh. Schenck published in his ' Colleetio obser-
vationum medicalium,' various notes on the acarus scabiei which had
been made by contemporary observers. A paragraph of especial
interest to Germans is one in which he quotes the statement of
Joubertus, referred to above, and adds to it the remark "Germani
vocant seuren ffraben." For this expression shows not only that
people in Germany were acquainted with the parasite, but also that
they knew how to extract it with a needle, and used the term " seuren
graben" for that manipulation.

The physicians of that 'age, however, were] far behind the natu-
ralists in scientific investigation. Of this Mercurialis affords a
very characteristic example. In his work, 'De morbis cutaneis,'
which appeared at Venice in 1601, we find him following his prede-
cessors, ascribing scabies to depraved humours, and labouring in vain
to find valid distinctions between that disease and pruritus. He has
not the very slightest suspicion that the true cause of the itch is the
presence of a living animal, the acarus scabiei. Mercurialis divides
the affection into two forms, dry and moist scabies. He regards it
as a disease of the whole organism, and particularly of the blood;
and he supposes that the blood deposits in the integument fluids,
which are " it^jcjf," " mired with bile," "impure," and so on, and
that these are retained there, and give rise to ulcers and to scabies. It
may be noted that this work of Mercurialis was the earliest specially
devoted to cutaneous diseases, but on the whole one may say that he
does little more than collect together and repeat the opinions of his
contemporaries. He knows that the itch is contagious, as had in
fact been especially pointed out by Galen ; but he accounts for this

HISTORY. 178

by sajing that fluids contmning the contagious principle of the
disease are deposited in and upon the akin, that they readily adhere
to other bodies, carrying the contagious principle with them, and
that in tJiis way the malady is coiomunicated.

The views with reference to scabies and theacams acabiei held by
the aatbora last mentioned are those likewise of Felix Plater, who
wrote in 11^02 ; of Andreas Ctesalpinus, in i6oj ; of Daniel Sennert,
in 161 1 ; ofFranciscus Joel, in 16 18; and of Aldrovandus, in 1638.
There is, however, in a work published about this time by an nu-
known author, a passage which deserves to be specially quoted.
It is to he found in the ' Vocabulario dell'Academia della craaca/
and is as follows : " Pellicello (the ocarua scabiei) i un piecolimmo
£acotino, il quale ri generd S Sognoti in peile e rodendo coffiona
un' acututimo plizicore." The point of interest in this sentence is
that tile writer evidently recognised the acarus as the cauie of scabies ;
whereas his contemporaries imagined that its presence in patients
afTected with the disease was merely accidental.

In the year 1630 there appeared at Tubingen a work by Samuel
Uafcnrclfer, entitled iravro\(Tov a\o\a^{piiov. In the tenth chapter,
which treats of the pediculus and the acarus acabiei, the author
includes the latter as a species of louse, and mentions that itch
Diit*s had been ab^dy known by various names, such as acari,
cyroDcs, pedicelli, &c. He also alludes to the German expression —
" Ubendige teuren."

Foot years later, in 1654, there was published in London a work by
Thomas Mouffet, called ' Insectoruin seu minimorum animalium thea-
Irum." This book, however, is made up of ([notations from previous or
conl(^mpo^ary writers, ratlier thauuf origiual observations. Tlieonly
passage which it seems worth while to quote is one in which Mouffet
says " the English call ' milben' niites, if they are found in cheese,

ior in books, dry wood, or was ; but, when these creatures iufest the
human subject, tbcy nre termed in English ' wheale worms ■' in
German 'saiircn;' in French 'cyrones;' in Latin 'pedicelli;' by
the Basques (Vasken) 'brigantes;' by the Tauri (Tauriern) 'sciri.'"
He is acquainted with the differences between the acarus and tbo
pediculus, and says of the former that il does not live on the surface
of the skin. The following sentence goes to show that he had Iiim-
«ctf looked for the acarus scabiei, and had been successful in finding
it: — "Minim tit," he snjs, " qitomodo tarn pvtila bettiola, nuUia
^itati judiim incedeni, lam hnsoe lUti cuticutd tuUot peragal. Uoe

174

SCABIIS.

obiter e»t oiiervandum, ^roMi ialot non tn ipiitjuulutii, tvilpropt

, habitare."

But although, as I have shown, there were published between the
fourteenih and aeventeenth centuries numerous works which i)rovc
beyond dispute that the acorus scabiei hnd in those dnys been dis-
covered, the animal was nevertlieless entirely unknown to the ma-
jority of physicians. Even by those who were acquainted with tlic
fact of its existence it was generally regarded as a kind of louse, and
as being only aceidentaUy present in scabies. In looking for tho
cauie of this disease, the writers of that period (among whom I may
mention Amoldus de Villanova, Theodore de Saussure, Biolanus,
CampaneUa, Kratzmann, Louis Guyon, Dolois, Buruet, Eerneliua
and Dimerbrock) simply followed the authors of antiquity, and
attributed it to an acrimonia tan^uinit.

As a specimen of the views which prevailed at this time, and which
were entertained pretty uniformly by all contemporary physiciani, I
may quote the following passage from a work of Iliolanus, who in
1586 was Dean of the Faculty at Paris : " Pruritu^' he says, "at
seabcndi dfiiderium ob coitclutu/it Jlatum aui mordaaf tenm; vtntm
nocet, empta dohre, volttpiot ; qiutm cepit ager voli^ialem lealpendo,
earn amitiii unffuHui cutem excoriando ; inih aca&iet."

The discovery of the microscope early in the seventeenth century
(in the year 1619) by Zacharias Jansen, of Middleburg, led to many
investigations, some of which had reference to the itch-mite. It was
imagined that diseases of all kinds were caused by minute animals,
which were therefore sought for in the discharges from ulcers,
the pus of abscesses, the bloocl, and other flaids of the body.
Among the founders of the theory in question were tiauptmuui,
BorcUue, Kircher, and Bonani. In a pamphlet by the first uf
these writers, entitled ' Uralter Wolkeosteiniscber Wanner- Bad- und
Wasserschatz,' there is the following passage, in which tha itch-
mite is refened to : " CridoMS «. Dracunculi, blatta, tinea, vari, tt
cemiculi iUi comdenles >n morbillit, scabie, et puttulU, cgnmM
$. acari, quo* Germani ' Eeitlieten' appelUtare toUnt, yuiqita «cu>
trites caiuanl." ....

Hauptnuinn was likewise tho ^rA to give a sketch professing

, to represent tho microscopical apjwnranoe of Uie acarus HcabieL
This drawing is coutoirtcd io a letter addressed by him to
Ktruher. Probably it is owing to the defective constniofcion of the

V microscope in those days, tltat one would be disposed to imagine any-

dor
is, '.
alU
diu
M
i
lion,
H of ft:

n jt

HISTORY. 176

ing nither than the itch-mite (or, as he torms it " Moolbea") to
the subject of the figure in (juestion.

Several otlier works published in the seventeenth century con-
in passages which show that the acarua scabJei was known to
their authors, as well as to many contemporary observes. Proofs
of this, for instance, are to be found in the writings of John
'ohiiston, Peter lioreHus, Samuel Bochart, Guiseppc Laurenzio,
> Itahault, and Daniel Ludovicus. Some of these writers, and
long tbem Borellus, speak of the animal as resembling a tortoise
form. Others, including Eahault, make special mentiou of some
of its characters, and particularly of t)ie scale-like structures on its
dorsal surface. The point of view from which they regard the acarns
is, however, generally that of natural history ; and they cither fail
altogetlier to connect it with scabies, or ascribe its presence in that
disease to accident, or, lastly, imagine it to be generated from pul rid
Auids.

It further appears from the works of the writers under considera-
tion, that in their day the extraction of the iteh-mite by means
of a needle (or, as it was termed, " seuten graben") was a common
itice. lliis little operation seems to have been generally per-
med by old women, who are said to have done it with great dex-
terity.

Alichael Ettmuller next published n figure of the acarus which is
much nuire correct than tliat of Mauptmann. But Thcophilun
Botmet and Blanchurd confound thnt animal with the pediculus, anil
the latter described all these paraaites under the general name of
Phtliiriaais (Leuasickte, Luisaucht, or, in German, seuren, Laus>
_wcht).

In the seventeenth century the most complete investigations with
Terence to the acams scabiei and its relation to the itch were thot^e
Giovanni Cosimo Bonomo, a physician, and Diacinto Cestooi,
apothecary, at Leghorn. The rcsulls at which these observers
ivi'd were announced by Bonomo in a letter which lie addressed
Francesco Rcdi, who liad previo'ttsly acquired a great renown in
scientific world by his opposition to the doctrine of ffeneralio
ivoca, and by his thorough study of insects. Rcdi himself
id high in favour at the Court of the Grand Bukc of Tuseanjt
687 he published tlie letter of Bonomo, at I'lorence, under
nirinj title, " Ouervatioai tnhrno ai peltictUi del eorpo
\o, fatte dai dolhr Oioi: Cotimo Bowmo, t dalui con altrt

176 SCABIES,

ouervazioni icritle in una leUtra all' illtulre Sig. Francetco
Sedi."

This pamphlet is so excellent, that even at the present day there
is very little to be added to the account which it contains of scabies
and the acarus scabiei ; &nd it is of such importance in rcfereDce to
the history of that disease that I think my readers will wdcoine the
following translation of certain passages,

" Diacinto Cestoni .... assured me {says Bonomo) that he had
again and again seen a ' something* (un non so che) extracted by old
women with the point of a needle from the skin of their httle children
when affected witli scabies. This 'something" was found in the
smallest vesicles, before they were quite ripe. It was then placed on
the nail of the left thumb, and cracked with that of the right thumb,
80 as to produce a slight sound. He had also seen the prisoners and
slaves in the galleys of Leghorn do the same thing for each other.

" He went on to say that he did not know for certain that the
mite thus removed was a living animal, but tliat all doubt might
soon be set at rest by any one wlio would (aa I had suggested to
him) make a series of experiments on a patient affected with scabies,
so as to determine finally whether it was, or was not, the case.

" We soon, therefore, found the patient required ; who, when &sked

where he felt the most severe and intense itchmg, showed me a

number of email vesicles, of which the contents were not yet puhform,

and which were such as are commonly called holieelte acqtiaiitole.

Into one of these small vesicles I introduced the point of a very fine

needle, and, having squeezed oat its contents, I liad the good

fortune to succeed in digging out a little round white body, bo small

as to be barely visible. This, when placed beneath the microscope,

was seen to be indisputably a minute animal, of a wtiite colour, with

a small dark spot (fosco d'ombra) on the back. It somewhat

resembled a tortoise in shape. It moved rapidly by means of

. six feet and a few long delicate bristles, and had a pointed head with

I two small horns or autennee at its extremity. We did not content

I ourselves witli this one observatioii, and afterwards examined many

3 of scabies, in patients of various ages and constitations, of

I different sexes, and at all seasons of the year. We always found the

laamD little animals, which existed iu almost oil the vesicles. Iniome

■Tesicles, however, they could not be discovered. On account of tbor

I minute size, and of their coloar being the same as that of the Aia,

r H is difficult to detect tkom upou its ejiterior. ilut lie have, never-

r HisroRT. 177

ubeli»8, aererol times sef ii an acorus moving about on the cutaneous

Bnrface, particularly over the joints, and in the small farrows of the

Blteg;uinent. It ia there that the animal 6rst penetrat«B hj means

Bf its pointed head, g^nwitig and liurrowing, so as to give rise to

^Roublesorne itching, until It has got altogether beneath the cuticle.

JBaviiig elTecleil tiiitt, it still continues (as may be observed without

BiBicult;) lo bite and tunucl its waj beni'Dth the epidermis, making

Fl passage from one point to another, and thus leading to the forma-

I tion of several papules (Knotcheu) filled with fluid. Of these we have

often seen two or three together, and generally quite close to one

snothcr .... We next exerted ourselves to discover whether this

lit ttc animal lays eggs ; and after many and repeated investigations

fortune favoured ua in onr inquiry. We had placed a mite beneath

the microscope in order that Isaac Cotonello might make a drawing

of it with his skilful pencil. While he was looking at it in making

his sketch, there was extruded from its hinder end an extremely small

Hlody, which was in fact a while egg,t ransparent, elongated, resembling

K fir-eone in shape, and no minute as to be scarcely visible . , . ,"

■ Asitisnota matter of great importance that the restofBonomo's

P'lettcr should be quoted in full, I will simply state its purjiort. He

I goes on to soy that Cestoni and he afterwards repeatedly found tlie

I tggi of the acarus. They did not succeed in discovering any sexual

[ difTcrencea in the animal, but they were nevertheless both satisfied

I Uiat reproduction is effected by the union of a male and a female,

■and not per genfralionem aquivoeam.

H These observers, theu, concluded from their investigations that
Hiere were good grounds for doubting the truth of the opinions of
Iprcvious writers with reference to iJie c^nse of the itch. Instead of
attributing the disease in question to the "melancholic juices" of
Galen, the " acridities" of Sylvius, llie " special fetmentation" of Van
Helmont, or the presence of irritating salts iu the liquor sanguinis
kr lymph, ns bad been supposed by later writers — instead of
Bulopting any of these notions, Itonomo and Cestoni came to the
Bondusion that the itch (the complaint called iu medical works
^mealiiet) Dri»es simply from the presence of nn animal which is in-
Hiasantly biting the skin. They supposed that tliis causes a certain
^ksntity of the liijinir sancriitnis to transude through the small
^Rteninga iu themi: il<- vesicles, iu which the animals

^BemsrlvcH live. I nue to gnaw, and thus produce

^■V«n itdiiog. 'J Ik lore compelled lo keep scratching

178 SCABIES.

himself, and thus not only destroys the vesicles^ but also wounds
the skin itself and some of its small blood-vessels, giving rise to the
formation of little pustules, excoriations with crusts on their summits,
and other effects of a similar kind.

As they remark, this view also explains the ease with which scabies
is communicated, since the contact of two persons might obviously
transfer the acarus itself from one of them to the other.

Bonomo further supposed the itch-mite to have the power of crawl-
ing with considerable speed, either on the surface of the skin or
beneath the cuticle, of adhering to anything which touched it, and of
laying ova so as to multiply with extraordinary rapidity. In accord-
ance with these views, he considered it to be possible for scabies to
be communicated by shirts, pocket-handkerchiefs, gloves, or other
articles which had been used by persons affected with the disease.
Finally, he supposed the acarus scabiei to be able to live for two or
three days outside the human skin.

In regard to the treatment of the complaint, it was obvious to
him that internal remedies are not of any essential service, whereas
alkaline baths, and ointments containing sulphur, vitriol, mercury, or
certain salts, cure it by killing the acarus within the substance of
the skin. If this result is not observed in all instances, the failure
is (he says) due to the fact that some of these applications do not
destroy the ova and the young of the mite, as well as the animal
itself. He therefore advises that the treatment should be continued
for a day or two, even after the disease appears to be cured. The sub-
stance most strongly recommended by him for external application
is tlie ointment of red precipitate, scented with orange-flowers or roses.

The claims of Bonomo and Cestoni to be regarded as the authors
of these discoveries in reference to scabies were subsequently con-
tested, in 1689, by one Giovanni Cinelli Calvoli, who asserted that
he had observed the " pelllcelli" ten years before Cestoni. He also
declared that he had had drawings of them made by a certain Sig.
Protasio Felice Salvetti, whom he accused of having made Cestoni
and Redi acquainted with his investigations. Calvoli, however, was
not, like Bonomo and Cestoni, of opinion that the itch is caused by
the acarus. He supposed its main cause to be a saline state of the
skin, and fancied that the rapid multiplication of the '^pellicelli"
occurs only in those persons who have excess of " salt" (salziges)
and " nitroses" in their integument.

Besides the authors already spoken of, several of their contempo-

His'i-onv. 179

I wrote upon tlie ncnrus scabiei. Auioiig these, for example,
terc Daniel Lipstorp, Joliaiin Doleus, and Carolua Muaitanus, but
icre is iiolbiiig worlby of special mention iu the works of any of
no, except the last named ; dikI of Mu^itanue all that need be said
■at he knew that the acarus should be sought for, not in the tetkle
t scabien, but in the extremily of the burrow.
MoBt of the medical writers of that day, however, continued to
rngard tlic itch-tnite as a kind of loose. For example, Philip Bonanl,
Lihhougb the title of his book is 'De Syrouibua intcrculanets,'
figures in it a six-legged animal which ia not the acairuB, but a pedi*
cuius pubis. Slany others, too, knew little or nothing of the investi-
gations of Bouomo and Cestoni. This was the case, for instauce, with
G. C, Scheilenhammer, Theodor a Pauliz, and Peter Keck. Iii their
writings (puhH^ird in the i8th centnry) the acarus is not always
mentioned as the cau»e of scabies. 'V\wy rather took delight in
creuttng various kinds of "acids" and "juices," and Jn the subtle
llBranings which tbey attached to tlieir arbitrary hypotheses. Thus
I'Belmoiitinfl taught that aeid in tbc stomach causes a good and
I nAtiiral taste, but that when it gets beyond that oi^an it gives rise
I to a morbid and hostile inQuence, producing strangury, if it pusses
I into the urine ; gout, if it is deposited in the joints ; and scabies,
I K it reaches the skin.

Lastly, it must be noted that in 1710 Cestoni wrote a Idler to
I Talisneri, in which be claimed for himself alone the merit of having
L&covered the itch-mite, hitherto divided between himself and
iBonomo. The letter iiiqucstion contains neilhermore recent obscr-
I vsttons, nor more detailed descriptions of the animal and the disease.
Lncas Tozzius, Lunzoni, and Kichard Mead remain to be men-
rtioncd as having tmnshitcd, and commented on, the works DrCe»toni
I ind Bouomo, and as having thereby aided in dilfusing more widely
I a knowledge of the important facts contained in their writings.

It is, however, in vain that we ecarcb in tbc works of (he most

mowned physicians of that day for the practical a|>p1icntion of

! new doctrine which they taught. Even to those writers who

Rittcogni^ed the existence of the itch-mite it nevertheless npjiearcd

I! probable that scabies arose from a dyscrasia than that it woa

KtROwd by the acarus.

To this rale, however, there were exceptions in Lnucisi, Ncn-
erus, J. Allen, Zwinger, and esjiecially Jacob Schwiebc, ^t hit published
1 1723 a 'Disseitatio de prnritu exantbcmatum nb acaris.' In thit

180 SCABIES.

treatise he adopts the division of scabies into 8. hutnida and 8, sicca,
but he knows that living acari are foand in both varieties^ being
solitary (vereinzelte) in the former, aggregated together in the
latter^ affection. In the plate appended to his work he gives draw-
ings of the itch-mite, taken partly from his own observations, partly
from those of Etmiiller and Cestoni. He supposes that the animal
is derived from sweet fruits, such as grapes and figs, and that it
may either reach the skin by contact from without, or be swallowed
in the fruit, in which case it is reanimated in the stomach, and creeps
from that organ to other parts of the body.

A similar opinion was professed in 1718 by Jean Junker, of
Halle, who attributed scabies to drinking birch-juice in excessive
quantities, and also to the use of the baths of Wolkenstein.

In an anonymous pamphlet written by one '^ M. A., CD.,*' and
published by an English physician in the year 1726, there are
several passages which show that the writer had an accurate know-
ledge of the acarus scabiei, of the scabies itself, and of the proper
method of curing it. A copy of this pamphlet exists in the library
of Dr. Auzias Turenne, in Paris.

Linnaeus, in his 'Systema Natures ' (i734)> placed the Mites
among the Insecta. But in a later work, the 'Fauna Swezica,'
published in 1746, at Stockholm, he classified the itch-mite (which he
names ^'acarus Aumanus subcntaneus") as a variety of the Acarus Syro.
In another place, he mentions it under another title, that of Acarus
exulcerans. "Acarus exulcerans" he says, "pedibus longissimis seta-
ceis, aniicis duobus Irevibus, habitat in scabieferina, cvjns causa est."

Many of the other medical writers whose works were published
about this time (and among whom I may mention Bichard Mead,
Johann Storch, Gabriel Avelin, Michael Backner, and J. Nyander,
the last of these being Swedes, and pupils of Linnseus) did little
more than repeat the doctrines taught by their predecessors,
although they seem to have been skilled in the art of extracting
the acarus.

I now pass on to name certain authors of the middle of the last
century, who were perfectly acquainted with the acarus, and with
its relation to scabies, and, moreover, exerted themselves to diffuse
a knowledge of the true nature of that disease. These were (among
others) "Wilhelm Eeichart, in Germany, P. S. Pallas, Morgagni
in Italy, Caspar Casal in Spain, Geoffrey in France, and Bosenstein
in Sweden. Their writings did, indeed, make the itch-mite knovo

• itc
del

HlSTultT. 181

professed naturalists, but llie_y were far from being equally
iccpssful with the physicians who gave the tone to medical opinion
that day, Hud by whom the existence of the acarus, and its con-
ion with scnbicj, were by no means onteservedly admitted,
meeming this point I may refer to the 'Tractatus de morbis eu.
ineis' of A. C. Lorry, which appeared in 1777, at Paris. This
Iras the first bool^ on diseases of the stein which was published in
the i8th century, and it did not merely rej^at the opinions of past
generations, but contained likewise the views of llie day to which it
belonged, and, consequently, became the authority upon dermatology.
In this work we find Lorry mentioning (in p. 230) that many
ibysictans of that time supjrascd difTcrent diseases, and among them
ibies, to be the result of a fite-a venninom {eredanf a vfrmi&in
ilere fabiem). Prom this view, however, he dissent-s for several
isons. In the first place, he believes that many febrile complaints
tuve been cured by an attack of scabies. He also considers the
itch to be a morbun drpuratoriut ; for he says, when it is impru-
dently driven in, affections of the lungs or other viscera frequently
krise; and, on the other hand, various diseases (»ucli as asthma,
iflammation, nwA/ebres mali morit] have been cured by the patients'
iwearing clothes taken from persons affected with scabies. Lorry,
ilherefore, inclines strongly towards the view which looks for the
CAU5C of the itch in a peruliar Arrimonia mnffuinu, residing in the
ftcid and saline serum, and consequently itself containing a principle
whicli has a saline taste {muriat'icwa quid ad ffuthim), and which,
although not volatile, nevertheless possesses a specific penetrating and
contagious smeU.

1 have quoted the opinions of this writer in detail for the purpose
of showing how closely certnin erroneous notions concerning scabies
which are somewhat prevalent among the medical men of the present
day correspond with those which held sway in Lorry's lime.

In a dissertation, ' Dc scabie humani corporis,' by C. F. Schubert,

published at Leipitig, in 1779, we read what views with reference to

scabies were imparted to their followers by the teachers of medicine

that period. Among other thiogs he says, "Although I will not

ny Ibnt worms really exist in the pustules of the itch, yet their

irescncc is no proof that they are to be regarded as its cause. It

quite as probable that they are in some way or other generated

by the disease ; for we find worms in ulcers nnd wounds, and yet

10 one would atsert that these wonns give rise to the ulcers, llie

182 SCABIKS.

same thing occurs in achor and in eczema of the ears (nassenden
Ohreii), tinea capitis, &c.

Another theory as to the cause of scabies held bj many medical
writers of high repute (including Werlhof, Eichter, Camerer, and
Daniel Coschwitz) is that which Werlhof expresses bj saying,
^' Scabiem humanam vera ex lana avium advenire/' So satisfied were
those whom I have named of the truth of this opinion, that Cosch-
witz attributes to it the frequency with which scabies is seen in
tailors, as compared with other workmen.

On the other hand we find William Buchan, of Edinburgh, assert-
ing, in 1783, that scabies may be caught by living for a length of
time in a damp house, and that it arises from an internal cause as
much as scorbutus or syphilis.

The first faithful representation of the itch-mite {mitfe de la gale)
is that given by C. H. Dcgeer, in a work of which a translation by
Pastor Gotze appeared in 1788 at Nuremberg. The writer describes
the feet of the animal, and the stalked suckers at the end of the
anterior legs, and explains how these arc used in progression. It
was in very great part due to his labours that most of the phy-
sicians who flourished at the end of the eighteenth century no
longer denied the presence of the acarus in scabies, although
opinions still differed widely as to whether the animal was the cause
of the disease, or a result of it.

A proof of this statement is afforded by the work of Otto Fabricius
on the Fauna Groenlandica, and also by those of Daniel Pischchecow
and Wichmann. Of these writers the one last named did more than
all others to make generally known the mite-theory of scabies, by a
book entitled ' iEtiologie der Kriitze,^ which appeared at Hanover
in 17^6, a hundred years after the date of the celebrated letter
written to Eedi by Bonomo and Cestoni. It is true that the descrip-
tion and the figure of the acarus scabiei are defective, which are given
in the second edition of his work, published in 1791 ; but his know-
ledge of the disease was so complete, that in this respect he has been
surpassed by none of his predecessors, and by few even of those
who have followed him. He was perfectly acquainted with the
burrows made by the itch-mite, and with the papules (Efflorescenzen)
near which young acari are to be found ; and he describes exactly
how to extract the animal from these different places with the point
of a needle or penknife. The following passages of his work seem
to be worthy of quotation: one on page 61, where he says ^'This^

iii-STOiir, 183

J the true Ecabies, never arises spontaneously, and is communicable
I only by contncf. ;" anolher, on page 87, " Tlie acnri are present
I before tlie scubies appears, and one almost sees that these insects give
rise tu the very first vesicles (BliLSCgeiis) ;" and, agaiu, on puge 94,
" I have good reasons for supposing tjiat tite scab in sheep is
idenLi<:al with what is termed scabies in man, and that the former
disease, like tiie latter, is caused by the acanis."

Wichmann Ukewise mentions in the work to which I am referring
that attempts had been made by G. C, S. U — , a friend of his, and
I by Prof, Hecker, of Erfurt, to ascertain ejiperi mentally the habits
of the itch-mite by placing living acari on their own pcrfons,

Now it is not to he denied that many of the contemporaries of
I this writer adopted his views concerning scabies. But it is equally
I certain that the theory in question was disputed' by many others,
I even among those who were' regarded in their day as sound pliysicians,
I inch as fiatdingcr, Crell, Schmuckker and Jilger. The reason for
I this may have bet-n simpJy the fncl that so few were skilful enough
eed in finding ihc acarus. Even ScUe, Justi, and Kcrsting,
I who were men thoroughly competent, and indeed posaes»ing repula-
I tJons above ihe average, were uusblc to free (hcmselvcs entirely from
I the prevalent views, 'lliey did, indeed, know that an acarus is
I prewjnt in scabies, but, instead of regarding it as the sole cause of
] tlie diseaiW, they supposed It to he only the monifntuta excifatu, bts
] lieving that for the production of the itch a momentiim ditpotifitt
I also is necessary, consistiag in a special predisposition on the part
I of the patient.

Nevertheless there were, even then, some great men who laboured
I to make the true nature of scabies more generally known. Such
I were, for example, Philippe Pinel {1789), Dr. am Stein, and John
[.Tiunttt (1788).'

> Prof. Hebra quotes a pusage of Jnha Hiinlcr's, wliJcb may be rrtranshled
I into Engiish as rollows : " I am aware lliat vkqj niedical men ttill doubt
r tlie itch is really caused by to insect 1 but 1 1tn«e repratedlj teen tb«
ViJniiDBl etlractti! from the skin wilii a acedlo in cases of this nature, Bad h^TC
Insmined it with a magnirjiDg. gloss."

I hate bern unable to Qnd in tbe published works of John Hunter the

VAuttiurllj for this teulence. Tlie only iTrrrcnce lo llie ilHi-mlte •hicli I hare

I'bccn able lo liiacoter ia at p. C18, in tlie Ijnl volume of Mr. I'almer'a editioD.

KU'liii is as CulluTa: "The discue tuu brcn said to arise from aiiimalrulo: : but

^letf, if prcient, are, I am lure, uiintceMsrj foe llie eKinleiice of Ihe disease, ss

* 1 eumined the matter, snd found 110 aniniali in it ; tel lliey may

184 SCABIES.

At the commencement of the present century physicians and writers
on natural history were divided into three parties^ as regards their
knowledge of the acarus scabiei^ and of the cause of the itch. A
small section only adopted unreservedly the doctrines of Bonomo,
Cestoni, and Wichmann. Another section, who could not or would
not deny the existence of the itch-mite, regarded it as a consequence
of the disease, which they supposed to be caused by an altered state of
the juices. The third party, including the majority of the profession,
adhered to the old worn-out notions of " acridity*' and " decom-
position'' or (like M. Favarielle, in his thesis on scabies, which
appeared in 1805) maintained that the complaint arose from a
syphilitic or scorbutic taint, and from a morbid change (Entartung)
in the perspiration.

Among the writers who were acquainted with the acarus scabiei,
but who held erroneous views concerning its relations to scabies, are
to be mentioned Jos. Adams, Banger, and perhaps Willan. The
first of these had been taught in Madeira how to extract the animal
by an old woman, who told him that in that island it was called
" ouQao," or " ougam," when occurring on the body, and " zagra,"
when found on the head. Both Adams and his friend Banger
afterwards tried to inoculate themselves with scabies, and in this
way not only caught it in their own persons, but gave it uninten-
tionally to others. In spite of these experiments, however, Adams
draws distinctions between the affection produced by " ouQoes" and
ordinary itch. As to Willan, it is very doubtful how far he was
acquainted with the acarus scabiei, the only passage in which he
mentions it being this which follows, and which is taken from his
account of prurigo mitis.^ " When persons affected with it neglect
to wash the skin, or are uncleanly in their apparel, the eruption
grows more inveterate, and at length changing its form, often ter-
minates in the Itch, when Pustules and Vesicles arise among the
Papulae, the Acarus Scabiei begins to breed in the furrows of the
cuticle, and the disorder becomes contagious.''

Of about equal importance with this passage of Willan's is a
remark of Alibert's, quoted by Rudolfi,^ that '^he (Alibert) had

sometimes be found in the matter. I forget who was telling me lately that
Dr. Teigh had shown them to be, not in the pustule, but in the akin near it,
as little black specks."— [C. H. F.]

^ *0n Cutaneous Diseases,' 1808, p. 70.

' 'Bemerkungen aua dem Gebiete der Naturgeschichte.'

HISTORY , 185

Lfound a peculiar kind of insect in the itch derived from the liorse,"
I andj again, timt " he waa acquainted with twelve kinds of scabies,
I each with its own species of acnriis."

New invea ligations with reference to the itcli-raite were about this
lime made by 1'. A. Latreille, who gave to it the name of tarcoplea
Wifafiifi. But the conclusions arrived at by this obaervor found
' nmoll acceptance with the physicians of his day. It is, iudeedj
evident from the quotations which I have made from their writings,
that even the great authorities in dermatology at that time cared very
little for the labours of men of science; and the majority of medical
practitioners were in the liabit of relying upon the statements of
those who were at the head of their profession, without making any
independent inquiries of their own.

Another cause which contributed to lead medical opinion still
I more widely astray as to the nature of scabies, was the doctrine of
I homoeopathy, which was then spreading from Germany over Europe.
I In fact, as is well known, one of the dogmas propounded by the
I followers of Hahnemann was, that most of tho diseases whicli affect
I the human body result from itch, driven in, suppressed, or removed
by inunction. Another of their assertions ww, that scabies can be
produced by rubbing in sulphur-ointment, and aficrwarda cured by
I sulphur; and this incorrect statement tended to revive the old theory
I of an "acridity of the juices," and still further diverted tho atteu-
, tion of the profession from tlie acarua scabiei.

Another physician and medical writer who, in [791, published a
little book on scabies, was Guldener von Lobes, of Prague. His
work, however, is full of errors,

While medical men were thus departing further and furlber from
a knowledge of tlie true cause of the itch, several excellent books,
I based upon experiments of various kinds, were being published by
I veterinary surgeons.

So far back as 1790, there nppeared a trentise on the scab of
[ sheej), by Viedebantt, in which this writer attributed the disease to
acari, " The scab," he ssys, " is primarily and essentially an atfec-
tion of the skin set up by the presence of insects; but the aeco-
roulation of irritated fluids renders it secondarily a mixed disease
(An sich und ini Aiifnng ist also die Raude eine bios von luseclen
[ verursachto Vcrderbung dcr Haut; nacliher wird sic durch dcn
cdu erregtcn Safle eine gemischte Krankheit). Everything

186 SCABIES.

is a remedy for it which kills the insects and their youngs corrects
the morbid state of the skiu^ and removes the acridity which is its
result."

By the veterinary surgeons of a later period, however, there were
published works on the scab, and on the acarus which produces it, of
so great excellence that even now their value on many points is
indisputable. I refer to the writings of Gohier, St. Didier, Bosc,
Huzard, Dumereil, and, above all, Walz. The last-named of these
authors, among other things, succeeded in experimentally communi-
cating the disease, and describes the symptoms which he observed
in sheep, when the scab had been produced by placing acari upon
the skin of these animals. He was aware that the acarus of the
sheep has two sexes, and knew how it dififers from the human itch-
mite. He gives figures of both the male and the female; and al-
though these are imperfect, they are, nevertheless, such that one can
recognise the outlines of the animals they are intended to represent.

The veterinary surgeons of the next twenty years (among whom
were Hertwig, Gurlt, Haering, and Bitter) made important additions
to these works, and contributed greatly to the accurate knowledge of
the duration of life of the acarus, and of the way in which it is
communicated from one animal to another.

Nor did these observations remain unfruitful. They excited
among medical men also (particularly in Paris) a desire to redis-
cover the human itch-mite, which had fallen into oblivion.

Alibert, therefore, invited M. Gal^s, apothecary to the Hdpital
St. Louis, to search for the acarus scabiei, and a reward was ofiered
to any one who should succeed in finding it. In 1812, Galis pub-
lished the results of his investigations in a work entitled an ^Essai
sur le diagnostic de Ja gale.' He stated that he had found more
than 300 acari, some of which had six, some eight legs. Moreover,
he repeatedly demonstrated living acari under the microscope, in
presence of a commission consisting of MM. Leroux, Bosc, Ollivier,
Latreille, Dumereil, Pelletan, Eicherant, Alibert, Dubois, and
others, who had been deputed for the purpose by the Academy, and
before a large assemblage of medical men and students. Figures of
the mites which he exhibited were made at the time by a skilful
engraver, M. Meunier.

These animals, which Gal^s declared to be itch-mites, were, how-
ever, sought for in vain by some of his contemporaries, among
whom were Muronvall and Lugol, as well as Galiotti and Chiarughi,

HISTORY.

187

[ of FlorencD. Lugol, tiiereforc, renewed the offer of a prize to any
one who would chow him the acarus. The effect of this was that,

\ in 1829, Raspail announted that he had succeeded in discovering
In ihe presence of scientific men iuvited for the puritose lie
placod beneath the microscope the fluid taken from n vesicle, nnd
showed that it contained a minute animal, which moved. But when
every one had aatiafitd himself of Ihe fulfilment of Raspail's promise,
Bnd had duly admired the excellent drawing of Meunier, which left
no doubt BS to the identity of llie uiiimal exhibited to them with that
formerly shown by Gales, finspail declared to the doctors assembled
(among whom may be mentioned Cloquet and llaUly) that this
animal was nothing more than a chcese-mite, wiiidi had been intro-
duced into the tluid for him by an obliging friend.

Afterward*, n certain Herr Patrix asserted, on several occasions,
that he \inew how to find the acarua eoabici. At his invitation,
Dupuylreu nnd the greatest savants in Paris attended to see it, hut
he had no itch-mite, nor even a chcese-mitc, to exhibit.

The result of the failure of theseottempts to demonstrate the acarus
Bcahiei was that (in Prance, at any rate) its existence became more
than ever a matter of doubt. In other countries, however, the true
itch-mite was known to certain observers, among whom were Olferi
(i8t6), Karst<.'U (181H), Lamarck, and Joscjih Prank; but these
were opposed by Hcrhrandt, Gankofner, Wenzel (1825 — 183s),
and several others, who expressed themselves decidedly against the
opinion that the cause of acabtea is an acarus.

In 1834 the itch-mite again ottracted a large share of attention,
both from physicians and from those interested in natural history.
A Corsican, named Bt-nncci, wlm hnd probably seen the animal
extracted by old women in his native country, taught the medical
men of Paris (who were still disputing as to its existence) how to
find the ncarus scabiei for themselves in cases of itch. He ofier-

I wards wrote a thesis on the subject, and presented it In the medical
facultj on taking the degree of doctor of medicine. Stimulated by

1 BeDucci's example, many of the younger members of the profes-

I sion io Pans made the moct assiduous elTorts to discover the acarus,
and with what success is best shown by the number of works pub-

[ tifhed in that year, and in the jears which followed, by different

I writers, including llaspail, Aibin Gras, Sedillot, Baudet, Lcroi,
Vandenhecke, Antoin Dugiis, P. Rayer, and Emery. The author
Wt named, besides describing his own iuvestigationa, gives a i6sam4

188 8CA6IE8.

of the observations of others. He also mentions the fact that acari
may be found in the fold of the axilla^ and in the skin covering the
genital organs, as well as on the hands and feet, where they were
previously known to occur. I cannot, however, understand his
statement that the animal inhabits the whiskers. Finally, it must
not be omitted that Emery treated scabies by frictions limited to
the affected parts of the cutaneous surface.

At this time, medical men in Germany (as, for instance, Adam
Schmidt, and Beese) still adhered to the old views concerning
the cause of scabies, and knew the acarus only by hearsay, and by
the accounts of the older authors. The German writers by whom
the itch-mite was first made generally known in their own country
were Stannius (the translator of Bayer), of Berlin, Baum, of Dantzic,
Wiegmann, and the veterinarians Hertwig and Haering. It is also
stated that Stannius was the first German physician who in recent
times succeeded in finding the acarus, or gave an account of it.
Oken, in his work on Natural History, speaks of the itch-mite,
but confounds it with the cheese-mite, saying that there is scarcely
any difference between them. The only noteworthy remark which
he makes is, that the acarus is conveyed from one part of the body
to another by scratching.

In the years which followed, the writers who did most to diffuse
a knowledge of the itch-mite, and of the true nature of scabies,
were H. Vezin, of Osnabriick (1836), Kohler, Heyland, Bohde,
Schwartz, Sonnenkalb, Deutschbein, Koch, and Veiel, in Germany ;
Auber, Dujardiu and Nerfe Got, in France; Kegelaar and Van
Leeuwen, in Holland; Sundewall, in Sweden; 0. Holhouse and
Erasmus Wilson, in England.

How extraordinary, then, does it appear that during this time
clinical physicians of great eminence and of European fame (such as
Schonlein, Fuchs, and Hildenbrandt) should actually have omitted
to make any mention of the acarus, or have regarded its presence as
quite an accessory element of scabies ; or (like Burtz, Horn, and
Bernhardi) have asserted that the disease still springs up de novo,
and that the sarcoptes hominis arises by spontaneous generation
within the pustules.

In the year 1846, there appeared in 'Froriep's Notizen' a paper
by C. Eichstedt, of Greifswald, which forms an epoch in the history
of scabies. It had previously been known tliat the acarus lays eggs,
figures of them having been published by different writers. But to

niSTORV.

189

BichsteJt is especially tkc tlie credit of having been the first, to
scribe accurately, and give drawings of, the burrows of the itch-
te, with the eggs, egtc-shells, and fteces which they coutaia.
■, lie gives an account of an acarus which he supposed to
bo the male, which is slightly smaller than the ortlinary kind, and
which, instead of forming a burrow like other acari, is found simply
..covered with a thin plate of epidermis. He does not, however,
J this variety of the auimai. He also describes the young
carus as a six-lcggcd larva. Lastly, he mcntiotis the interesting
t that be found the liuinau acarus in the crasts which were taken
rom a horse severely affected with the mange, and which had been
a to him by a veterinary surgeon named HoUt.
Thus Eicbstedt was the llrst writer who gave descriptiona of the
1 of the burrow made by the itch-mtte, of the positiou of the
!ggs within it, and also of the larval stage of the animal, and the
Isoulling which it undcrgnes. It would he dilBcult to determine
iwhcther lie was likewise the original discoverer of the male acarus, or
whether Professor Kriimer is entitled to the credit of having been
i Gr»t to find it. But however this may be, it was certainly
[ one of the two, and not the Preach observer, Lanqnctin, who de-
I ttinuslratcd the sexual difTerences of the parasite. The following
^ is Kramer's account of the matter :^ " I refer to the acarus scabiei
r the purpose of drawing attention to the fact that the male, to
c discovery of which Lanquetin and Dourgiiignon lay claim, was
cognised by me so far back as the ypAr 1S45." Kramer, however,
\ first eihibited a drawing of the male acarus {and not even then Uic
[ Animal ilselT) in September, 1846, at Kiel. The only distinction
} which he gives between it and the female is the fact that in the
fonncr suckers exist on the inner pair of the jiosterior, aa well as
on tie anterior, feet. It is, therefore, likely that both Kramer and
[ Eichstedt did discover the male acarus about the same time, and in-
I dcpcndently, but, at any rate, five years before it was found in France.
In the year 1 85 2, however, Lanquetin and Boui^ignon, from their
■ own investigations, described, and gave drawings of, the generative
of the male itch-mite. To Bourguignon in particular
I medical science is very greatly indebted for the detailed account
which he gave of the anatomy of the acarus, and for the experitnenta
which he made of transferring the parasite from man to the lower

' ' Frtf[nienti,riectie N'ottHii uud Abblldungen lur HelmiatholosiB aiid
Paruit«a]ebre,' 3 Band, p, 91)9.

"Wi

inimaw, tad iarm. '^seni u amu Wiea maasmm ic :»& mmtal

airniirj if ^^u inTh-miR. iiiw»!T«r. I -Hiail lan; ii srr -anc nn? ^ait.
^•^ irrr% in. li -nac jb mr^ Amu ika « nan^ Toer Fr-aci
▼^t-^r*^ ae iksxst^ x xieac issucmcs if :fii; ! Iiw;nLHPs if iiPEiri

•5»i tiiBciiUL i ii< f ** T **r . 31 it u -anmnE Jiiiir-<9Ciiiinn]r liaff fecm
t3u» ittbia if aieucat iiei. "aac fame tps^ mr rjii"Tii»t -rwHt bv
tile ■•'i.Teilisic TTork* -i Troici E irr?; lesi yi^&rrnsjz, "Pus* w«e
tt ^lac 'inu^. md "iieps ir -jvisl :idw ol lico^. .ffinmcjiiiescs
"if ixM. g^miTacani it Pm* iimnng TrmuL xm "xi in meacuixiRi
^^^*VT.^ GihfflPL ami CazHiasr»" . Trio, rnnnri muou* 5a isny d»i»
^isr^nrjt -f ^ft utaritf. jieti; j« lev^ ieei irnrrncwt MC in » «fee

l;chi»n iiut zrvrjT* ran zsas inr.^ scxiiesw jrhr^'mir ^ mrewn
irt-ir %n iaf;ii'.:r*u» i-jum"-9» :f "liis facase rm » aokiie cnly br
intXwitr 1 '•nnu!ii::i!ij m ^in-.TEzi ^m* TTuLi iZw^jj rsutifr? 53 ae acTBed

W'vmit, /•/ .Stwwtt, P?os*t imi Hirir : ^e writer Lka suaed

.-r"'

;/,n '.r..* t !',-'*►*•*, x:A '.brir cbsi^rriricr* were now roLcwrfd b;

i''^'' 'i-'^T. t// f.ft ^Ti!:?erk: rjr.e. Giiiiea his teai contmaallr r^sb-
»,*;,. r,7 'r^ r^n* •-* of his rwarcles, sonierimes in ihe form of
f/arf/;;>;.,*^«, %r,rf^i.Ti.*i^ '\Ti tbe i^xi^e? of the josmib. He his thus
t'v/»r, ?,;,V, tMt Lxrin^ bat slenier matenab is no reason for not
u^'i^U'j vyA n.v: of what one has. Some of his tows, indeed, are
}^f'l,7 jfj a/yy/f^ance with pracrical eiperence, bat this probablj
arv^ from hi< harinir *o *xall a number of cases of scabies ander
K.« o^^^rr/af/ion, I c/inriot d^jbt that, if a larger ne!d of investi-
j^4»>/ri w^r^. oj^'rn to hirn, his opinions wou':d verv quicklv be altered.
For \u*^^urj'^ I cannot ain-ee wiiii him in thinking that the emp-
tiofj irj •/^ao;''» i* f-xn-^'d by a sfcreiion po5?p>5in:r properties like
th'.i!'; of /raritharidin, d schari'frd bv the acari into their burrows.
v... -igain, can I find any facts to support his statement that the
ite frer|uently leaves the cimiculus; for the air-holes in ils
ribed by Gudden and Bourgaignon have never been seen

IIIBTDHI.

191

y myself or other observers. Hia observations on the act of copu-
mnong the cheese-mites are very intereating, but do not
r to me to justify the conclusion that this act is performed in
Bctly the same way by the itch-mites.

" " ' own views with reference to the diagnosis, etiolo^, and

eatment of smbies were first published in the year 1844,1 Since

Utl time I have repeatedly had occasion to write upon this subject,

1 1 would espucinlly direct the attention of my readers to a paper

L appeared in 1851,^ and in which I first made known in

Bernuny the existence of a peculiar form nf the disease, termed by

e the "Scabies Norvegica (Norwegische KrKtze)."

Soon afterwards the accuracy of my statements was conflrmcd,

rom their own observations, by several writers (Funhs, of GOttingen,

Bamberger, of Wiirzburg, and, lastly, Gumpert, of Wiirzburg, and

in, of Bonn] ; and the writers last named collected together the

pattered notices of this affection which had then been published and

bid them before the profession in a separate work.

. Most valuable papers on scabies have also been recently published

Rcinhanll, Lanqiietin, Leydig, and Eudolph Bergh {«f Cn|ien-

Blingeu). To the writer last named must be especially attribulcd

1 the credit of hBvin<; shown that the male scams is present in much

larger numbers than had been supposed. Karl Scggcl also, and M. H.

F. Fiirstenherg, have lately written on the subject of scnbies. The

work of Furstcnbcrg upon the acarus may, indeed, be said to be

unique. One does not know which to admire more, the comprehen-

eivencM and solidity of the obsi:rvations contained in it, or the

indefatigable industry and Sdelity of the author.

It is difficult, at least for a German, to understund how, afterni! these

I investigations had been made, it eould have been possible ftit Devergie,

I physician to the Hupital St. Louis, and one of the Professors of

Dermatology in the University of Paris, to have actually written, in

the year 1863, that "scabies may be a spontaneous disease;" — and,

Igain, that "even if Ibe acarus is constantly present in scabies,

Ebeory permits us to suppose eitAer that the insect is a product

F the disease, or that it is its cause and the moans of its commu-

Itication;" — and, bistly, for the same distinguished author to have

fajnced in the first rank as a cliamclcr of itch, the presence of "an

nruption of Ibe skin," and in the second rank that of " acari, or

' ' Wti. JalirbQctier il. o«st. Stuten,' Baud xlt'i and tlrJi.

' 'ZlKlir. J. k, k. Gci. d. Aente in Wiea.'

>\.'A5Ii>

I.-
■ \

"», ^

-^ - -., -

• --; 1-^

■»i •..:

^^ m ■ - ■ ^ ■ •'

. 1^ I

-■■ ■- ."1

'^ 1

« • • ^a* • ■ •

The contiDued study of the di^ase (of which 40,000 cases have

been under my care) has, however, given me repented occukioh to

observe that a patient may have scabies without it being possible,

on a first examination, to discover cither the cuninuU produced by

adult, or even the httlc papules ur vesicles generated by young acari ;

and j(A that from other symptoma the pliyaician may be justified, if

Lsot in assertiug positively that the case is one of itch, at least in

Iwying that there is great probabilitv uf its being so. lii exjihination

rof this statement, which to some will appear paradoxical, I may cite

I the following examples, taken from experience. As I shall show

presently, when I come to speak of its natund history, the presence

of the acarus scablei in the skiu is discoverable only when the

animal has formed a more or less distinct burrow. Now this takea

n period of n week or a fortnight, or even longer (according to the

invcBtigations of Gerlacb and Guddcn, a apace of time varying widely

from one to seven weeks). Puring this interval the patient suffers

L from severe itching, and, therefore, scralches himself in various parts

Kof the body; but those appearances which have been regarded M

K characteristic of scabies arc absolutely wanting, and, therefore,

■ according to the usual rules, the physician cannot diagnose the

|<disease. If, then, a patient witli a single itch-mite in his skin

I bappeus to consult a medical man who looks on the cuniciilus as

the sole means of recognising seaibies, iJie latter will mistake the

nature of the case, and, in the regular routine, will attribute to an

actimimia mnyuinu the itching by which his patient is tonnciited,

and, prrsoribmg baths and laxatives, will fuil to cure the disease,

and cousctiuenlly lose his confidence. At the cfimmericemeiit of

acabies, then, the appearances caused by the acarus arc not to be

detected, and we must search for other means of recognising tiie

disease. Moreover, not only is this so in the early stage of scabies,

but even when it has been of considerable duration the regular

development of the cuniculi may, by various c i reams tan ces, be

interfered with, or their discovery prevented, or (and jiarticularly

when seated on the hands) they may he destroyed as soon as they

tare formed. I'ersous who are cleanly, and who frequently batlie ;

f'tbe men employed in bathing establishments ; those who often wash

r hands, or other parts, and uae soap freely ; lastly, those who,

Kin consequence of getting their lingers very dirty, clean them with

h cloths, ooorse soap containing pumice, or n'en pumice-slonc

itself; all these may, by »uch means, destroy tbe cuniduli, audi
thaa reader it impossible fur the physician to discover the pre- 1
sence of the acarus. Again, there are certain ucuupations that I
expose the skin to contact trilli substances by which the acari are '
killed, or their burrows destroyed, in the parts to which such sub.
stances are applied. This is the case, for exnmple, among washer-
women, bricklayers, and hatters. Now, in snch persons, it is in
vain to search on the hands for cuniculi, or even for the little pap> ■
nlea and vesicles to which the young acari give rise; and yet it inajf I
be quite possible to diagnose the presence of scabies, from ths I
existence of appearances of a difi'erent kind on other parta of the I
body. In children, again, the thinness of the cuticle renders it I
a very convenient residence for the itch-mite, and, in consequence, I
the parasite, as is well known, inultipliea with extraordinary rapidity ; I
and yet it is far more difficult to detect the burrows in a child I
than in an older patient ; and they are often so few in number aa to I
seem out of all proportion to the abundance of the eruption on the 1
cutaneous surface. In these patieuls, therefore, it requires mach I
more time to discover a cuniculus than to take an accurate survey I
of the other characters of the disease. I would not be sitppoKd to 1
say tliat it is useless to search for burrows in such cases. On the I
contrary, it is always my first object to determine whether a parasite I
is present, and in what regions of the body it has taken up its I
abode. Wbat I mean is that the changes which are to be seen on 1
other parts of the akin are of no less importance, and should be I
duly considered. For, as I have already more than once stated, a I
diagnosis may by them be made more easily, more quickly, and with I
not less certainty, than by the discovery of the burrow of an ncarus. I
Lastly, it must be borne in mind that all medical men have not the I
time and opportunities required for studying the appearances pro- I
duccd by the acanis acabiei, and that the detection of tUexn uppeaN I
ancee may likewise be prevented by physical defects, such as pn-s- I
byupis. Now, under all circumstances, the other chaiacters of tfaivJ
disease can be observed; and this is surely sufficient to prove their I
importance. I

I, therefore, shall not, like previous writer;', describe the drarac-l
tcristic symptoms of scabies from a single point of view, nor makel
tbem consist simply in the presence of cuniculi. It appears to mel

■ SYUfTUHS. 196

PttettcT to divide the appearaD{»s met with in tliis lii^euae iiito llin-e.

I distinct groups, natneiy :

I I. TAoK Khieh ariie directly jyom the pre*enee 0/ aeari in lie akiu.

I 11. Those teiicA are lie retuU of scmkiing on the pari of Iht

WpaHeut.

I HI. Tiote wAici are productd, mAile living acari trUl in the

I tkin, 6y the aclion of other irritaatt of variom kinds.

I I. Appearances which arise directif from the presence of aeari
I in the skin.

I Before we cod undtTstanil full/ thr appearaaces which come under
I this bead, it is necessary that we should be familiar with the naturul
I history of the acuruB scabtei, &nd with the effects which result from
I the parasite living within the snbatonce of the $kin.
I Natural iislorjr of the Acarur icaiiici. Different jilaces in the
' fiatiirai system of classification have been given tu the itch-mite by
the different writers who have trent«d of its natural history, includ-
ing Linnsua, Degcer, Albia Gras, Latreille, Uaapail, Eichst^dt,
fiourguignon, Lnn(]uetin, Gudden, Qerlach, Worms, Leydig, Bergh,
and, above all, Fiirstciiherg. Tbe views of the last-named writer
are those which I adopt; and I extract from his oft-quot«d work
the paragraphs which relate to this subject.

The itch-mile, Acamt scaiin (Dcgeer), A. fxuleeran* (LinnEeus),

or Sarcoples hominis (Raspail), was formerly placed 'among the

Arachnida. At the present day it is referred to a special class of

I animals, the Acarina (mites, or Mjlben) , in which there arc, however,

I two orders, viz, : 1 . the dfar»«fl proper ; 2. the fl/Vini (ticks, Zecken).

I The animal with which we are concerned belongs to the first

of these orders (the Acarina projier], forming the first genua

{Sareopbs) of the fourth section (Laufmilbeo) of the fifth family

(Sarcoplidet, Lausmilben).

The foliating is the description of the animal : " Body oval,

I tortoise-shaped, with indentations in the lateral margins. Skm

I provided with shallow, undulating, transverse furrows (Riilen).

I Dorsal surface covered with nnmerous small and large appendages

I of a clavate or conical form, or resembling scales, and with spines

resting on papillary elevations. Head apparently distinct from the

trunk, with four pairs of jaws, and two strong tl]ret-'ji.')int<:d palpi,

placed near tbe jaws, and of the same length. Legs eight in number,

five-'jointed; the first and second pain provided with pedunculatol

^^ an

1^"

ickeni tbe peduncles of the same length as the leg? themselves, I
lliaving no joints ; the third and fourth pairs in the female terminating
in long bristles. In the male the first, secondj and fourth pairs o(
legs all provided with suckers, the third pair alone having bristles; tha
epimera of the first pair united. Larva presenting six legs ; the firet
and second pairs with suckers; the third pair terminating in long
bristles.

The acarus undergoes three moults before its full development

completed; but these changes of skiu ore not associated with
■ny very remarkable or striking alteration in ils form. It lires for
the most part in a passage whict it makes for itself within the
cuticle nf the human skin, but sometimes simplj lies beneath t^
epidermis, witliout forming a burrow. This parasite has also been
found, according to Fiiratenberg, in the skin of the horse, the boa,
and the llama, o& well as in an ape, and in a Neapohtan sheep. I
have myself found it likewise in the camel, the Egyptian sheep, and
the ferret {Pwtoriiit Furo).

The adult female acarus varies in size. On an average, its length
is 0.4526 millim. ; its breadth, at the fourth ring of tlie thorax,
0.3534 millim. The male is considerably smaller thau the female.
In length it measures 0.235 millim., in breadth 0.19 millim. It
further difiers from the female in the small number of scale-like
processes presented by the skin of the back, in having stalked
suckere at the extremities of tlie foortli pair of feet, and in having
a horse -9 hoe-shaped framework of chitin, to which the organs of
generation are attached, and which ia placed in tlie middle hno of
the body, between tbe hinder feet.

Tlie e^B of the itch-mite are of an ovoid form, and are 0.168
millim. long, 0.114 millim. broad. The larva;, when they firrt
escape from the shell, are slightly shorter and narrower than the
eggs from which they are formeti, measuring at that time 0.158
milUm. in length, and 0.104 miUim. in breadth. However, \hty
rapidly increase in size.

Certuin writers, among whom are Oerlach and Fiiistenberg, hav^
in their very valuable works, given descriptions and figures of
Tarious kinds of acari, some of which had been fonnd in differeot
vpecies of animals, while others had been taken from the human
subject, and hitd been nssociateil (as was supposed) «-ith distinct

Tms of scabies. Dut although I have the highest respect for the

itwa to whom I have referred, I cannot agre« with tliem i

NATURAL niSTOHT OF THE ACARUS.

197

matter. M; observations on the lower auiutals, as well aa on IiumaQ
patients, have led mc to believe that not only several of the acari said
by Qerlach to have been taken from different noinials, but those
described by Fiirsteuberg under tie iiamea of SareopUi tcaliiei, and
8, tcabiei cru4toia, belong to the same genus aud to the snme
species ; or (it is better to aay) are specimens of one and the snoie
animal. Differences in length, thiclutes.", breadth, or in the degree uf
transparency of the body ; alight variations in form, which is, in some
instances, a little more rounded, in others a little more elongated;
these all seem to be an utteHj insuffieient basis for the creation of
several distinct species of a tittle animal which cannot be seen plainly
until it is maguified at least joo times, and which undergoes several
moultinga and metamorphoses. On this question the opinion ex-
pressed by Gudden is similar to tny own. There is no better proof
of the identity of the acari which tiave hitherto been found in different
auimids, than the fact tliat the diseases produced by them have
always been communicable, whether by design or accident, from
those animals to man, and vici vend. This I have myself observed
both in tlie Vienna Museum of Natural Uistory, and in the
Imperial Menagerie at Schiinbrunn. 1 (km, then, firmly convinced
that the dilToreut acari described and figured by Gortach under the
names of Sarcoplen equi, S. ranit, S. suit, S. cat't, and S. irunieitli,
as well as those which I'iirslfnberg termed S. *cabiei crualoga, S.
vutpit, 8. eapra, 8. iquamiferut, and S. minor, arc identical. In
other words, Ihey do not form different sjHH'ies of one genus,
but are merely varieties of the sa me animal, which (according to its
seat, and according as it is fuund upon different animals) b some-
times retarded in its development, and, at other times, becomes
Ini^r and more- rounded. It must be remembered that similar
differences are observed in other Gpizoa, and, indeed, throughout
tlie oi^anic kingdom. Species, whetlier of plants or animals, are
commonly found to vary in different localities; being now strongly
develoi>cd, presenting a more ample form, and more powerful mem-
bers ; — now retarded in their growth, and (as it were) on a lower level
of vitality. Surely, then, we may venture to apply these facts to
the itch-mite, and to assert, without hesitation, that the various
forms of that animal belong to the same species, in spite of their
apparent differences in shape and size.

llie acari which infest various of the lower animals (and which,
as 1 have stated, may be communicated from them to man, and

IID»

SCABIES.

I vice ver$£), are invsriably fonnd belween the layers of tl

■ this situation eattsfying every eondJtion vhich is essential to iheir

Jexistence. Having, then, once enscoDced itself within tbe skin, an

DC&rus has no indocement whatever to leave its boirov. Hence

we can understand why the animal is to be discovered only in

the substance of the cuticle, and never on its surface. Tbe stniclnres

in which living it^h-mit^a are found are the deeper strata of the

epidermis near the lete mncosum, and the rete mucosnm itself. The

acanis is sometimes solitary, as is the c^se with the l&rva, the female

during moulting, and the male. In the mange or scab of the lover

animals, and in the so-called "Norwegian scabies," however, several

females and larvie are generally collected together, being accompanied

by a single male. Lastly, in ordinary scabies, the females are cam-

monly found in peculiar passages (termed MilbeiigBnge) which thqr

make for themselves to live in, &nd in which they moult, or deposit ova.

It most be admitted that searching for male scari, or for

^isolated krvte, or for the mites engaged in the act of changing their

rfflin, is a somewhat laborious and tiresome task. The way to nic-

l ceed is to examine the small papules or vesicles which aisy be seen

in the neighbourhood of burrows, or elsewhere. In the borden of

such papules or vesicles there will be found minute pnnctiform ele-

. vatious; and these may be removed by carefully introducing ■

t curved, inelastic, two-edged catnract knife beneath the epidcnnis.

I Another very good plan is to cut off the entire roof of the papule

I or vesicle, with the surrounding cuticle, by means of a jinlr of rltarp

pointed Lonis' scissors, with thin blades. The part removed is tfaiai

lo be placed beneath a microscope?, magnifying 50 or 100 times.

In animals affected with the mange, and bkewise in human pntimts
affected with the Norwegian form of scabies, the way to find living
aeon is not by searching in the thick crusts, or Icatherj' massen of
q)idcrmic scales, but by scraping the surface of the soft and moist
rete mucosnm beneath them with a knife such as I have jost
rpokeii of. The knife should be carried over some extent of sur-
face, and all ttint comes off on it should be placed beneath the
microscope. In this way I have very frequently succwded m col-
lecting upon the same slide several impr^^ated female acari, ai
veil as one or more males and larvK, and have aeen them morisg
[ about the field in tiie miMt hveJy fiuhion. If, on the other hand,
nrc esamine the crusta or masses of epidennia in siich rases, we
all not find any living aoari, although there will be ptentv

NATURAL IltSTORr OF THE ACARUS. 190

mites of fach sex, entire, or broken down into friigrnentB, bmules

lorvfB, eggs, etcg-sheJlH, niiil fwcps in abundance. The reason of

tliis evidtnlly is, tlint liie dry lioroj layer of the cuticle contains no

I nutritive material, and that the acari therefore necessarily i>ensh in it

I for vaiit of food.

The easiest way, however, of obtnioiug specimens of tbc acorua

' is to look for tho female animal in the burrow which it forms

for itself. Each of the burrows contains a single female mile,

of which the head is invnriably turned towartls the blind end, and

I the liiiidcT extremity towards the entrance, of Ihe passage. The

I eggs are armnged in a line one behind the other, from the posterior

lexlremity of the aearus backwarda. Surely, then, I am justified in

I asserting that the impregnated female mile digs her burrow simply

in order ta provide a safe place of deposit for the eggs which she is

about to Uy. It has been stated by Gcrlach, Bourguignon, Lauquctin,

, Fiirstcnberg, and Gudden, that the roof of the passage is pierced

kJiy aiiertures which might be cotnpored to shnft^*, and which some

■fenvc imagined to he air-holes, while others have sapposed that they

^anable the acarus to creep out on to the surface of the skin. I

wave, Lonever, seen nothing lo confirm this stutcmrnl in the courge

mVt my investigations, which now extend over several thousand cases.

By the following method an entire burrow may be viewed beneath

the microsco{>e. The putt cunlaining tiie burrow having lint been

thoroughly washed with soap and water, or the patient having been

made to take a bath, and mh himaelf freely with soft aoap, the phy-

fliciun should fix the surface of the skin round the burrow, and

pihould then cut out the whole of the cuticle containing it, by

I single stroke with a pair of Louis' scissors. The beat part to

Choose for this little operation is the penis. It is well lo begin the

^incision at the blind end of the burrow (that occupied by llie acnnis].

Old afterwards to carry it towards the open extremity ; for, if tbta

; not atleiidfil lo, the pressure of the scissors is very likely to

; out the acarus. The lam^ina of epidermis removed in this

vay should next be placed between two glass plates, which may be

slightly pressed together, and thus prepared, without the addition of

any Quid, it should be examined with a microscope which magnifies

60 or 100 times. If the operation has been successful, there will

Lgenerally be observed in the burrow, besides the female acarus, from

■ ten to fourteen egg«, numerous egg-shells, and small black scybalous

kces. Very often, in addition to the eggs deposited in the burrow.

200 8CABIS8.

another may be detected within the acaros^ bat I have not seen more
than one such egg^ and certainly never foor, as has been stated by
Boorgaignon.^ The eggs already laid are mostly dose to the hinder
extremity of the animal^ each with its long axis perpendicular to
that of the barrow.

In reference to the development of the embryo of the acaras
seabiei within the egg, we are indebted for very valuable investiga-
tions to Eichstedt, Bourguignon, Gerlach, Leydig, Gudden and
Fiirstenbei^, who, besides making simple microscopical examinations^
have succeeded in hatching the ova artificially. Their results, how-
ever, are not perfectly concordant; for, while Grerlach states the
period of incubation at from sixty-foar to seventy-six hours, Fiir-
stenberg says that the development of the embryo within the egg
takes about six or seven days,' and Gudden that forty-nine days

1 I attribate Bourguignon's mistake in this matter to the drcamstanoe of
his having seen an adult acanis, beneath which there lay three or four t^SS^.
The animal, particularly when somewhat compressed by a glass plate, is so
transparent that bodies really on ita under surface maj easily be supposed to be
in its interior.

* It has not yet been sufficiently ascertained by direct experiment whether
the rapidity of the development of the acarus is capable of modification by
changes in the external temperature. According to Furstenberg, indeed,
scabies spreads more slowly in winter than in summer, and the mite multiplies
with greater rapidity in warm weather, and is developed more slowly when the
temperature of the air is low. But for these statements there is no authority
beyond the opinion of Furstenberg himself, and they are open, both from a
theoretical and from a practical point of view, to certain objections. In the
first place it seems important to notice that the temperature of the part
of the skin in which the acarus resides is not affected by external condi-
tions in any great degree, such as might be suppaned to stimulate or to
retard the development of that creature. For, as is well known, the mite
penetrates as deeply as possible towards the living structures of the integu-
ment, imbedding itself in the deepest layers of the rete mucosum, quite close to
the papillary stratum of the cutis, in which the circulation is active, and of which
the temperature must therefore be that of the blood, and consequently nearly
uniform. Again, if heat were the chief thing required to favour the develop-
ment of the acarus, its instinct would surely lead it to reside in those parts of
the skin which are warm, or which at least are always at the same tempera-
ture. We should find it in the axilla, in the bend of the elbow, and wherever
the integument is soft. Now the exact contrary is the case. As is well known,
the regions most commonly infested by the acarus scabici are the hands and
the feet, and the penis, the buttocks, and the extensor surfaces of the joints ; all
of which parts are especially liable to have their temperature lowered.

Nor am I able to confirm the statement that the acams aoybiei (and with it

SATtBAL HISTORY OF THE ACA8CS. 201

are required for the growth of the acani5, np to the time vben it
becomes impregnated.

Again, obsvrrera are by no means agreed as to the dulj nnmber
of eggs laid by the itch-mite. The statements upon this point WJ
widely, some writers sapposing that the anima] rleponta only one
each day, others that at least two are laid. Tbc total nnmber which
can proceed from a single acanis in the courve of it* exbteaa is
estimated at fifty by Gerlach, who foaud by experiment that impreg-
nated female mites, which he plan-ed upon the skin of persons free
I from scabies, were still alive in the course of Uic setcoth or e^lh
I week afterwards. Now, if we aasume that one e^ only was depooted
1 every day by each of tbeae acari, the total nomber would amoutt to
I more than fifty. As yet, however, I hate wrtt nyiclf mco a
I burrow in which there were more than fourteen eggB, bendo teo or
I twelve empty sheUs.

The BubstaiK^ conliiine^ in the ovum varies in app(anncc,acconlii^

' to the period of development attained by the cmbrro. In llw two

j eggs most recently deposited (whicli lie close to the hinder eitremity

of the acarun), the perfect trausjinrenry of this tubitance i> inlir-

lered with only by a few molectdn. In the next two ova, tbc tliird

and the fourtli, it is ulrendy iiark<^ and more opaqne, and no

longer fills the whole intcrigr of the egg, so that a stma pellueida

gradually makes its appearance. Masses of yeUc-cdla may now be

observed collected at the periphery of the contents, and iiiiIent«tioiu

already indicate! the position of the head and forelegs of the rmbryo,

Li the fifth and llie sixth eggs the d liferent parts of the embryo arc more

or less visible, the head niid limbs being plainly distinguitilinhle. If

the burrow should contain morv than «x ora, the remaining ones

[ tbc itch) spreads less rapiill; id wiat«t than in *amn>er; to far from IbU

I being tlic caae, the winter months (December to febniai;] ut the very mm*

I in whicli tbc most numerons cue* of Msbic* CDOie nader mj obMrtitioo in llta

I General Hospital, while tlie autuniD months (Au^nil to October) are those ia

I wliich the disease oecurt tenit frrqui-nl Ij. A^n, it i* certain that kf«|iin|; the

I ikia wsrm (as, far inituicc, b; remainiiiR in bed) itie» not sreallj firnur Iha

f developcnent eflhe acsnu. ^nr when s patient who has the iUh la eonHiH^d to

I bb bed b; inj loni^-coiitiiiaec) febrile dtsease («ueh a* Ijphrts tit pneuouinia)

I the former cimpiainl aJwijra illminiiliot ver; nmeh in *e*Bnty, STCti if it do not

diMppesr tllogctber; bat duringeoDTSlnoence, when he taa lenn hii hril.Mid

aftcrimrdi hi* rnnm, and pctbaps (cron tliaii(h It ibmilil b« vintn) nauinB hi*

work in the open air, the *cabies boeomes again SKgravstKl, ami vniMiUBm

sctiisllj tttracta bis aotioe for tltt first tima, sod induce* bia lo tcnk Madigd

202 SCABIES.

exhibit embnros fallr developed^ in which morements maj eren be
observed. Lastly, in the coarse of repeated inTestigations one mar
be fortnnate eaongh to see the jonng acaros creep oat of the egg,
disengage itself from the shell, and begin to move about actiTelj
within the barrow. There is no necessity for it to make a new path
towards the surface of the skin. That prepared by the mother-
acaras is still patent, and is probably used by the newly-born larva.
The young mite is always at first smaller than the oTum, but qoicklj
increases in size. A.fter having left the maternal barrow, it again
penetrates the cuticle, in the interior of which it takes up its abode,
until it has moulted for the first time. Every acarus passes througli
several changes of skin, during which it is in a state of rigidity,
appears to be entirely devoid of feeling, and, in fact, looks exactly
as if it were dead. It may, however, be known to be really
moulting, by the circumstance that the new parts can be seen
through the old skin. Thus, behind the old one, a fresh head is
visible ; close to this, two fresh fore-1^ ; and near the old
hind-legs, new ones. During its first change of skin, the mite ac-
quires four hind-legs instead of two. This shows that it ^undergoes
at least two moults, in the first of which it becomes eight-l^^ed,
from having been six-le^ed ; while of course it has eight legs
before, as well as after, the second change of skin. The process can
he studied most satisfactorilv in tlie varietv of itch first observed in
Norway, and termed by me the scabies Norvegica ; and therefore I
may refer the reader to my paper on that form of the disease,^ and
to the accompanying plate.

It has been supposed that the acarus undergoes a third, and even
a fourth, change of skin. Whether this is, or is not, the case, I am
unable to say, having been unable to devote the time (although I
have had the material) required for such an investigation. I must
therefore confine myself to quoting the statements of others, princi-
pally Fiirstenberg and Gudden. According to the observations of
the writer last named, the mite after its first moult has eight legs
and four bristles, and twelve spines on its back. When it has un-
dergone the process of moulting for the second time, it has fourteen
spines. After the third change of skin, it retains that number,
if a female ; whereas the males lose two of their spines, and have
only twelve. He also states that when an acarus has moulted

ihrift der k. k. Gesellschart der Aerzte/ 8 Jahrg., 1853, Band i.

NATCnAL HISTORY OF TIIK ACAKUB.

3fW

iriw only, the hindermost spine of the pxtemal row on each side
inller than the three others in a line with it. But Guddeu him-
f admits that, careful as lie was in bis obsen'Rtion;', a sliglit error
Dtaj possibly have crept in here ; and he expresses the hojie that, if
leh is the case, it mny be corrected by further inquiries. I mast
Mnfess tliat I am not inclined to consider a ilifTerenre in the size of
the spines (which cannot be an essential character of the animal) a,
nitncient groimd for determining through liow many chsngcs of
«kin nn acarus has passed.

I shall not now apeak of the digestive nor of the respiratory apiw-
ratiis, nor of the general internal strnrture,' of the itch-mite, but shall
pass on to malters of more intert-st from a medical point of view,
such as the description of the genital apparatu!<, and of the way in
which the act of impregnation is probably effected.

The gnieral distinctions between the male and the female acarua

utot already been givai. With regard to the exact position and form

' the genitalia, however, writers are not agreed. According to

Qie observations of Qudden the female possesses two vaginte,— one

FfBegatlangsschcide) through which impregnation is effected, placed

■t the posterior extremity of the animal, between the last pair of

bristles, and hitherto supposed to be the anal aperture; the other

(Legescheide) opcuing nn the surface of the abdomen by a wide

aperture (which is surrounded by a cbilinoiis ring), and serving for

the discharge of the ova after their formation. The conclusions of

^jOudden in n'fitrcnce to these organs are, however, strictly applicable

y to the cheese-miles, on which animal!, and not on itch-mites,

ost of his observations were made. Hut he is convinced that the

-ongemeiils prevail in both kinds of ucari. The male sexual

rgan, placed in the median line, between the internnl pair of hinder

, resembles a horse-sboc in form, and lies in a forked support

iger), consisting of a stalk and two branches. Several other

tnatomical and physiological detnils concerning the penis of the

c itch-mile arc given by the writers above referred to ; but they

I not agreed among themselves either ad to the structure of the

trgsi), nor as to its use ; for no one has yet succeeded in Bnding

ttiG larcopUi iomtnU in the act of copulation. Some years ago I

> I refer thou of inj reulera who ma; be deiimui nf inronnatioa upon these
points Id Ifac ofl-quolcd works of Bourfuignon, Purelcnberg, Gudden, Bcrgli,

204

SCABIES.

poblislied' an observation whicli I Lad made Id ooe instance, bat which
I have not since had an opportunity of repeating. While searching
for acari in the human skin, I happened to find a pair of them
together, one lying over tlie other. A drawing of them, made bj
Dr. EMnger, is appended to my paper, from which I quote llie fol-
lowing passage: "As is shown in the plate, it seemed al first
sight as if the smaller, or male, acarus was contained within the
larger, or female. But this could not have been the case, for in the
smaller one the male genitalia were fully developed, and, moreover,
the itch-mite is not viviparous. It was also quite easy to sepante
the two acari, and indeed this was done accidentally by an unlucky
movement of the tnicroscope. 1 tlierefore think it most probable
that they were in the act of copulation when death overtook them.
It must be admitted that tlie relation in which theee acari were
found may have been merely accidental, for the penis was of the
usual form and iu ita ordinary position, except, indeed, that it seemed
to be bent slightly towards the right side of the male animal. Hoir-
ever, as no one has hitherto observed the act of copulation in the
itch-mite of man, and as the position of the two acari in this in-
stance appeared to me to be at lea«t suspicious, I thought it only
right to have a drawing made, and to publish an account of it."

In the works which have since been written by Gerlach,Gndden, and
FiirKtenbcjg, my observation has never been shown to be erroneous.
These authors either simply qnote my statement, or ignore it
altogether. No one has as yet succeeded either in disproving or in
proving that the two acari which I found in contact were engaged in
the act of coitus. This act is, indeed, asserted by the above-named
writers to be effected in a different way ; but their accounts of it are
based not on any contrary observations, but merely on a supposed
analogy between the performance of eopulation iu the itch-mites and

I in the eheese-mitcs (Gudden), or in the Symiiofet equi {Gerlach).
It is also doubtful whether the act of copulation takes place out-
side the cuuiculus, or within it. If it could be shown that the

I tu'O acari which I found one upon the other weie engaged in thifl
act, the drawing above referred to would do something to decide
this point, for they were taken from a burrow which also con-

1 tamed ova, and tlierefore could not have hccu merely a moulting*
gallery.

I ' 'UcitngcuT Ueu^JcliLe der tngcoMiaUn norwogisclicn Eriian' ('Zdt*
Bclirift dor k. k. GesolbcliBft der Ktrtlt,' g Jtiug.. 1853. Band a. n 36).

8TMPTOM8,

205

In reference both to the natural history and physiology of tlie
acarus, and also to patliology, it would be a matter of greal iuterest
to know exactly how long the animai can live, and for wliat length
of time its ova remain capable of development, even after their
removal from the humnii skiu. But upon these points nothing lias
aa yet been positively ascertniucd.

A fortnight probably passes from the time the acarus leaves the
egg, until it has completed its changes of skin, becomes impregnated,
and is capable of laying ova. And, if we may assume that ihe animal
deposits in all fifty eggs, laying tlicm at the rate of at most two,
and generally only one e^ch day, it would follow that the itch-mito
most likely lives abont two months. The experiments and observa-
tions made by Albjn Gras ' and Baspail on the human itch-mite, and
the investigations of the veterinary surgeons Giirlt,Walz, and llertwig,
in regard to the acari of the horse and sheep, have proved beyond a
doubt that the different acari of man and the lower animals live from
twenty to forty days, or even longer, according as they are placed
under favorable or unfavorable conditions.

It would also be important to be able to say how long the eggs
of the itch-mite, whether in the skin, or outside it, retain the power
of further development. But, bo far as I know, nu experiments
have as yet been made upon this point, and certainly no satisfactory
conclusions have been arrived at.

Having, in the preceding paragraphs, given a brief sketch of the
natural history of the itch-mite, so far as our present knowledge
goes, I now pass on to speak of the morbid appearances which are
produced by the presence of the parasite, and by its multiplying
within the substance of the skin. And, in the first place, I shall
describe those to which the adult female acarus gives rise. It begins,
then, by penetrating the horny layer of the cuticle, through which
it borrows from without inwards, in a direction more or less oblique.
This it docs simply for the purpose of laying its eggs in the passage
which it forms, and in order to make room for these, as they

e successively deposited behind it, it is obliged to go on under-
g the cuticle. This process continues during the whole lite of

c animal, which keeps moving at a slow rate witiiin the subatnn«
of the epidermis. The consequence uecessarily is the formation,

' ' BMherobes lar I'Acnrus ou Sutoples de la Gale An rBomme,' Pari),

between the layers of this tissue, of a passage vhich may be oom-
pared to a mine, aod winch is called a burrow or cimiculus (MU-
bcDgang). Il is qait« a mistake to liken this to the scratch which
may be made by a needle. The only way of producing artifidally
somethiog which resembles a barrow is, slowly to introduce a &W
needle longitudinally between tlie layers of the epidermis, so as, ID
fact, to uodermine it in the same manner aa is done by the acanis.

Varions appearances are preaeut*d by the burrow, according to
its length, the period of time which hns elapsed since it was com-
menced, its seat, aud the individunl peculiarities of the person in
whom it is found. As a general rule, the point at which the acimu
entered can easily be distinguished from that at which it lies at liie
time of observation. To these two points respectively I have given
the names of "head" aud "tail" {Kopf- und Schwansende) .*
Adopting these terms, I mny say that' the " head " (the point at
which the mite began to burrow) is slightly whiter, and is raised
more above the level of the sk.iu than the " tail." In the latter,
too, the acurus itself may be recognised as a minute, roundish,
sharply defined body, somewhat deeply seated witliin the substancfl
of the cuticle. Such are the characters presented by burrows on
the palms or backs gf the hands, the sides of the fingers (and also
iu the clefts between them), the wrists, the extensor suriaccs of the
limbs (especially over the elbows and knees], and, lastly, on the toes
and the dorsal and planlar surfaces of the feet, aud (particularly
in the female kx) the middle of their inner borders just where liic
dorsum is continuous with the hollow of the sole.

Sometimes, however, there are observed at the "head," or even
beneath the whole length, of the burrow, certain peculiar appearanoee,
of which I must give a mure minute description. In the first place,
the irritation caused by tiie acarus in penetrating the »kin fre-
quently gives rise to the formation of a vesicle of greater or IcM
size, or even of a postuic, or bulla, at the head of the cuuicutus.
Aud, when thia is furmtfd, it often runs on beneath the whole
length of the burrow, which tbns comes to lie within its roof.
But, even if the whale of the burrow should be underniiDcd
and raised by the effused fluid, the mite itself always keeps beyond
the vesicle or pustule, and, so to speak, lies in ita tangent. The
ctfutcd fluid subsequently driest up, and, with the cuticle over it,
becomes converted into a crust, which, as new epidermic cclU ire
" IJtbcr ilic Krattc," ' Med, Jiihrbilcli«t dea oat. Slules,' 1844, p. »&j.

8YMPT0US.

207

irmed, is finally thrown off and shed. Now, in such a crust, tliere

\j be put of titp ori^nal burrow, with the eggs and young mitus

"eh it contained, but never the mother acarus, for this always

ps beyond the circumference of the vesicle or pustule from which

crust was formed. Nor, again, is tlie female ever found in the

tcrior of one of these vesicles or puatules. It foliows from this,

cannot on a priori grounds deny the possibility of the

iiOoinmunicatii^D of scuhtes from one individual to another by means

of the crusts,' hut tlie etperiruents wliich have been made in this

direction have seldom led to tlie propagation of the disease.'

In other instances, again, a burrow liis on an clongat«:d red ele-
vation, or ridge, nlung the summit of whicli it may geiu-rally he
BCeti to mu in the form of a white dotl«l line. This variety of the
cuniculus is observed on all parts of the body in very little children,
and especially in infants at the bretists. In adults it is found princi-
pally on the penis, on those parts of the buttocks wlucb receive the
pressure in sitting or lying down, and (when burrows occur in these
parts) on the neck, the folds of the axillo, the nipple, the umbilicus,
or the trunk generally.

Another rooditication principally affecting such cuniculi as are

old and of some length still remains to be noticed. In progress of

time the vesicle, bulla, or pustule, which is formed at the " head "

of the burrow, and in connection with it, loses its roof. This neces-

'ily causes a break in the continuity of the epidermis, appearing

a red oval spot, surrounded by a white line, which poiises on

1 have recfntly found that <rhea acaliics is coniplieatrd villi eczema tlie
bruits ooDlain a coDaiderihb number of young Hcori. Tliese maj be delected
"by boiling the crusts in * dilute solution of caustic soda, which detlroys Ihe
pu>.cetla Mid oilier malten. Imiing the actiri ULidiMolted. Id ihis itay u)
mauj 15 twelre joung (six-legged) acari (besideB some eggs, and fragments of
moulted skin«) were obtained in sucb ■ eaae from about as much of the
cruel* u would lie on the surface of a chilling. It afijiears jirobable thai this
new method of discovering the ilch-mite will aid greallj in Ihe diagnosis of
those difficult cases in wliich, on account of the presence of severe ecxemn, none
of the ordinary appearances of scabies can be recognised. For fuitber details
Kc the ' Laiicef tor .ipril 4th. 1868. [C, H. F.]

* According to Ibe statements of Dr. Schubert (' Berliner CciilralMitung.*
1837, p. 4]), he has succeeded in com muni cat lug scabies by iuoculaiiug villi
poiaon (KiStzgift) which bad been preserved for sii months. The only way
to make »nse at ibis asseTtion is lo asiume that his " dried Kratz^irt," by
Rieiias of which be elfeoled this result, was really a crust, which still nrntaiiied
nra.

208

SCABIES.

' either side into the cimiculus itself. In Uiis way the onttine of the
I vbole barrow, or, at least, that of its " head," cornea to resemble
I that of a chemist's retort.

The leugth of a cuniculus varies from one luillimeter to several
centimeters. The longest which I have ever seen meaanred more
I than ten ccnlimeters. Of nearly font inches. The average length u
about half a centimeter. The usual breadlh is 0.24 millimeter;
the height cannot be Jelermined. The direction of a burrow gene-
rally approaches more or less closely to a straight line; but some-
times it is serpentine, semicircular, circular, or bent at an angle;
and sometimes one cuniculus is crossed by another. The appenrance
of a burrow is also liable to he modified by any colooriag-matter
which may have come into contact with the patient's skin. The
cuticle forming its roof, having been already loosened and broken
up by the aeanis, is penetrated more readily than that of other parte
by such substances, which produce etaina that cannot be removed
. either by washing or by mechanical friction. In fact, the moT«
completely the surface surrounding a cuniculus is freed of dust, dirt,
and colouring matters, the darker does the cuniculus seem to he,
and the more plainly ia it visible. On the other hand, in persons
who frequently wash, and thus remove all impurities from the
cutaneous surface, the burrows produced by the itch-mite oro
I actually paler than the rest of the skin, or even perfectly white,
Those which are found on the penis, buttocks, elbows, or knees,
almost always present this appearance.

Besides the burrows made by impregnated female acari to receive
I the ova deposited by them, other smaller canals may he discovered,
f -Khich are formed by the young mites, on their emerging from those
I in which they arc born. Tile canals in question are either found
I in small scattered papules or vesicles, or appear as little short
I cnuiculi, closely resemhling those which I have describci] in the
I preceding paragraphs.

II. Jppearancet which are the result of tcratckini/ on th4 part
I of the patient.

Aeari which have taken np their abode in the int«gament are
BjCoustantly attacking the sensitive organs which it contains, in tlie
■ course of their movemenbt for Che purposes of nutrition and of
BiproiisguLioo. The mechanical irritation thus inHictcd on tbu nervn
lof the papillte gives rise to the sensation known as "itcliing," aud

SYMPTOMS.

209

D iU tnm, leads to the re&n action which is termed " scratcb-
Now, according to the intensity of the irritation, the
iKratcUicg is of course more or less severe; imd it is scarcely pos-
[«ble to form an adequate ideA of the vehemence aiid (ono may
■Iniostsay), passion with which persons suH'ering from scabies scratch
ilheinselves, unless ouc has had tlie disense oneself, or has, at least,
been often thrown into contact with patients affected with this or
other prnriginoua complaints. I make this preliminary remark,
because to those who have not the opportunity of observing for
I themselves it may perhaps seem improbable that scratching with

■ the finger-naila should be sufficient by itself to give rise to morbid

■ changes in the skin so numerous and varied as those which I am
about to describe.

In endeavouring to enumerate in regular order the appearances

which arc saccvssively produced in the skin by mechanical irritation,

I I may begin by remarking, that gentle scratching or rubbing

■ gives rise to a redness, of which the form, direction, and general
(Outline arc determined directly by the course of the finger-nails

Ithemselves. Most persons scratch themselves by planting the
rthumb firmly on the part, placing the four fingers iti turn upon the
I surface of the skin, and bringing them with a scraping movement

■ toward the thumb. Others, without fixing the thumb, simply drag

■ the fiogcr-naiU across the integument. But, whichever way is
lidopted, it is only with the four fingers, and never with the thumb,
I'tbat the act of scratching is performed ; and consequently the effect
lof this act is, either to produce four separate lines, or (if repeated),
■a red surface, resulting from the confiuence of these four lines, and
1 generally of the same breadth as the hand whicii causes it.

Sometimes, however, instead of the above-described red streaks or

flpots, there arise red wheals (Quaddeln), having the form of stripes.

_ Li certain persons this effect is seen as soon as they begin to scratch

kthcmselvea, but in others only when the action has been several time*

Mkled. Tiie appearance in question has long been known, aad

rns described in the older works under the name of I'rliearia tub-

It was, indeed, formerly imagined (hat individuals in whom

Mratcbing produced wheals were tbe subjects of an acrimonia lan-

mffuiaii (Blutschorfe), which was set free ou the cutaneous surface by

the finger in scratching, and gave rise to the peculiar change in the

skin. At the prejtent day, however, we explain tiiis occurrence is

a mechanical way, being folly jnstiiied in doing so bv the fact that,

210 SCABIES.

besides the finger-nails^ various agencies of a traumatic kind^ or
such as excite inflammation^ produce similar artificial forms of urti-
caria.

I must especially draw attention to the proof which these ap-
pearances afford^ that^ even though the epidermis remains quite
uninjured^ scratching may give rise to important changes in the
deeper structures of the cutis. When wheals are formed^ serous
exudation and extravasation into the skin must certainly have taken
place ; and probably this is the case^ even when redness alone is
produced.

Now, when rightly apprehended, this fact of necessity involves
the possibility that papules^ vesicles, and even bullae, may arise from
the same cause, and also that the contents of these may be converted
into pus, and so pustules be produced. And we find by experience
that in cases of scabies all these effects are actually met with as the
results of scratching. There are, however, great differences in the
time at which such appearances arise, and also in the individuals in
whom they are observed. For instance, when a patient has gone on
scratching himself, the redness and the wheals which were first pro-
duced are generally followed by the formation, at the same spots, of
a number of papules, which are seated at the mouths of the hair-
follicles, and are about as large as millet- or hemp-seeds. Instead
of quickly disappearing, like the red maculse which preceded them,
these papules, which constitute the affection known as Tapul^r
scabies, remain for some time. Their development, however, does
not diminish the itching to which the burrowing of the acari gives
rise, and the patient, therefore, necessarily continues to scratch him-
self. Xow, when no papules existed, the nails attacked nearly
equally all the points with which they came in contact. But as
soon as the scratching has led to the formation of papules, these
little elevations of course offer a greater resistance than the inter-
vening level tracts of skin, and are, therefore, especially injured by
the patient's finger-nails, which tear off the epidermic covering of
the tops of the papules, and expose to a greater or less extent the
papillse of the corium. The laceration of these papillae, and of the
loops of blood-vessels which they contain, necessarily leads to the
escape of blood from the summit of the papule, and this blood at
once dries up into a little black crust. Such is the explanatiou of
an appearance very frequently observed in scabies.

In the morbid changes hitherto described, consisting oi^P !■

BTMPT0M8. 211

r £he Bkin, and the formation of wheals and papules, together
with CKcoriationa and minute black crusts, we have the ordinary
characters observed in the majority of cases of scabies.

Now it commonly happens that a person affecled with the itcli
« 80 tormeiited by the burrowing of the acari (which even in this
pirm of scabies may be very numerous) that he at once seeks medical
idvice. This, however, ia not invariably the case. Sometimes he
niits until pustules are formed, or large excoriations, or even ulcers
sovcred with crusts, all of which appearances, however different,
are nevertheless due to the same cause which produced the papules,
namely, his scratchmg himself with his finger-nails.

A point of very great importance in reference to the morbid ap-
pearances which result from this cause, besides their form and size,
I b their occurring in particular regions of the body. However re*
L narlcable, and as yet uncsplained, it is nevertheless a wcU-eslab-
*Mhed fact that, according to the nature of the irritating cause, a
will scratch himself in different places, and not of necessity in
l!ie part containing that which gives rise to the itching. For in-
ncc, we know that the pediculut capitis, when present in largo
mlwrs on the scalp, excites itching, by the irritation of tlie
Wpilla; which it produces, and thus leads the patient to scratch
ilimself. Yet kc do not find that this species of louse ever causes
Bcoriations and other morbid changes of the same kind as those
Which are set up by another species, the pedicalut pnLit, when
d among the hairs of the pub«s, axilla, beard, or trunk of the
)dy. And widely different from either of these are the appear-
1 produced by the presence of the third kind of louse, the
idicutua vettimentorum, which appearances are observed on the back
F the neck, and on the trunk and limbs of those whom it in>
Again, it is by no means difficult for the experienced eye to
t«rmine whether in a given case fleas or bugs caused the patient
I scratch himself. In other words, any one may, by practice,
idily acquire the art of being able to infer with certainty, from
B form and seat of the excoriations, what it was which gave rise
B the itching.
Now the effects of scratching appear in scabies on quite other
a of body from those which wc have seen to be affected when
liediculi are the cause of the irritation. In cases of itch Ihe ante-
r surface of the trunk and the thighs are the regions which pre-
mt the most numciDos excoriBtioiu. As a role, indeed, these

312

8CAB1E8.

appearances are limited to a perfectly well-delmed region, bounded
above by a line drawn from one nipple to the other, and below by
one taken transversely across both thighs at the junction of the lowrcr
with the middle third. I do not mean to say, however, that in
scabies excoriations are never observed in other regions. On the con-
trary, in females, and in children, and also in men when the disease
has lasted for some time, the limits I have laid down are troiisgrf saed
on every side, and it then commonly happens that no part of the '
skin is free from eicoriations. But even when this is the case, it i
will be found that, catfris jfari&u-t, the space between the breasts
above and the knees below is the seat of more severe and more
marked excoriations than other districts. The anterior part of the <
body, too, is always more violently torn than the postCTior ; and JO
particular, the back itself is generally not scratched at all, or at to09t
presents excoriations only over that part of its surface which can be
reached when the hands are stretched backwards for the pnrpORe.
Again, excoriations are very rarely seen on the face in scabies; and)
if we did not know that in other diseases (especially eczema) patients
scratch this part n-ithout mercy, we might be led to believe that the i
skin of the face is incapabie of the sensation of itching.

Since then, the region from the breasts above to tlie knees below
ia specially selected for scratching by patients affected with scabies,
the occurrence of excoriations on that region may fairly be regarded
as a diagnostic sign of the disease.

III. Jjjjjearaneet which are produced, teAUe living acari emitt i
(he tiiH, liy the action upon it of other irrilants qfvarioug kindl.

Experience shows that in all persons who for a considerable time I
have been infested with acari (or, in other words, have had scabies),

tubercles, or other appearances due to infiltration of the skin, arise ,

on those parts of the body which are from any cause subjected to i
pressure or friction. Such tubercles, like the excoriations above

described, may be regarded as infallible signs of scabies ; for in no I

other disease do we observe similar appearances occupying such i
parts of the cutaneous surface,

The first example I will give is that of men who sit for a long j

time together on bard stoob or benches. In such persons, when I

they get the itch, there always appear on the buttocks, and (exactly on I

those spots which correspond to the ischial tuberosities, cither p»- J

~ a or tubercles, or pustules and crnstii. On some of these (uber* \

S. NORVEQICA.

213

!, in the direction of their long axis, may be seen burrowa ; while
are simple elevations of the epidermis, and contain no parnsite.
; the workmen who present these appearances, arising from
" the above-named cause, are, for instance, cobblers, tailors, and
weavers; whereas carpenters, joiners, and bricklayers, nU of whom
work standing, and not sitting, remain free from anything of the
,, however severely they may be affected by the disease, A fur-
ler confirmation of the view I am advocating may be found in th<^
I8C of women who use stra|>s or belts, whether as part of their
inary wearing apparel, or to fasten things which they carry
liile nt work. Whenever snch belts or straps are frequently worn
id are allowed to exert pressure on the skin, the result is the for-
latioii, at tlie affected spots, of the tubercles above described, with or
ithont burrows on their summits. Precisely similar effrcts, again,
lUow tlie irritation caused by using trusse* or crutches, or by
; garters, girdles, or, indeed, tight clothes of any kind what-
Moreover, the morbid changes in the skin which are thus
luced, and which at first take the form of papules or tubercles,
liable to undergo the same transformations as the other eruptions
of scabies. Hence, when the disease has enlisted for some time
the parts in question may present vesicles and pustules, which, like
the tubercles, are from their special seat to he regarded as charac-
teristic of scabies.

In the preceding paragmphs I have described in detail how tlic

I different morbid appearances observed in scabies arc produced. I

lliave shown that each group of Ibcm has characters of its own. And,

I lastly, I have stated that when the disease is fully developed, all the

three groups present themselves simuttaneously to the eye of the

observer.

There still, however, remains to be mentioned a form of scabies
which has only recently been discovered, having been origioally
observed by Danielssen and Boeck inpatients who were affected with
the Elephantiasis Gnecorum, and having been first described by them
in their work on that disease'

When this book was published, MM. Danielssen and Boeek did
not know to bow great an extent the ordinary characters of scabies
could be modified by the presence of such an enormous number of

> 'Tiailj de k Sp^Jklskb^d, oa EleplsnliMii dcs Grtn' psr WA.
I Duielucn «t Bo«ok. 1848, Paris, J. fi- BaiUiire. (raduil pu- L. A. Coamn.

214 scABiza.

acari as ire found in ibis form of ihe disease. The accconr*^ which zhej
gave of itjinerefore.u that in patienu adecredTitii elephantiasis scabiiea
is apt to be associated wiih diiFosed eczema, lichen and imperlgo.

In April, I '55 1, however, there was admitted into the hospital
at Chriatiania a woman, in whom Tarioos parts of the body were
found bv Prof. Boeck to present crusts cf a rerr peculiar kind.
These crusts were i' ' or 3' " thick, of a dirty greenish-zrey colourj
firmly adherent, and so rem^jkably hard that they cut like pieces of
bark, and that their presence rendered it impossfole f :r the woman to
straighten her ingers. Tney existed on the paiT.ar and plantar sur-
faces cf the hands and feet, as well as en the dex:r aspects of the
thighs and legs, on the buTt.icks.. the elbow?, ani, lastly, the
scalp and back cf the neck. When the cmsts were removed the
skin beneath wis f lund to b^ rediier.ed. moist, azd uneven. The
nails c: the iigers izi tc-r* wrr? c^inverei ir.:o rcz^h. thick, raised
masses cf a vell:Tish br:wn ciloor. In the irs: part of Boeck's
'AtLis \l':er Hiiitkrankheiten,' he gives a g=:<d representanon of
lr.C5e crusts, occurring on the palzi cf the hand and on the sole of
the foct. It iTjpears that he had be::re seen two cases of the same
kinj, which, bein^ unlie anv knoT^ afection. had been zcsarded
as eximi'.es cf a new ani p^c'^^ar disease. Nd Lii-jris^r-r:: exami-
ni:::r- :: :he cns^ hivizg h.hrn zziit in these r^: cises., their true

I- • . ^ . , .

r. ::.t ::.:r:: iise, ..'.xtver, '^-::-i -s 1 lavr 5:i:ri: cine under

Ei'i.k"? .bscr-i-.tn 1: ChriivlLnii :r. iSj;:., he rlicei nzier the mi-

cnscirr 7.:r::;zs :: :'-r cru?:* t-::., h:i.: been rfz::ve-i. He then

::-7-". :'-j;: -T-rrr cr.e c: :':.r=:, -xlir:'.:-: :ikt~ fr:- :he head, trunk,

cr .:li:?, :::.:y.z:i z-L.mzs nunbrr* :: loii ::^h-:ri:rs, lirge and

s-.i-l. :? "^tL. 15 rzzi izl :'.Y-rs. Thr sjnir l ;:.:cn:s were present

r:- :'.-: r.z::^rs and the

. » ; ..

- • - .

Xi..... . . . ,,

■ •■- -I ^1.^ -• .• ^ •^ ■ * . - .

- • m^ ^mm ^ - * a' ■ * m-^ ^ ^ * A ....... •■-... «. ^.»V*« ••».^« ^.* . .a «. ^mA. -'1.

• • - • . . , .

..- -» J "•■■-." .-•— ■ .•,■."* " •"■ "■. ^* • - »• • -. .. «• . a^. J. •. . ^. . - .. . ^. , ^ . ^

■""» * ■ • * T^ * • \

= Z€.*s::.r.f: ct: k. k. Ge«!.Kis/: ic: .K<t:u/ J*:.rc^r.c. 1S53, Bud 1,
? 3>c

S. NOKVEGICA. 216

9 probabtj caused by a species of acaras different from Dint found
in the ortliiiar)i form of the disease, and that the acari did not form
deRnite burrows, but were scattered iiregularly beneath the epider-
mis, as is the case witli those which infest the lower animals. It
also appeared that they were present on the hairy parts of the body,
whereas it is well known that in cases of commou itch, these animals
and the burrows in which they lie are fomid only in those regions
which are not covered with hair.

Since then this disease has been observed by physicians practising

in other countries besides Norway, Two cases of it have been seen

by Prof. Tuchs at Gottin^en, one by Prof. Bamberger, in his

Clinique at Wurzburg, one by Prof. Rigler at Constantinople. One

M, came under my own observation in my clinique at Vienna, oud

tnothtr presented itself to Dr. Mittcrmayer, atPunchal.

New, the examination of the crusis which had been most kindly

ml to mii from various quartera (including Madeirn), and, above all,

E those which came from the patient umicr my own care in the

kneral Hospila), has led me to conclude that the acarus in the Sraiiff

itlwia is really the same as in ordinary itch, I have found that

when the skin is examined with sufficient care, a certain number

of burrows may be detexrted at different parts, and that Boeck

- was not correct in saying that in this variety of the disease none

rut dead mites could generally be discovered. So far as the emtfi)

tic concerneJ, this is no doubt true : but beneath them, in the soft

ratum of the rcto mucosum, there lie living acnri, of botii sexes,

1 very large iinmbers, as well as accumulations of ova, larvn and

following statement is a snmmary of what has hitherto been
ccrtained as to this rare form of disease. In eiceptional cases of
lies, probably in consequence of the presence of nn extrnordinarily
B number of acari (especially males), there appear, besides the
rdinary characters of the affection, thick, leathery accumulations of
iKiidermis. Theee, in the form of yellow homy (sohwielenartig) out-
rowtbs, cover the [mims of the hands and the soles of the feet. At
c time, the nails undergo degeneration, their lamime breaking
1, and becoming shrivelled, and in part detached from the bed, to
a tlicy ought to adhere. Lastly, on other parts of the body, as
11 OS op the face, tlie pinna of the car, and the scalp, crusts appear
hich'are dbtinguishable from those of an Ecxoma impHiginotum

216 SCABIES.

only by their containing dead acari, and eggs, fseces, and other
remains of these animals.

Those who have ever had opportunities of seeing any of the lower
animals (and especially sheep, camels, or rabbits), affected with
the mange, will notice an unmistakeable resemblance between that
affection and^ the form of scabies now under consideration. They
may also remember that Alibert described a Scabies pecorina,
although he endeavoured to distinguish it, not by special diagnostic
characters, but merely by the fact of its having arisen by contagion
from some one of the lower animals. Now, as I have already stated,
my experience has taught me that it is undoubtedly possible for
scabies to be communicated in this way, and, indeed, that it is a
sufficientlv common occurrence. But in cases of this kind I have
never seen anything unusual in the form of the affection, and cer-
tainly nothing at all resembling the Scabies Norvegica. Hence I
cannot regard this as a & pecorina in the sense intended by AUbert.
Moreover, Boeck has shown by experiment that when the Norwe-
gian itch is communicated to a healthy person, the appearances pro-
duced are those of common scabies. There is, therefore, no longer
any doubt that the so-called 8. Norvegica is simply a modiBcation
of the disease, and not a distinct species. But its rarity has hitherto
prevented its being completely studied, and I must admit that the
present state of our knowledge concerning it is by no means to be
regarded as final.

Diagnosis, — From the description I have given of the sympto-
matology of scabies, it is easy to perceive that the characters of this
affection are in many respects the same as those of eczema, the only
appearances of which this cannot be said being those produced directly
by the presence of acari. It would therefore be admissible, instead
of regarding scabies as a distinct disease, to describe it simply as an
artificial eczema, caused by the presence of acari, and by scratching.
Arguments in favour of such a view might also be found in the fact
that other epizoa which attack the integument (such as the various
species of pediculi), hkewise give rise to eczematous eruptions, having
peculiar characters of their own. Although, however, I admit all
this, I have not myself placed scabies among the artificial forma of
eczema, but, adhering to the ordinary arrangement, have described it
as a distinct disease. This I have done partly because I did not
wish to depart from the universally accepted method of naming and

DIAGNOSIS. 217

iefining these affections, partly becaase of the fact that in scabies
the eczemntons appearances have a definite localisntion, soA present
certain peculiarities.

Now, in laying down the differential diagnosis between scabies
I wi eczema, the peculiarities just referred to are the onlj pointa
I which require to be noticed, for the IivrToica {which I have already
I described in detail], being characteristic of scabies, are of course nil
I nbsolute proof of the jiresrnce of lliis disease. The fact that the
1 eruption of scabies may be either papular, vesicular, or pustular, is
I known to every one, and has indeed led to its division into a S. papn-
I liformii ifu ticca, a 5. vesieu/ota Jieie fympAatica, and a S. puainhta.
L And, although, at the present day, we attach no iin])ortance to these
I varieties, it is ncvcrliieleas to be admitted that they are really met
r with. But if it be asked whether these eruptions differ from the
I similar nffcctions met with in other cutaneous diseases, the answer
I must be that in their form they do not differ, but only in the way
J thfy are grouped and in their neat. For example, the small red
I papules which are seen in patients affected with scabies are not indi-
vidually distinguishable from those which are observed in the ecze-
inato ; bat tiie papular eruption of scabies, ns a whole, nevertheless
presents a peculiar aspect, from the circumstances that the
papules are mostly isolated, that they occur in preference on the
front of the trunk and on the flexor surfaces of the limbs; and,
lastly, that the patient sooner or later destroys their summits by
scratching, so that they bleed, and hence become covered with minute
black crusts.

Again, it is not possible to determine from their form, wbetlier

vesicles filled with transparent fluid were caused by the presence of

aeari (larva: or males) or by the action of auy other irritant, such as

oil of turpentine. But, since an acarus can irritate only a very small

tract, whereas such a substance as oil of turpentine sffecta an cxten-

I sive surface, the vesicles due to the one cause will at any pven

I time be few in number and isolated, while Ihose due to the other

I will lie numerous and collecteil in groups. Again, the presence of

a fete iiolatcd (vereinzelt) vesicles between the roofs of the fingers

I and on the palms of the hands, on the toes and on the soles of the

. feet, points to scabies ; but when there are many vesicles on the

same parts, the disease is more likely to be an Schema venailotvm.

What I have been saying of the papular and vesicular forms of
■cables applies also to the pustular. No pustules are, as such,

I SIS SCABIES.

I tharaetmstie of scabies ; and yet id some cases th
I eruption suggests at Grst sight the nature of the disease. For in-
\ stance, in Plate xliii of the oft quoted work by Willan and Bat«man,
I fsDStuIes and crusts are figiircd, wliicli are said to belong to uii
I Ecthyma viilgare. In tlieir form, these are in no way distinguish-
' able from those represented in Plate xlvi, which is marked as
Scaiirs purnl^nt-a, but they occupy different parts of the cutaneous
surface in the two cases.

Nor, again, can I agree with Fucbs' and other writers, who make

of pustular scabies a distinct species, and give to it special names

[Psora mcrocarpa et macroearpa, Serpigo, Paorhelcosia) ; for the

l»ustiiles of this affection differ from those of other diseases in their

sent alone, and neither in their form nor in the course which they ran.

At the same time, however, the itch has not, so to speak, any

I ntoHo^ioli/ of pustules affecting the hands and feet, and shores them

I with the eczemata, and with otiier skin atfections. But it ia never-

I thelcss true that an abundant pustular eruption on the hands,

I especially in young subjects, is most commonly scabies. In fact,

J for the majority of cases, the rule holds good that the occurrence of

I pustules on the fingers and toes, and on the hands and feet, justifies

I B suspicion that the patient has the itch. A pustular eruption may,

however, really be considered pathognomonic of scabies, when it is

seated on the buttocks of a cobbler, or tailor, or anyone whose

occupation compels him to sit constantly while at work. As I have

explained above, the parts of the gluteal region wliich correspond to

the two ischial tuberosities are those which are especially liable to

the presence of puslulcs and crusts in such cases, these being the

spota most directly affected by the pressure of the bony elevalioni

npon the hard stool, or bench, on which the patient sits. Since,

however, this pustular affection is never seen in those who ataod or

1 about, instead of remaining seated, while at work — as, for

Distance, in joiners or locksmiths — it is of course only in a small

proportion of the total number of ewes that the occurrence of such

1 eruption ia available as a sign of scabies. The absence of

, pustules on the buttocks, then, is no proof that the patient has not

I the itch; but their presence) is nevertheless a sure proof both that

he has the disease, and also tliat he sits while at work.

Lastly, I mu^t not forget to meation the pustules, cmals, and deep

[ MOQtibtioiu, which are found ia cases of aoabiei on the limbs, and

' Op. irft., p, 619.

PROGNOSIS.

219

utjr on tbe lega below the knees, having been caused by the

ecratching. They are not, however, in any way characteristic of the

itch, for exactly similar ones are observed io prurigo, and in eczema

when pediduli veBtimentorum are present, and abo in patients who

Ibave been bitten by bugs, &c.

PropnoiU. — According to our present knowledge and eiperiencc
of the course of scabies, it may be said that this disease is always
curable, and that it never endangers the life, nor in any way injures
llie health of tbe patient. In fact, we may remark, with Uip-
Ipoontes, " Scabtet tiirpUudo um^is quam morbas." In many mouii-
itainous countries (as, for example, t!ie Salzkammergut, the Tyrol,
and Norway) individuals are to be found, who have the itch from their
earliest youth to the end of life, without their general health being
in the slightest degree aficcled by it. And thus, in the cases
hitherto observed of the S. Norvegica the disease has lasted for
years, and yet the patient has remained perfectly well.

Of course, however, scabies alTords no protection against other
mplaiuts. An individual affected with it is just as liable as one
who it free from it to be attacked by any disease, whether general
or local ; and when such an occurrence is observed, we are ld no
degree justified by it in assuming that there is a connection between
that disease and the iteh. But whenever any severe complaint,
whether febrilo or non-febrile, arises in a patient who has scabies,
the symptoms of this eruption are found to become less marked,
iSud at length seem entirely to disappear. This is probably
due in part to the same cause which makes pediculi, leaving only
f tiieir ova adhering to the hairs, desert those who are very ill ; in
to the circnmslaucc that, iu coses of protracted disease, the
, becoming aniemic, fails to supply the acari with the same
itity of nutriment, and that they consequently jjerish. UTic
which are left retain their power of development, and this
lains latent until, when convalescence occurs, a more abuudmiL
;am of hlood flows through the cutaneous capillaries. The
"metastases" and " seqoelie," which were formerly so commonly
in scabies, must be set down to errors in diagnosis, and to
fcctivo observation. As I have already many times stated in
iric, the disappearance of a chronic cutaneous atferlion wht-n
» general disease sets in is to be regarded not as tho cause of
di»e»e, but u iU effect, and probably is to be attributed to the

220 acABiEe.

aDEemic state of the akin, which it for the time produces. The true
stqiielts of scabies would be the skin complaints which are set up,
partly bj the acarua itself, partly by different mechanical causes,
while the parasite is still present. These morbid changes in the
skin survive the destrnction of the itch-raites and their young by
medical treatment, and remain, often foe a considerable time, as
independent eruptions, in the form of eczema, impetigo, ecthyma,
serpigo, psorhelcosis, &c. To me, however, who regard scabies simply
83 an eczema generated by the presence of the acarus and by certain
mechanical causes, — who have shown how varied may be the phe-
nomena of eczema, — and who am aware that not merely excoriations,
but pustules of different sizes, and even ulcers, may be caused by
scratching — to me, I say, these eruptions give no alarm; I know
to what causes they are really due ; I no longer imagine them to be
the products (and at the same time the proofs) of a constitutional
malady, the psoric dyscrasia.

Morbid Anatomy. — Of the changes in the cutaneons structures
observed in scabies, some are produced by the acarus, in providing
for itself sheltering places within the cuticle, and in propagating
its species ; others are simply empi'tott* due to the exudation of
fluid, and its accumulation in the epidermis. Of the former I have
already given a detailed account, when speaking of the natural
history of the acarus scabiei j the latter are identical with those
which I described, under the head of morbid anatomy, in the chapter
on eczema. In this place, therefore, I have only to give Ibe
pathology of those appearances which successively arise in conse-
quence of the patient continuing to scratch himself.

The red striiE and raised lines, then, which first appear and indi-
cat« the action of the patient's fi.Dgernails, seem to be due to an hy-
penemic condition of the papillee ; the papules and wheals which are
formed afterwards, and the tubercles which are seen on certain
parts (such as the penis, the gluteal region, and the fold of the
axilla) arc the result of a serous exudation into the epidermis. Aa
this serous exudation increases in quantity, it forms vesicles, and
even builffi ; when it has become changed into pns, we have pastnles;
and the coagulability of pua sufficiently explains llie conversion
of these last into crusts. I'he repeated application of the 0ngcr-
nails in violent scratching accounts for llie destruction of the
and ptutulce, and alao for the wounding of the ei

leattg, and (or the production of even those extensive losses of snb-
I stance, vchich aie in Germau called KriitzgeBckiviire (itch-ulcers).

Eiiohgif. — As is generally known, the views of our fore-

I fathers in reference to tlie canse of scabies differed widely from

I those which now prevail. Even long after the discovery of the

' itch-mite, the diatkeiit ptorica played an important part in medical

theory, and, indeed, was expanded iuto an hypothesis upon which

the whole system of homceopatliy was based. And although 1

cherish the conviction that at the preseut day the notion of an

"itch djscrasia" is rejected by every scientific practitioner of

medicine, I nevertheless feel bound for the sake of completeness to

I say a few words on the subject, were it only to furnish facts by

■ which others may be armed to resist the attacks of those who

I «till cling to the older views.

I The writers who assert t!ie existence of a dyncraaia pai/rica have
I advanced in proof of their theory the fact that in cases of itcb the erup-
I tioD, instead of being limited to particular regions, is scattered over
I the whole cutaneous surface. A.nd this they have explaiued to them-
selves by aaguming that the individual is impregnated with an " itch-
poiaon," (Kratzgift), and that the "morbid products "residing in the
blood are dejiosited in the skin at various points. They have been
fond of comparing scabies in this respect with the exanthemata,
and especially with the eruptions caused by syphilis. And when
the existence of the itch-mite could no longer be denied, those
L vho were forced to admit it still urged in favour of the old view
I the great disproportion which there is between the number of acari
I and the amount of the eruption.

I Indeed, so long as no ade<juat« and valid explanation had been

I given of the origin of the eruption in cases of scabies, and parti-

I'Calarly of its abundance and diffusion over the cutaneous surface,

I the ndrocates of a dyscrasia had a certain advantage in their

Kcontest^ with those who supported the theory of an acarus. It

l therefore became an important object to determine what ore tlio

causes mainly concerned in the production of the papules, vesicles,

and pustules, which are found scattered over the whole cutaneous

surface in cases of this disease.

I Now, in a previous paragraph, when speaking of the symptoms

I of scabies, I showed that tlie itch-mites them.-ielves give rise directly

Uo but a small part of the eruption, this part including only the

'i'i2 SCA31ES.

papules and vesicles produced bj the young ncarij and the burrows
made hy the adidt females to contain the ova which tliey deposit ;
and I aJso slnled that these appearances are in the mnjoritj of cases
observed only on certain regions, and ef^pecialiy on the hands and
feet, the penis, the buttocks, &c. By far the larger number of the
morbid changes which arise in scabies are produced by the patient,
who is driven to rub and scratch himself violently m different placeB
by the severe itching to which tlie acarus gives rise, in penetrating
the cuticle, and tunueliiog through the skin. lu short, fie patient
himself creates the greater part of the eruption bg tcratcking.
For the benefit of those who, from want of experience, may deem
I this explanation not perfectly satisfactory, I may here mention
another consideration, which surely lends it powerful support.
I refer to the fact that scabies is not the only disease in wltich
the patient possesses the power of generating various eruptions
by scratching, the itch-mite being fairly rivalled by many other
, jiarasites and epizoa in this respect. Take, for instance, the pedi-
I culitt capiiit. This animal, when it infests the scalp in coontless
I numbers, causes an incessant irritation of the papillic, which compels
I the patient to scratch his head ; and thereby ecaematous eruptions
I are produced. Still more marked examples of the same thing are
afforded by those who have the pedieula* veslimentorum in their
' clothes, and by those who harbour the P. pubis. The former tear
I «-ilh their natls the posterior cervical region, the back, and all those
I parts of the body round which clothes or linen are fastened tightly,
\ 80 as to fall into folds. The latter, in proportion to the number of
I pediculi and tlie length of lime they have been present, and also to
the amount of hair on the surface of the skin, suffer from ui
incessant itching which compels them to scratch themselves, and in
consec|acnce leads to the formation of numerous red papules, scat*
tered over the whole cutaneous surface. Gnats, bugs, and flew,
again, are no less hostile to the human skin, and produce pre-
cisely similar effects in those whom they attack. Without pre-
vious experience of such cases, in persona who have long been
infested by parasites, and have been driven to use their fingernails
thus unmercifully, one would undoubtedly be iaclbed to attribale
i> n dyscrasia, rather tlian to scratching alone, the eicanations, the
e of dried blood, and the pustules which are preecntrd by thcte
ittts. The accounts wliich have been published of afaUe Kabiil
Hiies spuria, Pscudopsors, I'rurigo pedicul&riit, Kneimus acuiuif,

Kfierpigo, Phthiriasis, &c.). liave all been founded on cases m whicli
the effects of scratching had been misnnderstood.

Now, a comparison between the changes in the akin which are
observed in scabies, und those wljich result from the presence of
c other parasites above mentioned, will lead us to the conclusion
lat in the former (aa in the latter) case the so-called eruption is
produced simply by scratching. For the appearauces themselves
i almost the same, and differ Id nothing but in locality. I am
lot, indeed, at present able to explain why it is that a person
hfestcd with any one of the epizoa is impelled to scratch parts of
pus body which are to a certain extent definite, and peculiar to each
But nevertheless my experience has taught me that it is
a all caws ])ossible, from the characters and scat of excoriations, to
i with certainty by which of the parasites the irritation of
[be skin has been produced.

1 think that in the preceding paragraphs I have shown the

3-caUcd eruption of scabies to be the result of mechanical irrita'

nion of the skin, and that, so fur as this point is concerned, I have

efutcd the opuiions of those who suppose the itcli to bo caused

^S a dyscrasia.

But it has also been maintained by those who belong to the old

ichool that scabies may produce morbid changes in otlier organs,

well as in the skin, and that it freqaently alternates with intcmal

My answer is that these are but vague assertions, of

firbich no proof whatever has been offered, and whicli have tio

fonudation in fact. I think, too, that I can destroy their force by

simply pointing out that scabies occuts in the largest proportion of

cases among strong and healthy young men, belonging to the

irorlcing orders, and especially to that class of them who are com.

cd by necessity to sleep two in a bed, or to live in lodging

iionacs, or other dwellings crowded with poor people. This, again,

Bf^esls the true explanation of the frequency of the disease in

(hose who belong to certain trades, among which are, for examjile,

9 of the cobbler, the tailor, and tiie weaver. It is not that

tnything in the occupations themselves, or in the habits of life

Essarily connected with them, predisposes to scabies, but that in

me trades it is common for the men to live in the house of their

iBaster, and (from want of space) to sleep togetlier; whereas in

thcr tradf! such an arrangement is very rarely, or never, made

iVnuta, and indeed, ia lU 1h|;» towHir (Jwe am Ju^y «'

224 SCABI£S.

working men. Some lodge with their employer^ receiving lower
wages in proportion; others stay in their master's house only
while at work, hiring for themselves the rooms in which they live,
and sleeping alone. These last furnish a very small number of
cases of scabies; whereas in the others the disease i3 common.

Again, women, although poor, generally possess sleeping places
of their own. They are consequently much less liable to the itch
than men of the same class ; indeed, one may reckon that seven cases
occur in males to one in a female.

All these facts point to the conclusion that scabies developes
itself chiefly in those who have for some time been in intimate
contact with persons suffering from it. In other words, it arises
from contagion*

The contagiousness of scabies, indeed, was never contested, even
by those who maintained that the disease had its origin in a dys-
crasia. But, until the itch-mite had been discovered, it was sup-
posed that the contagion had its seat in the fluid of the vesioo-
pustules ; and, even when the acarus was already known to many
observers, the same view was still maintained, or else the con-
tagious principle was imagined to be, not the acarus itself, but a fluid
adhering to it, or contained in its interior.

But the result of direct experiment was to show that fluid taken
from the vesicles or pustules of patients affected with scabies had
no power of communicating the disease, and that the only way of
generating the itch is to place living acari, or ova, on the skin.

It was, however, observed that when this had been done with
single acari, or even when a whole cuniculus (containing, of course,
a certain number of ova, besides the parent acarus) had been cut
out and placed on the skin of a healthy subject, the disease did
not invariably follow. This fact led some to imagine that by a
special predisposition certain persons are rendered more liable than
others to take the itch. At present, however, I am of opinion that
such is not the case : I believe that every one can afford the accom-
modation needed by the acarus scabiei, the only condition required
being tliat the animal should be impregnated, and should have
access to his skin.

I have already shown how these facts apply to certain
classes of working men. The same thing may be seen in the
army. In time of peace soldiers live under wise hygienic rules, and
are very little liable to scabies. But on a campaign they are crowded

BTIOLOGY, 225

^ther b^ thousands, and it is not possible for them to wash
properiy, nor to clean their clothes. These conditions arc, of coarse,
favorable to the development of the itch-mite, and, indeed, of
every other epizuon which infest the hiimait skin ; and scabies con-
sequently spreads nnder such circumstances.

Espcriment, too, may be made to nfford proof of the name thing.
Forevi^n when failure attends the first attempt to produce scabies
by placing acari on the skin of a particular individual, subsequent
trials sooner or later succeed. It haa, indeed, been imagined that a
special predisposition on the part of the patient is ret|uired, or (us
AVichmann expressed it) that the exhalations from the patient's
skin may be more or less agreeabh*, and are sometimes entirely
disagreeable, to the sense of sraell, or to that of ta.'ite, possessed by
the ncams. In my opinion, however, the failures which arc occa-
sionally met with are due rather to the circumstance that the ilch*
mites employed were all of one sex, tind most likely all fi-malw.
I have, for instance, often been unsuccessful, when I had simply
placed imprt^nated females on the skin at ditferenl spots, although
^I had actually seen the animuls penetrate the cuticle. Indeed,
i sometimes bapitened, that even when the acari had formed
trows, these have nevertheless died away, the mites themselves
! perished, and wo symptoms of scabies have followed. On
^ other hand/ when I had employed an entire euniculus, removed
. the scissors from a patient affected with the itch, small
Ides and pustules have gradually developed themselves in the
Evidual on whose skin the euniculus liad been pUcod ; after
, burrows themselves have been discovered ; and, in short,
[the symptoms of scabiea bovc made their appearane^. 1 repeat
tefore, that, in my belief, the success or failure of attempts to
miuiioate the itch by means of the acarua does not depend on

' predisposition on the part of Ilie patient, and that the ono

condition indisiieosablc to the propagation of the disease in this way
is the employment of mites of both sexes, so that reproduction can
lak e place between them.

1^ shall, therefore, assume that it is demonstrated beyond dispute

Bcaros is the cause of scabies. But I have still to

t with certain questions which have important bearings on the

' of the disease. These are — llow does the aoarus WJjbiei,

r ordinary circumsUnces, get to a person's skin P Doca this

t iofut the integument of man alone, or is it able to reside in

226 8CAfiIK8.

that of other animalB alsoP How long can it live m artidw of
dresflj fomitarej 8co., away from its host P Are the ova capable of
comnmnicatmg the itch P How long do these retain the power of
development ? and lastly^ what view are we to take of the &ct that
the presence of acari in the substance of the skin leads to the pio-
dnction of scabies P

Now, although I «n not, at the present time, able to give preoiae
and certain answers to all these qnestions, I will yet endeavour to
apply my experience to the solution of at least some of them.

In the fint place, it is to be remarked that the acarus scabiei
finds in its host food, shelter, and, in fact, all the conditions neces-
sary for its existence, and for the propagation of its species. Henoe
it is not to be supposed that, even when present in ever so laige
numbers (or even, for instance, in the so-called Norwegian itch), it
will voluntarily and without necessity leave its abode, and undertake
long journeys, in order to seek with difficulty, and on a new soil,
that which it can attain where it is, so abundantly and so easily. Some^
indeed, have asserted that the itch-mite is a sort of nocturnal beast
of prey "which takes advantage of the night, in order to seek spoil
on different parts of the skin, returning during the day into the
dark passage, which serves as its hiding place/' A similar view is
advocated by certain recent writers, who maintain that the acarus
during the night leaves the burrow by means of openings which it
makes for the purpose in its roof. Gerlach and Aub^, again, term
it a nocturnal animal (Nachtthier), and Boui^ignon and Lanqnetm
speak of having always looked for the itch-mite at night-time.

Now, as I stated above, I have examined many thousand cuni-
culi, but have never yet seen any such openings in their roo£s; and«
therefore, I cannot assent to these views. Moreover, for the reasons
explained in the previous paragraph, I do not see why the acams
should thus leave its burrow at night, and make excursions simply
for pleasure, roaming from one pari of the cutaneous surface to
another.

Indeed, the fact that the adult female itch-mite is invariably
found at the tail of the cuniculus, and in such a position as to show
a tendency to prolong it further, appears to me to prove that the
animal never of its own accord leaves its burrow. It is true that
the young mites which have just crawled out of the egg, and those
which for the purpose of moulting have emerged from their former
abode, and are about to seek a new one, do for a short time wander

ETIOLOGY. 227

OTV tbe cutaneous surface. But even these, as is well known,
hasten to find sheltering places beneath the epi(lerini». Now, it is
certainly possible that an acarus which might be on the surface of
the skin for this purpose, or in order to complete the act of copula-
' tion (an act which no one has yet seen pcrfonncd), should pass from
one human being to another: hut such an occurrence has never
been observed.

On the othrr hand, it very often happens that one finds a cuniculus
iu great part destroyed, more or less of it being, in fact, gone.
Direct eijH^iment has shown that by means of tiie finger-nails, and
that withoilt particular violence, one can very easily dig adult acari
from their burrows, and even pick off Utile plates of cuticle, con-
taining the harrows themselves, with the ovu and mites which are
in them. Since, then, the severe itcliing to which scabies gives rise
impds the patient to be constantly and violently scratching himulf,
often at those very parta where burrows exist, it seems fair to con-
clude that his finger-nails afford the means by which acari are con-
veyed from one part of his body to another, and also to the akin
of any other individual who is aufiiciently long in contact with
him.

Again, it must not be overlooled that the serous or pnriform
fluid which developes itself bcncnth the burrows, dries up, with the
epidermis contnJning the burrows themselves, into crusts. These,
therefore, may, and often do, have ova of itch-mites within them.
It is consequently at least possihlo that such crusts and other pieces
of cuticle naturally cast off may be capable of communicating
■cahies.

I have next to explain how it is that the acarua, when it baa
penetrated the epidermis of an individual, gives rise to all those
appearances which make up the disease.

Now the abundance of the so-called eruption in scabies, in com-
panson with the number of acari which are discoverable, has led some,
even of those who have enrolled themselves among the supporters
of the parasitic theory of the disease, to imagine that either the
scan, or their ova, or excrements, get into the blood, and produce a
change in it« composition, leading to the formation of deposits in
the akin, and so giving rise to the well-known papular, vesicular, and
pustukr eruption. This hypothesis, however, has never been verified
by facta. Neither acari, nor any products of them, havt; ever beea
discovered in any part of the bud;, excepting the iutegummt, a;

228 SCABIES,

certain parts of the mucous. membraneB near where tlicse are con-
tiDUOUs with the skin.' Indeed, no one who lias seeu the itch-mite
uid its ova CQD posaibl; imagine tliem to be taken up into the blood,
and carried round in the circulation, eecing that their diameter ia
lar greater than that of the capillary vesaela. The notion in qaesr
tion is, therefore, merely a theorist's idle fancy, developed in the
sludy. So long ns it was believed that the eruption in scabies, like
those of the exanthemata and of sypluhs, is the result of certain
changes in, and exudations from, the blood, the only part that could
be attributed to the acarus was that of poisoning the circuUtiog
fluid. But since I have shown that the whole of this eruption is
produced by scratching,^ all thai remains to be explained is the
circumstance that the acari, although present only at certain parts,

I should nevertheless produce itching elsewhere, and even over the
whole surface of the skin, and should consequently induce the pntient

, to scratch liimself over a very wide area.

Now, my views upon this question are fully expressed in Uie
paper on scabies above referred to ; and, since 1 hold Uie same
opinions now, I cannot do better than quote the passage concerned.
"In reference to this point," I wrote, "experience teache* ns
that irritants appUed locally to the skin, even for a short time, often
give rise t* affections diffused over extensive regions, or even over
the whole cutaneous surface. This may be observed, for inslanoe,
in those (such as locksmiths, bakers, and cooks) whose daily occu-
pations expose theru to the heat of a furnace. In these persona,
it often happens that the heat acts directly on certain parts gf the
body only ; but we nevertheless find that various eruptions to vbii^
they are liable, (of the kind known by the name of ardjli^il eceetaa),
arc by no means confined to theses exposed ]]arts, but hkewise attack
those at a distance from them. So, again, in persons in whom the
skin is delicate, it is a common thing to see a senaral eruption of
papules, vesicles, or pustules produced by the Ivcal application of
&n ointment containing sulphur, potass, soda, lime, or tartar-emetic,
> It bu nnc(! happened to mc to Dud a most peTfeot burrow witluu llie mala
Dmllir*, abuut a iiuo from its ortGcB. Tliia borrow contained nn Dcom* t
cigbt ovL I liBve given & deMrlption of It, with a figure, in tbo ' Zciladin/t d.
k. k. GMclWiKft dcr Anrctr,' 8 Jahrg., Baud i, p. 390,

' Thrre i« a plsj on Ills word* in tliu originNi, wliidi con linnilj be ti
hlo KiiglUb- Tlie [apulps, *™itle», ftp., of vMn (liif KrUtwt ■
Krd/t-rSBonvxDua. Vm(. lIpimMjR iljotstDiwlli«f areprodueeitH

I ing (dM KraiuM) Uiej QUglit utber to be calln! Kratt-rSmwa

ETIOLOGY.

229

r an Itleobolic solution of canthwidea, amicn, or tpir. formi-

m, usif] tlicrapeutically as an epispnstic. Cases, too, have been

I observed in whicSi an extensive erytlicma, or an actual dermatitis,

I has been Ihe result of a blister, or of the octioii of mastnrd or

P leaven on the skin, or even of a simple sbrnsion of tbe epidermis,

I orasb'ght injury to the cutis. No one can hnve failed to notice

how easily tulierclea and wheals are produced in some persons by

siijilying any ointment or plaster (such aa the wny. rt*i«tt, or the

emp. tlemi) containing resin, or by rubbinj^ or scratching the skin

with any rough substance, or, lastly, by tbe biles of gnats, fleas,

bugs, or other insects. Now, under such circumstances, the tubercles

and wheals, instead of being eonSned to the spots directly injured,

appear likewise at parts remote from them."

These facts lead to the conclusion that difTcrmt irritants applied
locally to tbe skin have the power of producing itching of the whole
cutaneous surface, and also eruptions of various kinds.

Another point which seems worthy of notice is that while one
part is being scratched, some other generally begins to itch, and
renews the necessity for the use of ibe fingernails. The French sny
' L'appfCd vienl en inattffeati/,' and we may certainly observe that,
during the time a patient is scratching himself, the impulse to
■crotch becomes more urgent.

But why is it that certain special regions are chosen for the act
of scratching ? In searching for the answer to this question we
meet with no help from the analogy of the other cntaneoos uffeetions
caused by epizoa, and attended with itching. For it is perfectly
natural that persons who haveptdtrvli in their hair should scratch
their heads, and thus produce local eczemnlous alfections ; and it is
equally easy to sec why those infested with numerous ^frficB/i res/i-
mentonim shoald tear the skin at the back of the neck, round the
, wnist, oTtT the wrists, and, indeed, wherever the clothes nrc gathered
■Jnto folds and tightly fastened. For it is well known that the last-
lamed sjwdes of pedievliii dwells in the folds of linen and other
• garments ; and, as it naturally chooses to satisfy its thirst for blood
without going farther than is necessary, it wounds and irritates the
adjat-ent parts of the skin. On the other hand, its victim tries to
free himself from his enemy by scratching the same regions.

So, also, whim severe itching is prodncoil by the pediat/ivt pvblt,
Ltiu patient is, no doubt, driven to scratch himself in various places,
*" " E number of thejw^tcH/', and the extent of surface in-

230 SCABIES.

tested by them ; bat the parts attacked by his finger-nails are chieflj
those covered with hair. And when a person is bitten by a soffi-
cient nomber of fleas or bogs, we find the excoriations apon the parts
directly irritated by the insects in question^ and^ in fact^ principally
upon the extremities. In a word, we observe that in eveiy instance
the excoriations prodaced by scratching, as a consequence of the
presence of any of these epizoa, occur in the neighbourhood of the
regions infested bv the parasite, or upon the parts directly attacked
bv it.

But, as I have already shown, in scabies this is not so. ^le
principal parts occupied by the acarus are the hands, feet, penis^ and
those spots (such as the elbows, buttocks, and knees) which are sub-
ject to pressure. But the excoriations which the patient makes for
himself by scratching are found not on these parts, but chiefly on
the chest, abdomen, and thighs, over a space which, as a mk, is
limited above by a line from one nipple to the other, and below by
one from knee to knee. In severe cases of itch the skin of the legs,
and that of the forearms and arms, may, indeed, be scratched to
some extent ; but even then, the face and back invariably remain
endn^Iv free from excoriations.

Now, the only thing to which I can point in explanation of these
remarkable facts is the convenience and "handines^'' (das znr
Hand-Sein"^ of the parts which are thus selected by patients with
scabies to bo scratched for the relief of the itching. It seems as if
the (patient tormented by the acarus is not .as is the case with per-
sons infeste\i by other epizoa) informed distinctly by his sensations
at what STtot he is beinir attacked bv his enemv. He feds onlr a
cowmi '.iching. and therefore scratches most frequently those parts
which he can get at with but little trouble, and without much move-
ment of his limbs.

A point which mav be mentioned as streninheninc this view is
iha: ihf iixitAticn c»: the effects of soratohini: to the n^c'cn between
i":.: brt'ASTs sVv..ve and the knee? V't'::w is cbrknod pr!::::j^r in men,
a:..i c^^xviriV.i :n ;":.:iK ^h.i c.unnc v^v.r d;u"s work wear no
c".L>:hf:s, except thtir shin a',i draiaiTs. In women ana children we
d > n:-; f.nd :hai the scat cf ;hf txcoriaTi.^ns is thus connned. In
f^::. in wonun, thcv occur chiffv on the chcs:. and the folds of tLe

■ • - —

k\...x, and Su7r:>'^nd ihc- w&:si. m ihc fv^rm of a girdle, josi where
The p.-Tiicoat^ are fasienod. Thi-v are also very afai ^ en Ife
Jciwer limbs, which are rendered more accessible f^

by the way in which females dress, Lastiy, children (and particu-
larly infants at the breaat) wearing but few clothts and being fre-
qut-ntly miilressfd, scratch themselves promiscuously ou all regions
of tlic body, but nowhere »o severely as ndult«. In these little
patienta, therefore, we find no excoriations, such a£ I am now

I tpealdng of; but in their place, erujftiDnB uf various kinds, and [as
1 have ulrendy stated) burrows sealed on obWg, red tubercles, arc
met with on every part of the cutaneous surface.

I repeat, however, that I regard this view merely as an hypothesis,
which I [tut forward, only hecnusp I tiinnot ace.onnt for the facte
mure gjitisfactorily in any other way. I »hall therefore he very glad
if a better explanation should hereafter be given, whether by the
physiologist or by the clinical physician, — by mjself, or h) any other

, observer.

Trealimat. — Even when it wiis still conteuded that scabies hud

it> origin iu a dyscraata, all practitioners were agreed that, iu order

to cure it, it was necessaiy to use local applications, And yet till

quite recent timea it has been maintained that the ettemal must be

tided by internal treatment (and vvvn, according to some, by the

whole "antiphlogistic sppanitu«"), in order to ensure a radical cure

of the disease, and to prevent its being followed hy any injurious

eonseipieDces to the patient. But while Ibis was the opinion of

physicians {so that each of their patients was tormented by a long

ooune uf internul medicines, in addition to the local applications),

< tile <|usck9 and " old women" had more sense, and adopted a resson-

t able and simple treatment, by whicli they succeeded in gaining both

I credit and money, attet their hurued competitors had failed. If

medit^l men in those days had but observed with unprejudiced eyes

I the favorable results which followed the use of popular remciUea and

ft^rea for scabira, they probably would have much sooner acquired

Borrect notions concerning the nature and treatment of the disease.

Tot more importance was then attached to theoretical pedantry than

I the observation of fncl--<, and even men of reputatinn, sucli aa

ffichmann. Frank, and Guhtener von ]x)bcs, failed to liberate them-

!ntire!j from the views of tlieir day, although in many re-

s their opiiiiuns concerning scabies were perft-otly correct.

Ab I have already stated, the notion that inlernni remedies, a*

i as cxUsmal, must he employed in the treatment of scabies, has

1 to the most recent times. Even after it had become un-

23"2 SCAB115.

pc;s?:r'.e :c d*f=T th^: '..v^ appLioacoos 5i:£cf to care the disease,
iLrir c-xd efec:s wck aco:::r.:cd :cr bj sTzpposing that some of
ij:-:ir>::i3:::-er:5. ceinr brr-i^"::: iz.:: ir.dznie ccncact wiih the skin,
were i':.>:rcei ':t ::* bl:v\i-TeN?cl«. izi c-^rrlei ii.io the circulation,
— :JLi:, iz r'ic:. 5^:1': i-fs Ti5 currei *:t il^zi iz eiact> the same way

is s-^riL:* i* "rv zicrcurr. wjirz :lr iie;'::;c c: iznncdon is em-

• _ ■ «

M:rr :":Liz :t:z.:t veir* ir? I ;*jjt: ti :-: crnain exDeriments to
ner:^ :ri5 iTATiz: ^*-:. ii.i I r-':l:<"zf\i in L-XTZzzTr zt ibem in 1844 in
:ir T-iTc: :- joi'rifs :c w"i::"i i Live ilnaiT so c-hen referred.

Ms *

T*r 'I-IZ i-OC "Z.n* 1 *J^c *I.f I' _-■▼'. r^ TilT'iitTliTC I

ifz-z'.il. T.ii fj.-i.::*:*- r~f ; TrfS:i::f'i erfrr Tir/e:T c-: lie eniption,

rifs:_'r< fi::r.i:::z3 iz.i .L:-.:^ :- l_:::rii:: rf^:i* :-: tI* !K>dy; bat

'Ljz --r:. r:-5 ::i:t:t5 ir,: i.^ir. -ffii.'i -wtTt ::::z.i co ibem vere

:■- -If '::j:'..:i irl ::-:c il.r.r. i :!i:r::':rf ii:£ ;i-* ij^d* and feel

▼71:31: : --. :- "..I:- :".::: 5. vl::! t:;:^ "^-^-J -i**«:^«i, so as

.... .

w^ -:.r,T .. ^. ^j^-: ._•: .Ar.? — ^ -:>-..". U*: 1 TXilJr -i WIS llien

5.rr.TTe.:. i^i. '^ rT Tr:s:~:^f, :cr :ri:rxrT rjz.z'Zrzz'r for scabies
▼ L? nne.l :r.:: -Ji- ▼:.;.: .: i:> ":•:.•-. ii.-^T^ :V rAifis and feet,

« • - ■ i- <.- . k ■ . . i .. ? « . . I V . ... . _ V . .. . . ..4 .%, teC^^. ^liSll \%J

"' LL- '' " 'i--^-'-- "'^■►" -i : ' •" 1 "V ■ ■*-■ - --.' - - -- - £~t-'!* iTlS Ka^

V7^ r: .«:::;•;■ .:rr :. J. : :. .;>, >: : i,: : ; :-.: :C:i :■: izyi 0:iri dMj
;: : \ ■ :';\z :... :«:-A v...-: v^-.:">:;: - - • "• - ^ - . •' ■ - t '^- -.— t * >.* S^Tw Iia
IT". ::•;■: A:«::.: :^' ':•■". ;."7;-l> / : : ^ : "::^:t* "T:!^ isei. The
r-::. T:r: r:7 : :,:-:•:,'- :- \:r:: :.;-;. ;.?.; v : ,. -rrj-l^fi: lod ;be

• * »"-"^» ■• ' ■-. V-.«*.. , ■■• ... .,■ ■•... vatf.. - im mm m .*i i ••

•■ ».. . ... .1... •'., ».. ^.'^ s^Klf

« .»^ , • ,. . .^ V » . . _ ' r^_';.^£5»

--'.■"?•■ .'■■■* ' ■ " ■" 1':*: ! *". s: . . '. . *". "'*i"' '.ZJ\ ▼'.'-5 *>* rri »

T. :■ ■ . ■---■: T - ; . >;■ . - I- :c;-tr

V :•-■■ ' ■ . : : .: ■ . " • ^ . - > *; i.-. i.r tt:-j "

• --■■■■■ .-•- v^ ■■- •. ._• AA_ V •^^T^

. Iff '.'i^li L.l '■*" -1.^ »..li -Ifti: .1- it >i..!i^^ ^"■Mili - l»k. «i ■ . fc. :^^'iT» 2t C^

TSBATHENT.

S88

pl&eed under the microscope, when Ihey were found to be alive, and
cruwlcd about ticlivi'ly on tlic glass slide..

I al oncu ri*pent.cd t.)ic experiinenl upon foar otiier patients, and
obtaiucd exactly tlit; s&me results. All six were tlieu watched carC'
fully for a numlh. During the first week the disease appenred to
decline, niid in uiie cnse to be entirely cured, tbe itching having
tdino»t disappeared. But at the end of llial time the itching returned
in each patient with all its original intensity, and the dilferent
regions of the body gradually came to present the same appearances
Bs before, including those which we know to be caused by scratch-
ing. It was therefore concluded that the ting. aittipiorieHm had in
these cases failed allogether, although it had been rubbed into every
part of the cutaneous surface, excrpt the hands aud feet.

Counter experiinents vcre next made with the same number of
patients. 'I'be ointiuent was mbbed into those regions only wlitcb
contuinrd acari. In a short time the disease was entirely eared.

The two series of experiments, when compared together, surely
prove beyond dispute that the ointment cures scabies, not by being
absorbed and entering the circulation, but simply by its power of
killing the acjirus.

This point, then, having been established, the treatment of the
itch reduces itself to the cmplojrmont of such auhsttutci^s os may
be found upon investigation to possess the properly of killing the
it<:h-mite with the greatest rapidity, and of rendering its ova inca-
pable of development.

Now, by the observations of veterinarians (especially WaU and
Hertwig), as well as by the experiments which Albin Graa made
with tbe itch-mite, it has been shown that many substances
act injuriously on tbe life of tbe epi^non in question, but that
there arc dilTercnccs in the time witliin which these produce
their eft'ccts, and in their mode of operation. It has been found,
for instance, that, without being killed, the aearua can remain for
seven days in cold water, for ten days in hot water at 100° Fahr.,
for two to four days in vinegar made from beer, in horse's urine, in
lime-water, in a solution of black soap, in an alkaline liipiid prepared
from the ashes of soft wood, or, lastly, on tbe surface of a glass-
plate smeared with blue ointment. On the other hand, it was killed
in from two to twenty hours by n soluliou of common salt,
bichloride of mercury, arsenic, noetate of lead, alum, or of the sul-
phate of copper, iron, or line, by a decoction of tobacco lesTea,

284 8CABIV8.

henbane, or belkdoima, by wbite or liMtk hellebore, by staphysagria,
bj chloride of Ihn^ or, liatly, by pore solution of ^mmmim More
r^id still was the action cl enqpyreomatic pyroligneons add, tur-
pentine, petroleam, stinking animal oil, a strong or even a dilate sola-
tion of caostic potass, tar, or any of its preparations, iodide of
potassinm, and solphnr. By ai^ of these substances the acams was
killed either instantly, or at least within a few ndnotes. The
solphnr was foond to be eqnally effectual, whether it was used alone,
or in combination with potass, soda, or hme (as in i^Mr ^pimrU).
The TarioQS substances of which I have been ^waking do not, how-
ew, seem to possess the same power of destroying the e^ of the
itch*mite; at least, they do not produce any reeogmsahk change in
thcar form, or in that of their contents. (X aU the agents with
which I hsTe experimented, creosote is the only one which I find
to haTe the power of rapidly destroying the ova, and, as it wev^
diasolnng than into a pulpy mass.

But, besides these substances, which by their chemical actions kill
the itrii-mite, there are others whose effects are due aimpfy to their
power of removing mechanically the lamine of epidermis whidi
contain the acari and thctr ot». Thus, in many places, a pqpnlar
method of treating scabies consists in the use of coarsely-powdered
substances, such as brickdust, pumice*stone, chalk, and sand. But,
since whaterer destiovs the acaras cures the itch^ it is easr to under-
stand that the same lesuh mar be attained br a eieat manr remedies,
and by tcit diderent methods of treatment, which yet would, at
first sight, appear to be exactly opposed to one aaotha in their
action.

It might seem to follow from these remarks, that it is almost a
matter of indifference whether we use one or another remedr Ux
acabiess sace all of them are alike capable of effecting the object
aimed as. But it is not to be fcnrsotten thii in treaur:^ thi^ disease^
we hare, tesaies lie acara5« to d«l with aaother aniaixl. the mam
who » c^ir ran^:::. ind whose <i".ii sius: bv ro ci-^jir-s re It:*: out of

:De ccoace cc x Kciecj ::r scarce? :5 a rufcttcr o: so3je im-
rcr:xrjce w:di ir?iee%i. appear S*,*:: wh*: hxs Kxr. 5a:i in the
crarciff mpcc ecseza. Fn.-c scce c: :be *uS*:ArA.Y* wr.::h >.^«s«ss the
rcwer cf r'"7'"^.-g ie aorss scabc-ei iit? also the vr.nxr:^^ :: creailr
xznsiC2g the skxa^and so pcccair^ arcicsal ecres:4Sou$ or p sdCukr

imi c«m CQDsaierab«e losses of »ab«rawBe>

TREATMENT.

M, Althoagh tliey remove the actual cause of the disease bj
(iestroying the itch-mite, they yetf in themselves, exert rather an
iDJurious than a beneficial action on the integument. It cannot be
denied, however, that veterinary eargeons have in this matter paid
more respect to the skin and hitir of ^^V patients than medic&l
men have to theirs. This, indeed, is not surprising, for the
fleeces of sheep, and the skins of other animals, have a far higher
market va!*e than is poasesaed by the int^nment of a man who has
the iteh t Moreover, veterinary surgeons, in the diagnosis and treat-
ment of the mange of animals, have from the first paid considerable
attention to objective conditions, wliereaa formerly these were (com-
paratively speaking) overlooked by phyncians in dealing with scabies
in the Imman sabject. Thna, when an artificial eruption was pro-
duced by the application of any one of the substances which destroy
the itch-mite, such an eruption was supposed to be a sign of the

■ evacuation of an acrid matter (die Kratzschiirfe) ; and it was con-

■ ndered highly satisfactory, both by the medical man and by his

■ patient, if the first efi'ect of the treatment was to increase the number
' of papules, vesicles, or pustules on the patient's skin. At the

present day, however, our fundamental views concerning scabies are
exactly opposed to those which then prevailed. It is our object, in
I curing the complaint, to irritate the skin as little as possible, and to
I ftvoid producing artificial eruptions. Hence our indications in
J treating a case of scabies are entirely different ; and the remedies and
m methods of treatment which we should recommend most strongly
vouid he such as, without giving rise to irritation, should kill the
litch>mite and its ova, and, at the same time, ttxnove the eruption.

Unfortunately, however, I have not as yet been able to discova-,

t Among the numerous substances with which I have myself

l«X|ierimeuted, or in any of those recoraroeoded by other writers,

r a remedy which completely salisfiea these conditions. I must,

therefore, content myself with eaumerating the medicinal agents

and pluis of treatrnt-nt which approach most nearly to what is

required.

There is, perhaps, scarcely any other curable disease for which so

Kmany and various remedies have been proposed, as for scibies.

pViose enumerated in medical works amount to hondreds; all of

which if 1 wished to mention, I shonld have to dcvot« to them

many pages. Recently, however, several wliich had fallen into

■oblivion have been revived by writers who have seemed to 1

them forward as discoveries of their own, and liavc extolled tltetn
loudly. I, therefore, deem it not altogether superfluous to speak,
in this place, of those at least, which have long been most. generaDjr
employed.

in the 17th cPntnry, tUe Fulia Tabnci were recommcDded hv
K*di; in 1811, decoction of stavesacre st-eda by Rnnque; Pringd
adi-ised the Helleboms albns; Bruckmann, the railh InuUt;
Linnatus, the PoTrum; Watson, the clematis; Hundertmark, the
common daisy; Tiiomann, powdered charcoal; Grille, the oxide
of manganese; Ackermann, potash, and the caustic soap made from
it; Helwig, Andr^e Bry, and H, Gahn, dilute sulphuric acidj
Leschen, nitric acid; BorellusandBrinkmann, chlorine; Ilcgcniaflh,
the sulphates of Kinc, copper, and iron, sulphur and prepamtions
of that substance, turpentine and the ethereal oils, tlie different
tarry bodies obtained by dry distillation from various kinds of wood,
soft soap, &c.

These remedies were applied in various ways: sometimes com-
bioed with lard, in the form of ointments ; sometimes with soap,
as in the so>called medicated soaps. Sometimes, again, they wen
added to hatha; and a few of tbem were even employed in the
state of vapour.

Of oinimfnt-9 against scabies the name is legion. Medksl
writers and hospital surgeons have vied with each other in con-
tinually extolling the value of new ones; but hitherto no reason
baa been shown for preferring one of them to another.

The different observations which have been pnbhshed in reference
to the cure of scabies have been collect*'d together and compared by
Mflicr, in the ' Journal General de Mudecine,' in which therw is
also given a list of the various remedies for the disease, which bad
been employed in France up to the time when he wrote.

Several of these formulse I quote in this place, — some becaoae
they have remained in use down to the present day, others because
they are repeatedly mentioned in certain books, which neverthelna
give no precise account of their composition, nor of the way to
prepare them.

JHrst of nil, then, must be placcil Helmcrich's ointment, con- 1
fisting of two parts of pure sulphur, one part of subcarbonato of
potass, and eight part^ of lard ; and nest comes Alibcrt'a, whieb
contained one ounce of flowers of mlphur and two drachms of
muriate of ammonia, to two ounces of iard.

TREATMENT.
Again, Jadtlot's formula was tlie following :

^ Kali Sulphonti (Pelame SulpAurala, P. Br.), Jtj ;
^pooitiklb., Oij;
01 OIJT., 5Fr ;
01. Ttijmi \altt., Jij.

Jaasei, on the other hand, ordered :

R. Pultr. Flor. Riilph. {Suipkurii Sublimeti. P. Br,),
Lauri Bacoarum,

Yilriul. alb. \,Ziiiei SnlpAa/L), part. Bt;. ;
01. Lid, q, >. ut fiat ungueatum.

Of all i^uc)! ointinfiitii, however, the simplest ia that of Joseph
Frank, consirimg merely of sulphur, rubbed down with fresh butter
to tht^ pro])er consistence.

Again, ct'rtaiii prt-pnrations (generally coDtaining sulphur) have
of !at* been greatly ])raisc(I. Among these, that of V&in espe-
cially requires mention; it« formula ia as follows:

»■ Flor. Sulph..

Sapon. alb.,

Axung. Poro. (^Adipu). aoajvj ;

PuIt. Ilellebor. >lb., 5ij ;

Nitti pori {Potaua NUralii), gr- X.
M., Gat ung.

Another ointment, consisting s
■ that of MayssI :

uply of sulphur, soap, and lard.

{t Sulphur. Tcoalis, Jiiv ;

Saponis domeat., Oj ;

Aiuog. Forci {Adipit), Oi*.
M., fiat ung.

In ^Villiinson's ointment, again, there are the same ingredients,

' iritli the addition of tar, chalic, and bydrosnlphuret of ammonia.

I have somewhat modified this ointment by diminishing the sulphur

uid tar contained in it, and by leaving nut the hydrosulphuret of

^unmoiua, as sopctfluous. My formula is as follows :

9, Flor. Sulphurls.

01. F«gi vel 01. Cadini. ana ^r] -,

Saponi* Viridia,

Adifni, ana Oj ;

CrM«.SiT.
M., fiat ung.

238 SCABIES.

Bourgaignon's ointment is one which would probably be rerj
useful in practice among the higher classes, on account of its
agreeable smell. Its ingredients are the following :

9) 01. Lavand.,
Menth.,
CaryophylL,
Cinnamom., ana 9j ;
Gammi Tragacanth., Jj ;
Kali GHrbonici (Poiassa Carbonaiii), Jj ;
Flor. Sulpharis, Jiij ;
Glycerin!, Jvj.
M., fiat ung.

Adolf, again, ordered the following ointment :

9) Flor. Sulphuris,
Juniperi Bacc.,
Lauri Bacc. pul?.,
Axung. Porci, ana ^. M.

Blasius :

Banque :

9) Afangani Oxid., Jj ;
Axung. Porci, Jiv. M.

9) Pul 7. Sem. Siaphysagriffi, Jss :
Ext. Papav. Somnifer., 5U ;
Axung. Porei, Jij. M.

Another formula is as follows :

yi Acid. Sulphurici fort., ^ ;
Axung. Porci, Jij. M.

Lastly, Emery prescribed the following :

^ Sulphuris, Oss ;
Alcoholis, 5J ;
Aceti Vini, 5ij ;
Calcar. Chlor., Ji) ;
Saponis nigri, ^ ;
Sails marini, ^ss. M.

Instead of ordering ointments, however, many physicians have used
8oap as the vehicle for the drugs with which they have treated scabies.
Indeed, soap by itself has frequently been employed with success
for this purpose, and is so employed at the present time; and
sulphur was combined with it by Hom^ in the hope of obtaining

TBEATMKNT.

239

more active therapeutical effects than those yielded by aoap alone.
I A very simple extempore metliod of preparing such a combination
I is to take equal parts of flowers of sulphur and powderud soap,
1 and to make them iato a semiduid mass with a proper quantity of
I water. This is a plan which haa loog been in use, and which is
I very convenient, capeoially to those who practise in the country.
I Quite recently, medicated soaps have become articles of manu-
I facture ; and at the present day many such are made, of which the
I most important {so far as the treatment of scabies is concerned)
' are the simple sulphur soap and that which contains powdered

pumice. The soap of iodide of sulphur may likewise be nsed for

thia purpose, but is probably leas effectual than the other two.

Neumann, lastly, has prepared a aoap according to the followiog

formula :

^ Ammonia Mutiat. crud., Oj ;
Sulpliur. -ii'iuir,. Ovj ;
Sspoab donii'st. nigr., Oitj.

Various remedies for the itch have also been dissolved in water
or other fluids. Under this head comes, for example, the following

"chlorine lotion";

ft, Cnlcis Chloret. {CalcU Chloriaata), ^ij ;
Aq. dutill.. Oij.

The " SpiritUB Lcc
It

lardi," again, ia a preparation of a simitar kind :
Ksti Carbonici {Potanai CarbouaiU),

.. Nitrici {Potaua Nilratu), ana Jij ;
Spirit, frumcnt. ("Cam ipMI"),
Aqun FoQtan., ana Oss.

Again, several aromatic lotions, containing also spirit, have been
used in scabies, especially by Cazenave, who was very fond of pre-
scribing them. The following three formnlse are his :
ft Herbic Thymi, 60 grmm. ;

Aqaie £uUienLi», jooo gnnm, ;
Fiat infusum : eolo, insujicr adde
Alcohol (75 p. 0.), 100 grmm.

(t Herbw Menlli. Piper.,
„ Rorisranriui,

Lafnndulm, ana 150 gnnm. g

340 SCABOS.

HerlMf ooBCttit par diet deoea m aqoa tk
Ihirtiifiin cokL ct ttoontm Qm onotin vteadft
ffoiHiiiiCififiir

fk Ifftiit Mwitfffff^

Pf Horitmriiiiy

„ Citri, ana i ad 3 graa. ;
Alooholu (75 p. c), q. a. ;
Aqiifl% ad 5 litr.

The formabB last given are especially lecommeiided by
for acabiea oecarriiig among the higher daaeea.

LoUona containmg iodine were likewise emplojed by htn,
iog to the following fonuols :

JH Lixiim lodnraUB, 8 grmm.;
lodiy 2 grmm. ;
Aquie, 1000 grmm. ;

or,

or, laitly,

lf» lodnret. Sulphur., 15 grmm. ;
Aq.y I litr. ;

Jli loduret. Sulphur.,

Lixivia loduret., ana 6 grmm. ;
AquK, I litr.

TluH lajft \H Haid by Cazcnave to be particularly effectire. Bat it is
mlniittcd that all auch lotions require to be used for a long tiiiiey
and to In: 8U|)])l(!mcntcd by baths.

TIhtc is, howev(;r, no loCion which has played so important a
part in tlic treatment of the itch as that first recommended by t.
Vlciningkxi of Brussels. His formula is as follows :

li Calcis Viyic, Oss ;
Kl<»r. Hulpliur., Oj ;
Aquic FontatiK Ov;
In TAno f(!rrfto rr>i|iii!, ct Bpatula ligncA usque ad perfectam unionem tere.

In tliiw |)rrparHli«)n, li«)W(!V(!r, u considerable part of the lime,
(which in j<n*uily in vxcA^nn), falln to th« bottom of the vessel as a
white dc'p«)wit. Thin in ii iJiHiMlvimtjigc, because, when the lotion is
ai)pli(j(l, tlu! litUi! p«rti(!li'« of tlio prcci])itate irritate the skin.
Ilcncc;, UH I liavu ulnwly »tiiU*d, Dr. Hchnoidcr, Professor of Che-'
mistry in the JofM*fNakiMliuniii of Vinnnai lias suggested a modificatic

TRKATMENT,

241

of Vlemingki's solution. 1 h&ve already given hia formula in the
olupter on pBoriasis,' and I have novr only to add that the quick
Umc should be rubbed doKH with & part of the water into a perfectly
uiiifonn powdtr before adding the sulphur.

This solution, which is used ia various cutaneous diseases, ma;
be simply rubbed into the skin; or, if artiliciul sulphur- batlis are
required, it may be added to the water of the bath.

The "liver of sulphur" nmde with potass or soda (polatta vei
soda tulpkurala), is likewise often employed by tbe Preuuh for this
purpose. They pat into each bath four ounces of it, either alone,
or with the addition of a pound of gelatine.

Lastly, " acid " baths (consisting of one or two ounces of con-
centrated hydrochloric or sulphuric acid to two pails of water), and
"alkaline" baths (containing oii« ounce of potass in the same
quantity of wat«r) have been recommended by different writers for
the cure of itch, as of other cutaneous diseases.

The BOK^lled "sulphur fumigatinns" alTord the best eumple of
tbe employment of remedies in the form of vaj/our, in the Lrcatmcut
of scabies. So far back as the 1 7th century, those were tried by
Qlaubcr, and suluequently they were recommended, in 1776, by
Lalouetle, in 1816 by Galds. At Vienna they were introduced by
He Caro in 1^19, and they were afterwards employed in Naples by
Asalini, in Dublin by Wallace, and in London by Anthony Clerk.
A trial of these fumigations was made in the General Hospital of
Tiennn, the boxes invented for the purpose by Gnles bi-iiig used :
but the results obtained were not such as to lead to the further
adoption of the method, for it wss found to set up artijicial ecxe-
natous eruptions, which so greatly prolonged the treatment, that
its average duration exceeded four wteks.

The simplest way to cure the itch is, no doubt, to rub the
whole surface of the body with one or other of the above-named
ointments, repeating these inunctions until the itching has ceased,
and the affections produced by the acarus and by scratching have
disappeared. This procedure, however, is very apt to give rise to
a urtiticial eczema, especially when the application of the oiiitmcut
I coutiuued for too long a tini^ and when tiie substance employed
■ pne of those which are particularly iiritatiug. On this accouut
! substituted local for general inunctions, taking one of
I which kill the acorua, and rubbing it for a considerable
' V. p.46,

242 SCABIES.

time into those parts only (such as the hands and feet^ the penis,
the ghiteal regions, &c.) upon which burrows are most commonly
found. The result has been to show that the disease may be cared
by this method. As 1 have already stated, I employed it for twelve
years, in the course of which time I treated about 15,000 cases of
scabii^ in this way, curing them in an average period of from two
to ten davs. But I must admit that local inunctions are suited
only to cases of no great severity, and that they require the super-
vision of some one who is thoroughly familiar with the diagnostic signs
of the disease, and witli the characters of the burrows made by the
aoarus, and of the oilier efficts of its presence. Xow it cannot be
exjHviod that every medical practitioner should have a special know-
leJs^* of scabies and other alTeeiions of the skin. Moreover, cases
real'iV do occur, in winch burrows exist on the trunk of the bodv,
and on oilier parts bt^ides tiiose at which alone they are commonly
four.d. ConsoiV,:o!:t*.v, the inratmtiit of scabies bv merelv local
inu!w::vn^.s can nevir be universally aJv^pted ; in the majority of
cases u is nsc* fu!, but to some it is inapplicable.

To cure s^^abies iliorouirh.v ar,d Q-.u^klv was the main object of
two r:av.s of tn?-atme::t, of \»::ich or.e has bet^n called the ''Ensrlish
nu:h.\:." a:id :V.e vv:ut. the " ii:. .i r.-.vl ET-^lish tneihod." The
or ^- ■- v. a\ " V. \z\ <'\ '^'. c : ':: .\i " w .is ;i< : .'. c'x s : T: . e : a::r ::: was first put
i:;:^ a V.-:::. :■::.: ".isho.i £1 s v:r \i::': <:a:\ a::.: ::v was then rubbed

1* . . .1 ?.. ■ ....'■«. ..•.•.«..... .1...* k .•.v.h. ......A V .• _.. ^ . «4 k/v. •■ CTTU fc W U

r. -v::<. l:crt :e «.%s .v.;.: :.: :.::;.-: ^r.: 2:-:^. ciar.^g vhich

: -r If r;c " "^.i* -.;::.:.i-\;:A a: .i ^: >:a: : ic-rrr:*:::;* of — '

l...r.. *A .".•."cv.r : . ;■ ?i:As;:". .: : f vt.i.r. a/.t* :r:: :::::> wtr^ repeated

t».-. v.. r. ■ c .v.* :".:.,:. .-.: .: ..; u^s ::■..«.:; :; ir.:.k wmn £uids

i-TiK ' , < . . . * ". : ■ " ; r. ,l s; : V. -: . v. : .-^ * . -: .* ;: > :y ?< :• : -.1 : -. ; -. . S: zie ri t siciaas

*>. rT. . '. -. .."cc. A: : \v ;:.: ;: :.: : :-: -i~:.i. :ie pa:ieni
■ . - ■ .... . .

IB i.< ■"*■.' . v" * <-"•■• =" " *'■ ■ " '< -_-•...■.. .-^, •-J .'>'« — v^ka

« . ... •

y '■ ■ " ^'^ T" "■ ■ ■.■;■;.. . : '.> k:. : ■.:";;: .rszT'ir::". in J

.. >.

■^ sot

TReATMENT. 243

5mng in other respects unaltered. Thia was now called the
Jified English method." The alteration did not, however,
ate the b^tideiicy to the production of eczemAtous eruptions,
nor did it diminish lo any great extent the discomfort experienced
by the pntieat, Moreover, the wa.'thing of the blankets and beds
wan still attended with considerable expense. The " English method"
of treatment, therefore, gradually fell out of use.

Nothing, however, did more to effect this result than the intro-

ductioD by Hardy nf the "rapid treatment" (Schnellcur). A similar

plan had, indeed, been employed in the Hfipital St. Louis, by

Bourdin, as far back as 1812. Accordiog to Bourdin'a method,

the patient was washed in a hath for half an hour, and well rubbed

with black soap. On ibn following day, Helmericli's ointment was

applied three times to the whole of his body ; on the third day he

was again washed witli soap and water, and he was then dis-

I charged. But Hardy first reduced the period required for this

■"wrjoirf trtaimenf" to a really short time, and thereby justified the

Imme. His method is as follows: The patient, having bren placed

Ein a warm bath,' is rubbed vigorously with black soap for half an

Kbour; he remains in the bath for another hour, at the end of which

Itimc he is taken out of the wat^'r, and has Helmericli's ointment

' rubbed forcibly into the whole surface of the body. This terminates

the treatment, the patient, before being discharged, being merely told

to take a few warm baths.

. Some unimportant modifications in this method of treatment

■ bBve since been proposed. Eronmiiller,* of Fiirth, for example,

ft gives the fallowing directions : The patient is to be placed in a well-

I warmed bath-room, where he strips off all his clothes, and ia rubbed

w til over with soft soap for half an bour, except that the face and the

ft genital organs are left untouched. Those regions are to be espe-

P cially attended to which are known to be the favorite seats of

the acarus, such as, above all, the cicfta between the fingers, the

wrists, the forearms, the abdomen, the thighs and legs, and the

L back of the feet. The patient is then to be placed in a tj-pid bath,

■in which the soap is washed off, and in which he remains for an

■iiouT. At the end of that time he gets out of the bath, and, stand-

\ > ApFOrdin^c to llie plan now adopted by Hanlj si llie Hdiiilal St. Louis,

tbo friellnns villi snip take place berore the {uitienl. cnlera the batli. — [Gp ]
\ * ' Ueber dis acue BttbaiuUuug iat KiilM ia a — 3 Slundea,' v. FrooiuiiUer,
^ tvxi\ t85>.

I S44 SCABIES.

ing new the stove, rubs himaelf with Helmerich'a ointment for half
Bu hour, in exactly the aame way as he bad previously done with th«
soap.

The difference between Uiis method and that of Hardy is, how-
ever, ao elight, that it simly requires no special name, and is not
worthy of any particular consideratiou. I have already,' in 1 854,
fully expressed my opinion with reference to these and other "rapid"
methods of curing' scabies which vere attracting much notice at that
timR, and wliich I am about to mention. The view which 1 tbeo
took is conlirmed by all my subsequent experience, and I shall,
therefore, repeat my remarks in the present volume.

Perhaps, however, I had better describe, in the first place, 801116
of the other moditications of the "rapid method" which have httsa
proposed.

The following plan is that of Fischer and Hebnentag, of Cologne.'
The patient is first qaickly rubheil over with a small piece (one to
two ounces) of soap, and is then placed for an hour in a batb at n
temperature of 92 — 95° fahr. At the end of this time be ta
wiped thoroughly dry. The attendant then takes a ball of tow aa
big as a man's fist, faatened to a handle of wood, dips this ball into
It tepid solution of caustic potass (of the strength of half an oonce
to five or six ounces of water), and rubs with it the whole of tlie
patient's body, excepting hia face. This takes half an hour, or crco
three quarters of nn hour, for it must be done thoroughly, no part of
the body being allowed to escape. When the frictions are completed,
tlie patient returns to the bath for a few seconds, in order to rcmova
the potass from bis akin, and to wash olf the " acabtea-tutue"
(Kftitzgcwebe) destroyed by the previous treatment. The maia
thing to be attended to in applying the frietiuns is, that no regioD
of the body should be passed over, or inenJficiently rubbed. The soap
should, in fact, be nppUed for a definite length of time to every pait
of the skin. The treatment is completed by wushlng the patient
with soap and water and with a piece of fiannei, and finally hf
directing a stream of water over him. He is then made to put oo
clean Imen.

If one wants to make the cur? still more certain, Uelmcntag sug-
gests that, after the frictions with caustic poiiuli, uuU lufure iha

■ -ZtiUfhrid li. It. L. Gtr». d. Aeut*!!. Win./ n. r.,

• ' DanU-llDiiit dn e
Isolilagei ill Biirs^rspiUJ lu I

TKEATBfENT.

245

pliced in the bath, ho afaoold be thoroagbljr rubbeii with
the C'rtff. Ani/licum ad teabiem, and shoulJ theu be wrapped in b
roollcti garment, and be made to sit in this for nn hour. "Thia part
of the treatment is not, however, considered to be essential, for the
application of the solution of potass satisfles every principle involved
in the cure of scabies."

I have quoted in extetuQ the description of their method given by
Fischer and llelmentag, not becuuse I wish to induce others to
adopt it, but for the purpose of showing what unpractical propoai-
tions arc sometiraea made even by hospital physicians of eiperi-
ence and reputation.

Among those who have thought Bt to write on the treatment of
•cabies must also be mentioned Buscb and Wucherer, The former
advocates the use of Peruvian balsam, the latter extols the value of
oil of turpentine, which has likewise been recommeDdcd by Upmann.
It is asserted that by these remedies (he disease may be cured within
two hours.

Lastly, Scbinzinger and Kiichenmcistcr must be named as having
also introduced new methods of treating the itch. Schiuzinger'a
plan is the following : — The patient is to be rubbed three times a
day during two days with a paste made of soft soap, powdered
chalk, and a little water, the paste being applied to all those parts
of the akin at wliich acari are present. On the third day he takes a
bath, after which the diifcrcnt regions infested by the parasite ore
jHiinted over with a liquid contjiining thirty minims of the ethereal
wl of aniseed to twenty minims of alcohol. Kuchenmrist^r employs
the oil of rosemary for the same purpose. These ethereal oils give
rise to severe pain, which, however, passes olT after a few minutes.

But of all the modiGcatlons of Hardy's plan of treatment, ihe one
which has been most extensively employed, and which is most
generally applicable, is that which was flrst used in the Belgian army
by Vlemingkx, Eicept that tlie process for preparing the solution
of aulphide of calcium has been altered by Prof, Schneider, tlie
method of Vlemingkx has for some years past been used both in the
military hospitals of Vienna, and also very frequcnlly by myself, in
the department for diseases of the skin in the General Hospital of
this city. I have not, however, employed it in all cases indiscrimi-
nately, but generally only in such as appeared to be well suited to it.
The following are the directions for it :
, The patient is litst to be placed in a bath, in which he is rubbed

' vigorously for half an hour with pieces of coarse flannel and '
with potass Eoap, or even cnmmaD washing soap. He is to be told
beforehand that llus part of the treatment is of great importance,
since it enjwises the burrows of the itch-mite, soflena tlic epiilermis,
and enables it to be more easily penetrated by the solution of sul-
phuret of calcium nbicb will afterwards be appbed. After
the soap has been well rubbed in, the patient is left for another
half-hour in the bath. During the third half-hour he is again
nibbed all over, and no less forcibly tlian before, with picc«»
of flannel, which, however, are now dipped in the solution of
snlpburet of calcium. The fonrth half-honr (which completes the
period of time devoted to the cure of the disease) is again passed in
the bath. At its expiration, any particles of sulphur that may stiU
adhere to the sVin may be washed off with cold water, or by limn*
of the douche. Clean linen should then, if possible, be given him
to wear, and this terminates the course of treatment. In tlw
Belgian army, Vlemingkx'a meth<Ml is carried out in such a way, that
a soldier sent to the hospital for scabies does not even have his naaM
taken off the list of effectives. The treatment above described is
gone through ; and at the end of the two hours the man is sent back
to his regiment, there being no necessity for considering either his
own feelings in the mutter, or the opinions of his comrades.

Tilings are very different In the General Hospital of Vienna, and in
civil practice generally, but especially amon^ private patients. Por
when it is said (and with perfect truth), that, in a Urge proportion
of cases, Vlemingti's method cure* scabies, what is really mesut is
that the burrows of the acarus are destroyed, the animals tliemsdves
killed, and the eggs rendered incapable of development. It is ob-
viously impossible that the excoriations and eruptions whidi mtj
have arisen in the course of the disease should be made to disappev
entirely within a period of two honrs. In fact, at the end of Ibe
treatment, the patient has exactly the same aiipeannce u beToce
it was begun ; or he may even present a more abundant emptknt
than ever, and be conrrd with new maeuls which bare ariaea I
during the process of cure, bein<; set up by the irrilanl action
of the soluliuD of uilpburel of ail<*ium, aitle<l by that of the #a^ and
the warm bath. U i« rTiiif.-n, ilimf.in-. lluil m iite ews Lif a Uf
observer soch a patienl " i

But pcTRHu aflrctcd <* ' ply

for faospltal rdief), arr :-. :• to

TRKATHENT.

247

^
n

follow their oocupations, unless their state is such that even unpro>
fessiuiial persons will rt^ard tliem as healthy. This is the case, for
exain|)le, with domestic servants, jouracyinen, and other classes of
workmen, none of whom will be suj)posed to be veil, so long as they
present eicuriations, and the different eruptions wliicb are produced
by scabies. Obviously, therefore, it is only under certain cuuditioos
that the solution of eulphuret of calcium is apphcable for the cure of
the itch in these patients.

Now these conditions are the following ; — Either the disease most
be of slight intensity, and have been of short duration, so that the
amount of eruption is small ; or the skin must po^'Si-ss a certun
toughness which warrants us in expecting that by the application of
the Viemingkji's soliilion only a very slight eczema, or tjven none at
sll, will be produced, and therefore that the patient will recognise
the fact that he is cured. It is also necessary that his circumstances
should be such thiit his means oF livHihood would not be imperilled,
even if the skin should still present some remains of the eruption.

The fact that "artilicial" afl'ections are so often observed when
scabies has been treated by one of the rapi<l methods has led certiiia
physicians (es]»ecialiy Hardy and Gilbert) to use in these casta the
tincture of tobacco or tli&t of stapbysagria, instead of the prepara-
tions of sulphur. In my belief, however, the former arc no less
liable than the latter to give rise t« eczcmatous eruptions ; and I
tiiereforc prefer to employ the tar-oiutment of Wilkinson, modified
accordijig to my formula.

Now that I have spoken in detail of so many different remedies
and methods of treatment which have been proposed for scabies, it
must surely occur to every one of my readers to ask which are the
remedies most applicable to particular cases, and which is the method
whereby the patient may most quickly be cured of the complaint.
In answering tliise questions I must, in Ibe first pince, draw atten-
tion to certain points which have always to be taken into conside-
ration in choosing a remedy, whether for scabies, or for any other
disease. These points concern the amount of severity of the case,
and tbo nature of its symptoms ; — the degree to which the skin is
delicate, and hkely to be injured by irritation ; — the position in life,
and the external conditions of the patient ; — and, lastly, the cir-
cumstances under which we attend him, whether in public, or in

iwte. practice.

Thus, in a case of slight uit«isitT, or in which the eraption conn«ta
chiefly of papules with a few Tesicks ; — when the patient is an ndult
male, and belongs to the labouring claas ; — when it is probable thnt
the skin possesses a great power of resistance ; — when the disease
comes before us in hospital practice, where expense is taken into
account, and where it becomes important that a cxire should be
ctTected quickly ; — under any euch conditions we may advantageoiuly
employ either the modified English method {with Vezin's, Helnie-
rich'a, or Horn's ointment), or one of the plans rccnmmendeil b/
Hardy and Vlemingkx. But for patients who have red or fair hair,
whose akin is delicate, and in whom (as is well known) irri-
tation of the skin is more comnaonly followed by severe effects;
— for children, and young persons ; — for those in whom the
disease is already of long standing, and who consequently present
numerous pustules and excoriations on various parts of the surface ;
— for all such patients it is preferable to nse either Wilkinson's
ointment (modified according to tlie directions I have given) or soft
eoap, or one of the so-called medicated soaps, or some lotion, or,
lastly, baths containing some agent which has the power of killtng
^the acarua.

Tn private practice, a^in, it is often important that the treatment

I ftdopted should be such as will not deprive the patient of the time

Ivhich he is obliged to devote to his business; and nnder thtse cir-

B«umstances one can hardly employ any remedy which is easily rvcog-

1 nised by its penetrating odour. For patients of this kind, therefore,

one can neither use the English, nor the modified Engiish, method,

nor prescribe any of the fretid tar- or sulphur-oinimenis. Sach

casea liare to be treated in other ways, according to the individual

L conditions of the patient. Thus, if the man is occupied all day

3 that he can devote no part of that time to the cure of the

r disease, wc must endeavour to arrange a plan of treatment whiob

may be carrii-d out during the nighi only. One way of doing this

ia to make the patient each evening go through a process, resembling

more or less the " rapid method." After leninioing in a bath of

Lsonp and water for half an hour, lie may be well rubbed with one of

Uhe above-named ointments, and nnay then bo made to he wnpped

I woollen blankets all night. The next nnmiin^ l,e m.ir taks

mother bath, or simply wwbwith «oap and »ii;. „ ..ipi,

e ointment was appliwl, and he may then p , ,^

e same course of treatment should bo rcpi:,; i ■ . r loar

■

TREATsntNT. 249

evenings, till it is fonTid that the bnrrovs h&ve been destroyed, and
that the eruption has subsided; after which a few simple baths will
complete the care.

Siiould even such a coarse as this be impracticable, the patient
may be Bubjccted to trrntmcnt {on the plan of the " rapid method")
for eeveral days in succession in an establishment for baths, instead
of at hia own homo. On each occasion he may perliaps devote two
hours to the eure of the disease. The first half hour should be
passed in a bath, in which he should be wdl rubbed with soap.
During the second half hour, he should still remain in the bath, by
which the parts imprecated with the soap will be softened, and the
•OBp itself removed. In the third half hour he shoakl be vigorously
rubbed with one or other of the above-described ointments. If it
is important that there should be no disagreeable odour, Bourguig-
non'fi is the best ointment to use; or, according to KiJchenmeister,
Helmerich's, with the addition of oil of aniseed and oil of rose-
mary. The fourth half hour, lastly, may be devoted to removing the
ointment from the skin.

By one or other of these methods, we ought to be able to satisfy
the wishes and requirements of every patient who cornea before us.
But no strict rule of practice, applicable to all cases, can possibly be
laid down beforehand, since the treatment may have to be altered in
rarious ways, acconling to circumstances ; nor again, can one say
positively how many days or hours are required for the disease to
become cured. In general, it is a good rule to continue the treat-
ment, so long as we can discover traces of burrows, or of any other
of the effects to which the acanis gives rise. The persislenre of the
subjectirc sensation of itching, however, need not lead us necessarily
to continue the treatment, until the patient no longer complains of
it. For any of the "antipsoric" remedies above described may
cause an eczematoos eruption, an<l, since all such eruptions produce
itching, it is obvious that while th« cure is going on the patient will
experience such sensations, which will nevertheless cense when, the
mites having been destroyed, the remedies employed for the pnrpose
of killing them are discontinued. His complete r«vr*wy (by which
I onderslftnd the entire disappearance of the eruption from the
■kin) does not takes place — whatever mode of treatment may have
been adopted — for a considerable time after the termination of that
trratraent. tTnder this head 1 have still a warning to give, which is
that warm baths should not be talcen too frequently, oi at too high

250 SCABIES.

a temperature. For it is well known that they sometimes act as
irritants to the skin, giving rise to itching and even to eruptions.
Speaking generally, one may say that the itch can be cured without
any baths; and that if it were necessary, in treating a case of
scabies, to choose between no baths at all, and many baths^ the
decision should be in favour of the former alternative.

Treatment of the so-ca/led sequela of icaiiet. — WTiichever remedy
or plan of treatment may have been adopted, it will always be found
that among any consiJerablo number of patients there are some who,
after the disappearance of the symptoms proper, present eruptions,
part of which are to be regarded as belonging to an artificial eczema,
while the remainder come under tiie head of excoriations, or consist
of pustules such as would be termed ecthymatous, or, lastly, are the
so-called itoh- ulcers (ulcera psorica — Khitzgeschwiire, die besser
JSrr<i^jge?ch«iire genanut werJen kounten).^ Thus, as has already
been explained, et-zenutous eruptions are very apt to appear in cases
of scabies at any regions which are exposed to re|)eated or continued
pressure or friction; as, for instance, on the buttocks of tailors,
shoemakers, or weavers ; round the waists of women, and on other
parts whtre the clothes are tightly fastened : beneath bandages, and
the pads of trusses ; an J histly, upon spots which have received the
pressure of crutches or imj'Iemenis ^Geriithschaften) of any kind.
^'ow such eczematous oniptions cannot always be cured at the same
time as the disease itself, bv tiie remedies which are brought into use
against it. Sometiuus, iadied, it ikvs luipjvn that this is effected,
especially by the ointment cotiiaiiiini: tar, which I employ. But in
other cases, and particularly when tiie deeper layers of the epidermis
are affected, or even the cutis its<^lt\ it is imjvssible that these affec-
tions can thus be curtvl. since the rep'aceir.em o\ the tissues which
havt b-e:i dcstroveJ r.ectssunlv rcvUi'.res a much loi^cer time than
that wi.'.ch would suffice I'or the nure killci: of the acari, and for
tr.e re :i; oval c: i'::e eruj^tioii caused a:nv:l\ by tlitir presence. In
fact, we have ir. su.h cas^s. after ouri:!;: the scabies, to deal with a
sec. L.i ana ir.arron.icnt c'JMiux^as :':::ic::on.

N -^ to :::?se w::.-, w.:': i::e. rtiT.ir.i the :tch as a:: ar::r.o'al eczema,
produced par:ly by :":.e rrser.cc of :::e acar^is, farily bv scratching,
and panly by irr::a:: :i cf :l.e >k::: from o:"::er causes, there will be
no difficulty in understaiidicg what measures an? needed foir the

* S« fjomote to p. ;}2S.

TKEATUENT.

261

cnre of snch an affection, as that of which I am speaking. They will,
in fact, treat it in exactly the ^ame way as any otiier eczema oc-
curring iiidepenileiitly of scabies. Thus, wuUt- dressing {kalte
Uffl^chl&^ej niHj be applied ; or soft fonp, or some simple ututmeat
may be robbed over the eczematous patches i or, if the affection
should tuke tlie form of an E. tquamotutn, the preparations of tar
may be employed. £:icuriatioii9, ecthymatous pustules, and ulcers
(pBorhelcosr) may be treated with simple water-dressing ; or, if they
cover an extensive surface, the parts may be wrapped in wet cloths.
£y such applications, combined nilh the employment of tepid or
cold baths, we shall favour the reproduction of the cuticle on any
parts which may have been denuded of it, and the cure of any sub-
epidermic abscesses which may have been formed. But it must not
be concealed that cases occur in which a long interval pnsses before
I complete cure can be effected, and in which it is impeded by
various complications. Under such circumatances, however, one
Uust not lose courage. A very good plan is mentally to place
oneself in the position of having to deal with the ease for the first
I time, and to ask oneself, wfant treatment ought to be adopted on that
I tuppnsition. The answer can only be that we must continue pa-
I tiently and perseveringly to employ those remi^ies which are indi-
cated by ihe nature of the case, and which 1 have described in det&il
when S|)eaking of the treatment of eczema.

I have still to refer to the relapses, which, in varying degrees of
severity, will be found to occur in some cases, whatever treatment
we may adopt. They are, however, far less common Bft«r scabies
than after any other cutaneous disease ; and probably more often
triac from a fresh infection than from the failure of the remedies
which should have dcstrojed the itcli-inites. In reference to this
question, it would be very interesting to know exactly how long the
eggs of tilts parasite can retain their vitality after having been
brought into contact with any of those substances which kill the
itch-mite itself; and also whether ova which may find their way
(while the patient is scratching himself) into bis linen or other
clothing remain for any length of time capable of further develop-
ment. As yet, however, too few experiments in regard tu these
points have been made by medical men (Menschen-Atrzten) to
enable us to draw any conclusiona from them as to the way in which
the relapses of scabies are brought about. Formerly variona
methods of disinfection were employed, in order to destroy any

iknUbft
gM ihmld bft

poMJUefar^aUB
ft good bgihw^ t

WittOtt OOiglji cdVS of w( piiVlfCfc,

of iriapscsk dnt sbnts^ dnvcRy «oc
scalded, wvbed aai dried* asi i^
tt9ed to dismSNt uie Teat of tbe cjcdies. m vdl
panes v*^ ^ vmbtt couaaed m ikaB>,
» jouraejineo cirrr.

But in UT pdeiMat v*^>^ lio«fver« I wkmk to be pnivnonel)
all these pRcaatioiis aie ubwwsskit. Ik tfe GeDsal Hoi^ilal cf
Tnna, vheie 1500 ca»» of icahN9 coi
jear and ai« cured, the ivUpM9 wrer exceed 1
this establbhiMfit do ine >s aie » of dtscalMtiaii
plojed, althoQgh w hare bc4}i aa oren and a Tapoor-lMdi aich as
are aboT^ described, which «y oiMild eas^^ i»e tf it vere tlioi^it
desirable.

Ail such pnxrdun^, hovrrrr, Tiecessazihr iniuie dodies to a
gmter or less extent : and sulphnroos acid, in pardctilar, deat i uym
their colour. Honoc. since cxjx^ncnce has ik« shown the need of
disinfecting them in any wav. we air clad to avoid the injnrr
the process of disinfection w^niK) inentahir cans^, and at the
time to aare the hovpit^I the e\)KtUke of the fiael.

[JuckhtaUem, JKchbldlterchen.)

HlBTOUT, — When we consider the defective knowledge of cuta-
neous diseaat^s in fortner times, and the difficulty in tlic diagnosis
of this malady in particular, we shall not be surprised to lind but
alight grounds in the wrilings uf the ancient physicians fur believing
lat prurigo w» ever recognised by them as an independent
" eaae.
Hippocmlea, it is true, describes an affection of the skin
loinpsnied by violent itching, which he called ^v<tfi6^^ a name
irwards changed by the Greeks into Kwofii^ or Kwtio^, and used
denote any kind of itching of the skin. But it is more than
■obabte that Hippocrates himself attached the same loose notion to
le word, and be can scarcely have meruit by it prurigo jiropcrlv so
'Billed.

Galen defines the word "prurifut" as a biting feeling in the skiu,
and explains it to depend on excreta being thrown off; accordingly
be regards those persons as subject to this seusation who are troubled
with " crudities" of the blood.

Celsos uses the term prurigo to denote a sensation which is of
unfavorable prognosis in diseases; but Pliny appears to have
already appreciated the difference between seabies and prurigo.
This is still more certain in the case of Avicenna, for ho states, " /»
jiruritii non sunt ptutula (' bofor') tieuti i» aeahie." The other
ibian writers used the name " Essera" to describe all kinds of
itaneous diseases attended with itching; from which it is evident
they confoonded prurigo with Bcabies urticaria and eczema, aad
knew as little of its peculiar characters as did the other physicians of
Uie middle ages.

* Svirfisl raS irti^OTWc VK'v, Aphar. iilt 3I.

It is not before the sixteenth ccaturj that we find, in Ternelins
Ambianus,^ an author who waa well acquainted with the disease
under discusision. For, under tlie title " Impetigo," he brings
forward the characteriatica of a disease which completely agreea with
our modern prurigo. He says, " Culit e«t asperilat dura et ticca
cam ingenti pritrir/ine — ej- aiccia enim pustulix ft, leabirt vera «g
Aumidit." After he has further divided imjwtigointo four specie*,—
he defines the first of them as follows : " Una admodum eimpUx, qii4
cutis rubra, dura erasperataqne tehetnenti^ pmritv roditur, aimplieit
j)ruritu» nomine coiitinef-ur," a passage in which it must not be orer-
looked that the words " 6 kvijojioc, prurigo" occur in the mar^n.
But ia the works of later author;, as Sennertus, Ingrassias, Manardna
and others, we. do nut find the least acquaintiince with prurigo as D dis-
tinct dermatosis. Mercurialis and Hafenreffer make use of the worti
"pruritus" to express certain diseases of the skin accompanied with
itching, but witliout any eruptions on the surface. The former
writes: " Praierea in aliig affeclitma qui jvnclum Aabenl pTttriium, a
cute temper ematiat aliqua taniei, in prvritu nihil emanat ;" aiid the
latter, " PrurituB e*l Iriatis sentatio, demUrium tealpendi exeilant,
tine cutii afperitate vel vtceratiorte." Both ajipear in these passages
to have had a vague notion partly of prurigo pmper, partly of other
diseases which produce itehing ; and the same remark applies to tfafl
illustrious writers of the last century, Sauvages, Lorry, and Fli^ck.
Sauvages, it is true, mentions pruritus as a symptom of other
disorders, and distinguishes it from scabies, but ho has nowben
honoured this imjiortant disease with a thorough description. L0R7
describes, under the title "papula," the diseases now known as
scne, sudamina, and urticaria, as well as those which, as he
maintained, were included under " pruritus" by the Arabian writers.
But he only notices the itcliing and the disorder of the blood
{lumma acredo), which was supposed to be its cause, without
entering into any close description of the outward appearances of
the malady. And in the works of Plenck we fail to lind even the
name pruritus meutioned, the only one of his aphoristic dc&nitionB
which at all agrees with our prurigo being that of Herpe* tivipltx.

It wan not, indeed, until the time of Willan, who treats of this
affection at length under the name Prurigo, and figures it in his
plates, that it was placed in ita proper position as an indiipendeiit

' ' Johaniiit Fcrndii Atnbiani UniTerM MeJieina,* FrucoFortii, tjigj. * Dt
Eil«niia Caqxtfii AtteetibiM,' hb. Tii, cap. 4, p. 341.

HISTORY. 255

disease of the skin. He ranked it in his nosological system among
the papufa, and tbe physicians of his own and other countries
followed his views wilh but very slight modifications of tlieir own.
Among them we may mention Bateman, Piumbe, Green, Wilson,
Hunt, and Ttmmson, in EiigUiid; A-lilwrt, De Chamberet, Muron*
wall, Rfljer, Diert, Cazenave, Gibert, Bevergie, Chausit, Duchesne,
Bardy, and Bazin, in France; and Riecke, Fuchs, Simon, Joaeph
Frank, Behrend, and Struwe, in Gcrmanv.

But amoTig all these autlionties I have not found a correct
df^nitioD of this disease. Willan himself has committed the error,
in my opinion, of associating prurigo with other itching affections of
the skin. His species are Prurigo m'ttis, P. formican*, P. aeniUi,
&aAP.localii : butwliile intlie first two he mentions the occurrence
of papules, in his description of P. tmilia he lays almost exclusive
weight upon the itching, and states explicitly that in this variety the
akin may either present a sniuol h and shining appearance, or may be
nneven, or may be covered wiih little papules without any eruption
of distinct vesicles.

He refers, moreover, to the circumstance that in certain cases of
P. tenilis a number of httle inse<'ts are found, which, indeed, he does
not appear to have seen more than once, but which he descrilies and
figures in his work, placing them in the genus Pulex. But he goes
on to remark that more frequently the condition of the skin in this
variety of the disease is favorable to the dcvelojiment of a different
insect, namely, the Pediculut homiiti*, and especially the kind called
clothes-lice [P. corporii uru rexfimfnlarum]. Lastly, in describing
the forms of P. UxalU Willan makes no mention at nil of any
outward apiwarances, except tho^c which are produced by scratching.

This incorrect mode of subdividing prurigo has been blindly
followed by all the writers mentioTicd above, who have only slightly
altered the names devised by Willan for his four species, or varied
their order, or at the utmost added fresh ones ; so that in course of
time tliere have grown up, in addition to the original varieties.
Prurigo lirhenoides leu furfaran»y P. pedieHlarla, and the several
local species known as P. podUit, P. pudendorvm, P. tcrott et
vulva, P.perinm, P.palma mttnut, P. planfie pedis, &c. Bnl my
own conviction is that between Prurigo e papuiu (under which
Willon's P. miti* and P. fi-rrxieani fall) and Prurigo lateni vel
tine popHiii (including all other kinds), there is no relationship at
sU, cither in their anatomy, pathology or etiology ; and I '

igly, there is no sort of justification for classing these
distinct forms of disease as species of a single genua.

Depinitios. — If we examine the phenomena of prurigo closely and
without prejudice) the result vrill be thai the essential differences
between the many atfuctious which liave received this name from
Willan's time to the present wn'U become evident. We may
distinguish the following :

1. A peculiar cutaneous disease, characterised by intolerable
itching, and by the development of small papules of the same colour
as the healthy akin or only somewhat redder, correspondiug with
WiUaii'a descriptions of Pmriffo miiU tLndJbrmicam.

2. The irritation of the skin so often observed in old age without
any visible change — Prurigo tmilia.

3. The same sensation often experienced in various disorders, as
dyspepsia, albuuiiuuriu, icterus, amenorrhcEa, or affectioua of the
bladder and ovaries, a sensation nhich may be tocali:ied in different
parts of tile body, and has thua been described as Prurigo loeaiit
{P. podicis, planlaruin, palmarum, gcnilalium).

4. Lastly, that condition of the lutegument wliich is characterised
by numerous excoriations in various regions of the body, produced
by the repeiited and violent scratcliing of the patient, and depend- I
tng upon the presence of divers parasites, chiefly Pediatli witU' \
nt^ntontm. This condition was called by Willati Prurigo pedumlarU,
by Alibert Psoriiie papuleute pciH^ml-aire, by Fnchs Caeamua aear-
iatit, aud has been described by several ancient as well as modera
authors under the name Pktheiriatin.

Now, of these four affections, ouly the first deserves to be called '
a di^ase of the skin in the strict sense of the word. For it is only
in P. mifis anii/ormicaHS that morbid changes in the tissues of tlio
integumeut precede and cause itching : while in ihe other so-called
species of the disease, this sensation is supposed to depend un soino
as yet unknown cause (probably disordered iuuerviitiou of tlus skin),
as ill P. aenilit, or on morbid conditions of certain other orguu^ ,
prhaps including the blood, or Eually on the obvious irritatioD
caused by the presence of lice. In my opinion it would be better to
use the old expreasiou Pruriliu eutanevg for the Inst ihnx conditioiu, ,
because, excepting the results of scratching, the ouly deviation froia
health is the sensation of itching: and then the wonl prurigo {
wonid be confined to that affection in wUicli this symptom la I
preceded by an eruption of papules. In other words, 1 only adoiit I

»1

" I'rurigu" what WUImi mrnitil J', mlfis and J'vriiiirti/is, ami call
cvt-ry tiling else simpiv itching of thu skin — Pntritu* cutuHeun.

( 'oxjwt. — III order to understand l1ie iliFease as tlius ilbRnetl, it.
i» not i-nough to keep in view certain of tlic symptoms which ap])car
ill its course; as Willaij did, in making the papular cniptiou
which, 110 doubt, docs nppenr, the ihagiiostic mark of pnirigo.
fWi; must tjike into due cotisiderattou all the morbid appeBmace!<
'hich H[icce»sively occur, and the changes that lake place in
Iffi-rent parts of the tiitegumeul. And this can only be donw
'hen not only the characters common to all cases of the malady
arc studied, but aUo those more nnusual and excrptioual gequela
which occasionally follow an attack.

Dur first business, then, is to expound the Qniiimry s^mptomB of
prurigo (P. Bimplejr of tlie autbor, P. mili» and formicatu of
WiUan).

In every case the earliest appearance is that of aub-epiderinic
papules, as big as hcnip-secds, and recognised rather by touch tlian
iiy aiyht, since tliey rise but little above the Icvd of the skin, and
do not differ from it at all in colour. Tliey are always isolated,
lad though they may appear in all sorts of places, constantly
ive some regions unafTected. They produce great irritation, and
us, from being scratched, soon rise somewhat above lite surface,
id also sometimes become red. Continued scratching destroys the
lidermia at the summit of the papules, and by this menus eitlier
teir contents come into view — sometimes a transparent and
colourless, sometimes a yellowish serosity — or eUc a papilla of the
corium is at last wounded, and from its capillary vessel a ilrop of
blood escapes, which dries into a black crust at the top of the
papule, as big as a pin's head. There are always many papules
developed ; and this process, rei)eated according to the extent of
the eruption, will produce the appearance presented by onlinary
irigo.

When, however, this disease h.^ lasted fur some time, fresh phe-

imeiui arc added to those already mentioned. We notice a

islanlly increiisirig deposit of dark pigment in the epidermis,

rhich is proved to result from the patient's scratches, by its always

isponding with the excorialiotis both in distribution and in-

isily. Ill nil cn^es of long-Standing prurigo we ob.4('rve, more-

that the slight dcprc«9igM|^to^adforf0ir», which cover the

nf th* i5 '^HHIHBlHJJy father ^epDrated

;:c ^ • i~ liGO.

frir. :i:f s^ziiLtz, lzji :-:.::si»^.cr SKper-ed: this is particularly
rrniri^V.r ::: :lt ±IX'=^!^. ''zjt 'zall :•: ibe bind, and the wrist.
T-t ::::zitr:"i5 ziinzzz l.-nj liir* -rrii pkice the skin CTerr-
▼rere, i? -i-tll is ilr :'::::'i:zr ir.i l:c.r»r cites ^PP^U' to be torn out
CT :i.f «-«ftr^ir"5 u^. 4i.£ .: z^z-i f^rrelT ibsmi, are mach shorter
3Z.L *~-j: -.liz. :jjf T -- — ^"t -w-e^^*, LasiIt, ih-e skin itself seems
:;■ :«t n:::* Lsri izl It-sc. iZiL if & f;Ii cf it be pinched op, it
feel? zii.:J: :":i::kfr :'i" :: £:e5 -visi iz. & betlihT state.

MiHT ca«*:s :: irjjrlr: -tTrr *i:-r iz.^ c-iber chincters than these,
ir::^ ;r less jr:i.:::zcei.. ere- •/_:::ir'- il^ diseise should last for
& 'jzt:L=.t. B-: in cier izi zi:re n.::*::*! cases, a farther series of
;:lrL:iir=^ ifrel:?. :hfr.5tlTrs- iri :i«e I vill now descxibe. The
£rs: zk-zzHatt-t :: :'ii5 ii:rs se-rtr^ rr:* cf the disease, which
I irZL i^nf Pt .-.• .:.'".j I. -;-.v. i« ihi: all the characteristic
5Tz:r:;r:5 c: :'iz :rv"*.*T ::m rr-:^^': itciselves in an exagge-
ra'.cc ir,i:r^: z'zt Tariilr* i:^ lirj^r. ibe iichiiur more intense,
tie ci:\:rii:::i* =::re serfr*, 5i:i ija blood-cmsts they cause
n::rt ibimiii.:- E-:, iz iiiu:- :c all i"ni5- we mav observe
ui«:l :ie criTz ziinzrZTcc skir.. "beiween iLe black scabs of
cried nr bljCvJ. :ii: :ie uvr^em:*: liver* cf e:}:dermis are detached
frill :'-f res:, i:: :-e ::rz: :: a w'«::c neilj iu*:, which yet clings
i: 'It surfice. azi i-u? 5i:i.zli.:<:s :ie irresrance of WiUan's
P. ■ . \" j-> " « . ■ •-• . : r Al: ZTr. *5 T: 1:1 1 .•* . i x -v: V. In oiher cases
c: :ll5 >:Vrrr ::m ::' y:;ir:r:. ""^r nij s^sif ill :h.e pheiiDmena of
E.zz .z r:;-:. : irve'.:? :l:r:::xlv:<, c.:Jifr c^er ihe entire surface,

cr :- nii::^ virs :: :!:= iLTcc^^-iii-". ifrviec. uriil one misht be

• • •> - ^»

tcrrtel :: 1: :i :n :Le w':::lr i* .-. sjuvle r^:;ezii• sr completely does

-^r >T--.«.-irT — i..: -• > ^>> ..j*r ._: > « — .. Z-s i.- •—- <..nin>.3L Cue. viTm
• • • _ ^ #

h^'.'.y. :ir iuii c:-:i:it.; :z :lie v:.i::^.z:'-5 r^riiles mav become
puri-rL:. fic- y.\y.:le :^':z:t5 ^ r-5:ulr.ani eiiLer we nnd an erup-
t:.r. ::' :h^<e v..:t.::j ir. sij. ,»ui nuziber, bu: :::•>. glcd with the
vriiii.vTv er.::-:>::::.i, ?,::i i.::t:Tj;r.:5 :urninc :: skubs: or, ii the
r y: \: . v ? ..rv ^: . : 5 -. . v r .-. : k -. .: . : ".. : ; v. < : ./. ■;< ii.: : ^'r.\ jii : h -; v are tran<-

m -■- — - -» " *, . -- .-^' . . _. . -_. .«. V. , .w . . ,.. ..■« . ^..^ ? , «■« . mix tX iJv.'li«

... ^...: ^ — - ■.. «- s... ^_ a.^ri^arui ilTleS

ii:. ::::r:5 c: li:.:^ ^:": i:?:.::?. W:;;.::: 5i^-> :: Live had this
b^NL.-LtiJLrl fj :■::::::::: ::: v:ew ^L-:: lir ^i>:::VeJ his L .ji^ti^o
s:- .: a5 i d:?e:iK' cLj-r.., :<.::<;:.: ly :!:-- ::m2:::n of laminated
cnifts up:n the l.wer rv.rcxitu:?. wiiicl: mav in course of time
cover them compleiely.

r t'OUKSf,. 250

r It will at once appeiir from what has been stated, that there arc
many cases of Prurigo which may, at first siglit, be taken rather for
some other affection — for iehthyosis, eczema, impetigo, or ecthyma,
from the i>eculiar ami characteristic papules of the former disease
being obscured by other more obvioua symptoms. That we may not
be mialed by these accidental appearances in forming a diagnosis,
it is necessary to take the diagnostic signs of prurigo not from what
may be seen here and there upon the skin, hut from the general
itnpreuion which the eye should always be trained to receive. Look-
ing at the disease from this point of view, we soon observe that
first it^ universal distribution, and then its peculiar localisation,
farniah characters which readily distinguish it from every other
cutaneous atTeetiou.

If we go over the different regions of the body in n patient
aifected with prurigo, we shall find the scalp quite free from any
eruption, but the hair will appear dull, will feel dry to the touch,
and often look as if it were sprinkled over with dust. The face,
especially in young patients, is usually clear, and of a paJc com-
plexion, or a few scattered papules may be found on the cheeks,
aome intact, some wounded by scratching. Cases, however, occur
in which a considerable number are observed in this region; or it
may be the seat of an impctigiiioua eczema. It is rare to sec any

L marked traces of prurigo on the throat or back of the neck;

Fbnt the whole of the thorax, both iu front and behind, in covered
retty nnirormly with papules, some only to be recognised by the
(if touch, white others rise above the surface so as to become
bitible to the eye, and others again are tipt with a minute crust of
iried-up blood. A similar aspect ia presented by the skin of the
abdomen, the sacral region, and the buttocks ; but the most intense
form of tiie disease is displayed on the Umbs, especially on their
extensor aarfaces. The skin is of darker hue than elsewhere, and
thickened in proportion to the duration of the malady ; its lines and
furrows are more plainly marked on the extensor than the flexor
surfaces, and most of all on the wrist, the back of the hand, the
fingers, and the corresponding part of the ankle and instep, where
may be seen deep and obvious lines more widely separated than in
the normal condition. The eruption is less abundant above the elbow
than on the forearm, on the thigh than on the leg, and on the upper
than on the lower extremity. It is then below the knee that it is
molt iDt«iuely developed, and her« one may, vith a little practice.

2W i-HViiif

rr'cogiiisi' evcrv cuso oF prurigo by llie toudi ul*iut ; for tUr stin fee
II' rough as a file, ami wlien (ke closed hand is pnssfd over it, pro
■luccH a »uun(l like a ^hurt-hairt'd imiibniHli or rough ])aper,' luifl
c-.iusca a pricking sensation of the tingirs. Not only ilo tlie lowi
rstremities in ordinary prurigo pn-sent more papules and more rouglu
uess than other parte, but it is here nUo that we find the greatn
number of pustules, or the most severe eexeino, whin ihese are supi
added. It is, honever, verv' remarkable that in all ca?es of pn
[he skin covering the bend of a joint either remains perfectly wholu
and appears smooth, soft and lieulihy, or, in verj- rare and escqillOQa
<-ases, offers a few pnpules, or n slight degree of ecuenm. ITic i
pits, elbows, flexor side of the wrists and palms, the groms, liainB am
Allies are therefore abiost altruys unaffected both to the sight and t
the touch.

When much craemn or ecthyma of the legs is dcveloiwd, tU
nearest lyrapliatic glands will become enlarged, esjiecially tlio)
situaled on the front and inner side of the thigh, and so as often t
attain the size of a list, lliese buboes are of courw not pecolifl
to prurigo : they are well known to occnr whenever tberr ia liln
tiou or exudation of the ports from which the iuSamcd glanq
receive lymphatic vessels; but in no other disorder do thej' so oFtq
appear symmetrically swollen on each side of the body, and 1
liey might without impropriety be styled " Prurigo-buboes." If i
these symptoms be added a |iigmen(alion of the skin, which pre
cccds iiari paun wiib the escoriations produced by scratchin|_
have a connecli-d series of pbenomenn ("eineu Symptomcncompln^
which is foiuid eoinplett^lj iu no other disease, Aod may, thcscfoi
lie considered as pathognomonic of prurigo.

The course which this aiTcction runs, whclfarr tn its milder L
more sen^re funn is very chronic, usually lasting for lite patimfl
whole life, bo tliat cose* of spontaneous and cnitre rccorciy antfl
me at least unknown. It is much to be regretted that in d
lliv unliuary works on dermatology is the strcaa Uiil U)>uo tlie i
wiiabilitv of prurigo which llie fact* of the ease dininni). T W^\J\
ihat this is partly lo be cxplaiui-d by the comiaoti]i
of what coitstilutes this di«cise, which has becii i .
aboTo; for, of oMirae, lbo»c only will «f tlw iin
[iniiigo wbo da not confound it with case* of envrialuni ;

> The (Mrac ptj Oenun pkpet wbich a awd ia ^
th ti^ m\uA are impofttd in bosn bto lU» o

COURSE. 301

tlic preaence of lice {/*. pedicnlnri-x), or with tlie hypertesthcgia of
ulil age (Prurilm senilU). Moreover, we must not forget thiit
I here are still phyiiiciaiis to be found who nre not so fnuiiliar wilb
ihc diagnostic marks of seabits lu to distinguish every case of
jirurigo from Ihiil (lifteagt;, and particuhirly P. mHia from the so-enlled
(tiipuhir form of ilch — n mistake which even professeil dermatoi(^sti
have madi'.

Kui althougii 1 mniiituin tliat prurigo oa such can never be gut
rid of, eitluT hy its natural involution, or by artificial means of cure,
I nilmit tliut it does not preserve the same degree of intensity
throughout tlic patient's nhole life, anil that there arc periods,
rspeciallv in less severe cases, in which the disease is reduced to n
miiiimiiui, so thnt for those not versed in diagnosis, it may even
seem to have disappeared. This is frequently the ease in summer,
when hy free perspiration, aideil often by a more ^qiient use of
r baths, the cuticle is softened, and so becomes less rough and dry,
■ ud less covered with papules. Indeed, this is not at all an in-
p6«(|uent phenomenon in the course of prurigo ; for every more severf
atlBck in the tihii|ie of /'. agria will, under the same circumstances-
increased (em{)erature and freigucnt bathing — appear from time 1o
time to be rcUevr<l, and though it docs not entirely disappear, may
be reduced to a minimum. But these exacerbations nnil remissions
which n case of prurigo exhibits Juring its course, are only what
we observe in every chronic disease.

It has been maintained tliat when this malady has lasted for a

considerable time it may produce various other disorders, us dropsies,

nHections of the mind, tuberculosis. My own observations do noi

I oonlirm this view, though I do not pretend that prurigo is pro-

I teclive against such diseases. A pntieul may acquire them, or nny

lotfaer»~-pneumonia, for instance, fever, melancholy, heart disease;

'wt his pmriffo has no more power to prpdi."pose him to them than

Km pfote.-! him from lli<m. If ■<■ jtMn fnuiiil lliem in ^mli

"hoidd b" iihli-rfii lo Iud<- that pniris;ii prevented Ihiir

tseriinn nf h iijiiihiriiitlnii hiiiI uli^rnuiiou betwi-rn priirii,'>>
md iilhi-r lUifn*-* ii* iiriibnhly tii 1"- explsinril by a inistak'? in
Tlirff «iv- M<>iii> lufrt'ivi- iiMil rhrniiir iiflw'lion- -hi-'h ■■'•'•■
Accompanied by itching, and hence by the excoriations caused by
ratching. Thus the skin of a person suffering from simple pru*
\ will olTcr a cerlniu reseinblauce lo that of one affei'ted with

262 PRCRIOO.

true prurigo. But if we remember to pay attention to the general
appearance presented by the latter disease we shall have no difficulty
in diatingaishing it from the other. We will give examples of this.

It is well known that jaundice is in many cases accompanied by
violent itching, though there are quite as many in which there is
not a trace of it. Now, if a jaundiced patient scratches himself
to relieve cutaneous irritation, he will produce excoriations like
those of prurigo. But they will never either attain their extent, or
preserve their precise localisation, nor will the other characteristic
changes be seen. ■

Since it has become known by the investigations of Bright thatfl
renal diseases may cause an excretion of albumen with the urin^ I
and that the ansemia thus produced may in its turn lead to' '
serous infiltration into the connective tissue (anarsarca) , or into
the diiTerent cavities of the body (ascites, hydrothorax, hydrocepha-
lus), c^ses have been observed io which albuminuria and dropsy
were accompanied with itching of the skin : this led to scratching,
and thus to a state of the surface resembling that of prurigo. It
may have been such cases which led Alibert to assert that prurigo
and dropsy are sometimes combined. But there is no need to dilate
on the ditfereoce between such a condition and true prurigo, because,
on careful consideration of the circumstances, there could be no
doubt as to the diagnosis.

If we remember the misery which a giatient is condemned to
suffer during many years of his life from the inconceivable annoy-
ance of this disease, we shall not be astonished if he sometimes
loses his moral courage at last, and in disgust of life relieves himself
of his burden by violence. To ascribe such an act to more or less
alienation of mind is a charitable and perhaps a correct assumption ;
and so far the opinion that prurigo leads to disorders of the mind
is justified. But the rarity of this result is proved by the fact that of
all the patients I have known affected with this malady, only a single
one has committed suicide because of it. When we consider the
course of life of a pruriginous person — how in childhood he is scolded
by his masters and schoolfellows for his constant habit of scratching
himself; how afterwards, and especially if he belongs to the working
classes, and is unable to procure a separate chamber or even bed,
he is jeered at by his comrades, who will even refuse to liave any-
thing to do with him, from fear of infection, or because his con-
tinual scratching disturbs them in bedj how, if he is in tho I

DtAGNOBIS AND PKOGN'OSIS, 268

jhcr ranks of life, he finds it impossibk- to mix in society, to make
liiinself a home or to marry a wife — we sliaU not wonder that one so
sadly plagued should acquire a distaste for life, and find his solitary
comfort, exemption from military service, but a miserable compensa-
tion for his many woes.

Diagnosis. — Tlie folness with which I have described the c1iarac>
teristic appearances of prurigo render it superfluous to speak again
of them here ; I will therefore merely enumerate the diaeaaca with
which it may be confounded. These are — (i) the appearances
caused hy Pruriiui cutaneut or irritation of the skin arising from any
other cause than a papular eruption ; (a) the excoriations and other
effects of the injuries caused by divers epizoa, such as lice, bugs,
Bcari, &c. ; {3} scabies in all ita varieties of appearance ; (4) Urti-
caria cironica; (5) eczema, impetigo, or ecthyma, when they com-
plicate a primary attack of prurigo. Whoever follows the principle
given above of founding the diagnosis not on any single symptom
but on the geneml appeiirauc* of the whole, will find no difficulty in
distinguishing the true disease from those which resembled it in some
its symptoms.

P1100NO813. — The prospects of an unfortunate patient afflicted
ith prurigo bave been already depicted in no very cheerful colours.
le may do whatever ho pleases ; bis malady will follow him to hia
grave. Only those who are unacquainted with this disease in its
entire extent can assert that it is hardly curable, ^o, it is not
hardly curable, for then it might under certain conditions be
cured — it is incurable. Hence, all lliat the physician can do is to
use means by which the sorely tried sufferer's lot may be rendered
more tolerable, and he be prevented from falling into utter despair.

AuATOMii. — If the point of a pruriginous papule is shaved off
horizontally with a, pair of scissors, there flows from its interior a
drop of yellowish, transparent tluid, which shows under the micro*
sco[)e epidermic cells and blood discs, with here and there a pus
corpuscle. But the layer of cuticle which has been cnt off docs nut
all differ from any similar portion of the normal skin. V/'c may
ifore conclude that each papule of prurigo is formed by a colUc-
ofjiuid hi the deejier layeri of (he epiJermii, and by the consc-
it elevation of its upper layers : so that it essentially resembles
icle in structure, ami only differs from it by the less quantity nC
contained, and th« greater thickness of the covering. The fact
epidermic cells thns elevated contain more pigment than

264 PRURIGO.

others, is obvious to the naked eye, and is only confirmed by the use
of the microscope.

In many parts uf the skin^ and es|>ecially on the back of the hands
and about the wrists of pruriginous patients, it will . be obsen^ed
that tlie papillu' are larger and more fully developed than else-
where : but this is not peculiar to prurigo, and is well known to
occur in all chronic cutaneous diseases after a time. Whether the
glandular ap])aratus of the skin is included with its other struc-
tures in this process, and if so, how far, cannot^ we admit, be
defined with certainty. But the facts that the palms and soles
remain constantly free from the eruption, and that on the other hand
l)apules are often seen pierced by a hair, are of considerable interest,
and point to the possibiUty of the sebaceous follicles having a share
in the pathological process. Moreover, the circumstance deser^Ts
mention that the disease called by Willan MoJInscKta coniagiosuM
which consists in a more or less soft atheromatous sebum collecting
in tlie excretory duct of a sebaceous gland, and dilating it into a
tumour, frequently occurs in cases of prurigo; and this may serve
to teach us that in such cases the sebaceous follicles are at least not
uuaflccted.

Ktiolooy. — We meet with the most divergent opinions in the
works of dermatologists as to the origin of this disease. Tiiose who
believe in a BtiHcrasla psorlca are inclined to represent prurigo as
the product of the most severe cases of this disorder, and more par-
ticularly as sprung from an inveterate psora. My own views on this
supposed " dyscrasia" have been already fully explained when dis-
cussing tlie etiology of scabies, and to that passage I may now refer.
Indcrd, since the majority of modern physicians are convinced that
tlie Dj/scniftia jisorira is to be regarded as a mere phantom existing
in the heads of certain romantic pathologists, and nowhere else, its
im])ortan«v in :i discussion on the eau«:iti<>n of pniriir^T has disn^-k.
1.. ;.rin. :inil M ni'jiM> ^^\\\\ ;i -nWonliii.iti- Iii>rMi-i.-.,i ii»r<Mv>r.

.■.•.!/ . f * . . • ' I <

I ■-'... i *■ I . I • !>».-.

tuents of the urine being exeroiiHl ihrouirli ihr kiJnexs, iLe\ arc in
part n^taineil and got rid of in sonu- other way. Although as Fuchs
himst»if admitteil (Kk\ oil., p. 4-'' "^^ *^"e had over in his time
cxaniiued the blooil 01 a per;*on sutlcmig trv»m *• L'lopUnia.'* jet he

ETI01.00V.

I apoH ths eipcriments of Pri^v6at aad Dumas in excisint:
ilic kidney§ of animnls, tlie belief tJiat similar resiJt^ uoultl occur
ill tiiehuiiumbnily wilhout »uch mutilation. ITe docs not sljitr upon
what special observatious lie rests the next assertion, but he iicoccetls
lo cx|ilaiu tlmt when Urophvuiii is preaeut, the retained coustituenlH
of the urine arc most frctjuently niul in the first instaucc exeretcil
throngli the investing titisues of the body and especially through the
skin; and thus " DtrniaposliiseV result in the form of Vriilroii*
(excretion of nrine by tJie sweat ), or of " Cnfimtu" eiilyarh {prurigo
iicuilis) and Ciu-*miif apariaai* (V. ]*dicularisj, or of Piflophlgi'm,
Pompholir, EttMommtia and Vrrkeli-osig. This hypothesis of Seliiin>
lein's followers is quite opposed by our present knowledge, for cases
in which the excretion of urine is really prevented hy diseases of the
kiducys, ureters, bladder or urethra present quite different symptoms
from those described by the so-called natural history school of medi-
. The condition which reauita from iiilerfereuce with due excretion
if ariiie, now known as unemia nod supposed to depend npou decoin-
^sition of urea,' may give rise to violent sweats, and in some cases,
rubobly m a consequence, to itching of the skin; but I have never
t observed an eruption of papules, vesicles, bullse or ulcers on the
c or limbs, in the course of a genuine case of unemia. So that,
out the knowledge we now |>o.'(sess of prurigo, there con be no
doubt that it does not ever depend on disor<tJ;r& in the sccreliou or
excretion of urine.

AuoUicr view as to the origin of this tiiulady, which is supported
y Cazennve among others," is that, it has its chief seat in the ner-
[Vous system, and arises from a supposed peculiar alteration in it, a
l^pcrmlhaia cutanea, which lends tu itcliing and scratcliiiig, and thi«
B its turu to a papular eruption. If such were the case the itching
nust of course precede the development of papules ; then we might
I donbl regard the cTuption as th*" re*nlt of the ilcliinjc, jnat as in
Mbies. Rui iiHwrinl iini iif prurljfx If.nrhes rmielly tht opposil-' :
oly Lii lliuw pliiei- nlirr-* papidi-- itppmr lliat itching i*
a fur II* we r^ii r!r.-.ir>iy Llir' fnniirj^ the lilt^r diMppear* :
j{ as the miirn of (xqinl''* e^n W prfvrnted, the pati^ni
ft free from Ibe irrilaiiuii which tormented him bel'on-. Ii is there-

' Tliit Ujpoibetis, suggesUtl by Ptot. fniriclis, liu been rendered more tfanii
iloubtful by ihn reaeiiiclics of Dr, Kuline, — [Ed.]
' 'Atinalcs des Molidiet tic la Fenu et do la SjphiliR.' Aoiit, 1844,

&m nnifeit tint tbe dndajnieBt of papules pmxdn
mdtsEtiane. To sroid Bkandentiaaiiie I bbiL he

exprcKly tint Ubs is onlj true of tlw discMe vUcfa naOj ttearrns
the BUEw cf pnrigD ; for then eertamlf ue chns i& ^lidt itefaii^
is Ibrt ftit, «Bd the cxnaequot icntchii^ pra dn ees ill ibe visihle
sppMnaeet on the ricm. Bat these sre diflfamt fmm those of
pmrigo; thej oeenr b ffoeat penons, ic diftmit tunes, and
ander different eoodttioni ; «> that I hme fkwiid it necesaiT to
dnw s mufced and exact distbctiaa betveen fmiba and j»ntny«
properi;' so ailed. In bet the whole mistake of Cnenxve and jtit
foilowets has ariieQ from their not having acenratelj distii^atBhed
betveen the sabjective and the objectire s^nnptonia oomwcted with
cntaneoos initation ; when this is done there is do possibtlltr of
confoanding hjpenesthesia cat&nea with pmiigo, Erasmus WiUoa,
it ii tme, draws a distinction between pmritos and pmrigo in the
fifth edition of his work (1863) and reckons the former nndei hy.
perreatheaia of the skin ; but yet we meet in his account of prarigo
with certain species, as P. lenilit, podicia, teroti, pudemialit, which
in my opinion do not belong to it all, since experience proves that
these rarieties of prnritus are not accompanied bj the change:s on
the «urface which are characteristic of prurigo.

The " acrid theorj" of the medical writers of antiquity gnd the
middle ages, which supposed the existence of acids in the blood
{acrimonita ianguinig) bs a cause of cutaneous irritation, has been
maintained until very recently ; and we may read even ia modem
works on dermatology of prurigo depending upon some mechanical
or chemical changes in the blood. At one time bile, at another
I, or an aerimonia ptorica, or a uric acid diathesis, ia assumed
;be materia peccnns. And to crown all, a Parisian micro-
tjiist (Dr. MiindiJ asserts that in all cutaneous afl'ections attended
' itching, and so of course in prurigo, the corpuscles of the blood
B corroded by its natural acids, and so appear under the micro-
t with wrinkled edges, exactly as if they had been treated with
' aretic acid. If ail these fellow-workers of mine had spent
wvch time in actual study of t}ic appearances, the eouisc and
t AYUtrcncc of prarigo in different patients, as they have in
"1 hypotheses or in makinif oti^crTniii.n. ,in iIl.. ,.,.,(^.
r blood-coTpuBcles, whidi 1.

: would have done mon , ;

i their own toWb.

ETIOLOOT. 267

these tbeories aa quite at vaiionce vith the facts of the
case.

The statement of some writers, nod particularly of Alibert, that
prurigo is an hereditarj affection is eqoally inadmissible. Nor hare
I ever met with a case which supports the theory of its vicarious
connection with other disorders. Those in which itching of the
skin has attacked persons sutTering from piles or from amenorrhcea,
or children who were free from the ecjematous eruptions of the head
and face which are reckoned peculiar to their age, are not to be
regarded as cases of true prurigo, but simply as Pntrifvi culanevi ;
and even then the connection of this cutaneous irritation with the
above -mcntioued conditions is not by any means certain. We know
for ioatance that in cases of amenorrhcea, itching of the skin is very
apt to occur so long as the menses do not appear; but this is not
prurigo.

The extent to which such imaginary explanations of the etiology
of a disease may be carried is shown by Alibcrt's account of a case
in which a child had a paroxysm of prurigo as often as its mother's
menstrual period approached (!)

Almost every writer on the subject attributes this malady either
to the snnguineo-iymphatic or some other temperament (Devergie),
or to a coDgenitally white, soft aud transparent skin (Alibert), or
to radical weakness of the whole lymphatic system (Alibert and
Wilson). Then, moreover, it is ascribed to living in damp and ill-
ventilateJ places, to abuse of spirituous hquors, to eating salt and
"high" meat, to idlenei», sloth and intemperance of every kind, as
well as to excessive labour aud night-work — in a word, nothing has
been omitted that a human being can do or leave undone, in-
cluding of course what is never absent from a list of causes of any
disease, the passions and emotions of the mind. AJibert's oft quoted
work is in this respect well worth reading for the sake of the
striking and extraordinary stories with which he regales his readers.
He tells us for instance of a man who sufTered five and twenty years
from prurigo and showed a peculiar perversion of appetite ; for " he
was remarkably fond of dishes made with garlic, eucumhers, vine-
gar, mustard and other such condiments," with much to the same
Every one will see from his own daily observation how
tntenable these theories are : and none more so than we in Tienna,
I live in the centre of a population observiug the strangest
1 respect of food. Thus the lyrolcsc are great cheese-

earn?. SuLvrrozsLZ:* ycassanu sucbciis vviazinse* of cocamber?,
HizCTrais iirror ir^airam^r "rri ricr'i.i-'- imi Jew* an? rerr
::iX)i :c priic : lac ihha :l 'Jj^x T3txs ^arnurhny i brger pro-
pcmca :c :a:se$ :c ^nr^: t^: :ii£ jgrnfrii iti^iE^ uisizl else Iraliazis,

jCicsccal necLCii ijrfaii" ifi<:cr^I 'ji i<?sc22^ 2L peccskSf, ve find

:. ^i kucT :c s: jr^u.ir r^ :iie ^la. ij ▼oiird. prurizc can be
ur:c:i:r:c. Hiautf :■: ::i;ti>:c ii:r:e!iji z^ua pwixr :r jh» cLeanli-

iLtfo: jl' 'raisf^ laii. iieia:szj« — ■:3. :iie T:ri. 3nr»: » Mrer pro-

sesKi:c :£ :it; varje*!: ti-Ii; <: — 1 :;aXr -•iiificcii ^±rz zo ^even
'iiT? :nl/ Tiry^-Ttf 'si i:ciL :c j.Cfaiyr/ i\ir.m£ iie wijiie oc like
rfsc :i ".f:. 7:-: :ciZ.-:n :ja: jrir-ir: r>c if|T«r5 n jJ^Lt life i>
lieKcrp; *j:o:*rT:n:c. :. -^r ir-'jci "::i:* ::< :r:r-i li niizirj. sico^h

* :• •:: >-:;•: ■.■5 i— -i i-Jct — - .. _:>* ;*i _• :iii..Li':«.C- j^-i 5*: rj.:a.:
.-. 1 •-. :^lI.L■.:-p^ 111 ":i:Y-ri.> :: "rf.: 7: .a« t":.; j^.- -7..

i':* . t...

^^^H .i:tioi.O(iv.

Wpwigii uiudi iillmu(i-il iiiid llie wliulc skin Ju n )ik-aauiit »lalc of
I, perspiration ■

I 6. IIuw I'ur nell-kiiuwii (ft'iierul ilii»ejkae^ tatty contribute to pruri^^u

I I ciiimot ci-rlainly determine ; for in more than a tliounaiid cnses 1
lliave liad oeciisioii to oliservi-, lliiTe luive \>een strong, robust, wcll-
I built, aud wcU-Tiourished iktsous, as well as broken-ilou n, einacintetl
inud cacbcctic oms, or even tliosi.- \t1io bore evident marks of tuber-
I culosis, riK'hitis ot scrofula. Attltougli, therefon-, we admit tbc
I occurrence of prurigo In those uffected with general dyscraeiir, wc
f cannot allon the hjpotliesis Ihat it stands in immedintf: dejiendencc
I iipou the Intler; and ciiu only conclude that while scrofula, &c., do
I not pcevont prurigo, so a patient afHicted with the latter comjilaint
I mny become scrofulous, ra<!!iilic and so on, as well as nnj ouc cUe.
I 7. Xor dow this disease exclude any more the presence of other
I aireclions of the skin, such as cutaneous syphilis, scabies, eczema,
I imixitigu, aud ectliyinu, for we have seen it combined with each of
I these, without losiug its individual character or course.

I H, 'We may lazily assert that prurigo is neither contagious, nor
I produced by any kind of rpizoii. ■

I From all this it is clear that wcr cannot aK^ribe the origin of thin
I malady either to any external disturbing influence upon the skin nur
I lo any of the iritenial constitutiumil sUtes above mentioned, but
I must pronounce it to be iu the strictest sense a disease of the skin
I in itself. For my part, it is Just as conceivable that tlie integument
f nmy becoine primarily and solely diseased, as that cutaneous aflec-
I tioiis can only be the result of real or mjiposed morbid conditiuun
I iiftlic humours or the «olid organs of the body. In fact I uiain-
I tallied tins view of the jiathologjr not only of prurigo but of many
r other cutaneous diseases at a lime when the humoral pathology
I was uiiivtrsuUy accepted : and I may hew ri'fer imrlicularly to the
1 opinions put forth in an article called " Dcnnatological Sketches,"
I published twenty years ago,' in which I said that " the idiopathic
I all'eetions of the skin must not be overlooked." 8inee thai lime iJie
I investigations of the illustriona Virchow on the subject of ecllnhir
I pathology have modilied the commonly received views ns to ilu-
I origin of local diseases ; and hence it in now more ea?y to eiplaiu
K nil thi.-- principle the etiolo}.'y of a disorder which, at len»t at tlr*l,
I ittrects the iikin alone.

I ' • Zeiuolirifl der It. k. GwUscWl ilrt AcKle,' jttl «trie», rol. i, \>. 314-
I Vic■lUl^ 1846.

370 HRUftloo.

If, then, we seek to eatablisli the chain of cansation which leads
prurigo, it will not be difEcalt to admit the folloviiig theor/j which
is bused upon the physiological process by wliicU epidermis is formed.

For the cuticle to be perfectly healthy, there must be at every
point of each papilla a proper amount, as well as quality, both of the
epidermic cells themselves and of the inter-cellular fluid which unite*
them together. So that not only will a change of quality lead to
morbidproductsin the thin layer of cuticle which coiers the body, but
also the slightest excess or defect in the amount of these epidennic
tissues. Let ua, then, suppose that in a case of incipient prurigo
the epidermic cells are from some cause or another not properly
developed at certain points of the cutaneous papillse, while a minute
drop of intercellular fluid (blastema) collects above the normal
quantity : the latter acting as a foreign body will of nreessify pusi
up the layer of cuticle which covers it and thus form an elevatioi
a papule ; while at the same time its presence will act as an irritanl
upon the papilla beneath. But it is well known that the nervoaa
system of the (aHUe papilla, when irritated, does not cause the
sensatioH of pain, but one peculiar to itself, and known as itching :
this feeling produces in its turn an imperative desire to scratch, and
the injury to the skin thus caused leads to the further effects which
have been already so often and so fully detailed in other parts of
this work.

That itching in prurigo and other cutaneous diseaaea depends
upon mechanical irritation of the papiUce and not upon any con-
stitutional excretion, was maintained in the article above mentioned;
and the experience of the many years which have since ela]
has only served to strengthen me in the same opinion. But as
further confirmation of my views may serve the fact that in ackuoi
ledgcd dyscrasiic such as the exanthema, syphilis, and scrofula tb<
is either no itching at all when the skin is affected, or it occurs
at times and in a slight degree : while on the other hand the lot
cutaneous affections which result from the presence of episoa or
from mechanical irritants, such as urticaria from the contact of
Urdca iirent or from inunction with oil of turpentine, ut nccoi
panied by violent irritation.

Another opinion I have formed on the subject of itching
following, which has only been confirmed by fartlier irx[)erica<
since it was first expressed in the above-mentioned article,
former times it was held that itching of the skin denoted that

lie
lal ■

ETIOLOOV.

morbid bodies called acidities and acrbuonies were preseut in the
: owing probably to a confusion between tbis sensation in tlie
imeut and tbat of sharp acids on the tongue, or perhaps from
ising the eSect of certain articles of food in producing
urticaria and, with it, itching of the skin. Unfortunately this theoiy,
which is quite unsupported by actual observation, has been so
widely difl'used and ao generally accepted by physicians and by the
public, that it is now a most difficult task to drive it out of people's
heftds ; and daily experience gives us examples enough of solemn
warnings against so-called " acrid " diet, especially in cases of cuta-
neous disease.

But that tbis is an entire misconception, any one may connuce
himself, whether suffering m his own person from such irritation or
not, by the simple facta that on the one hand millions of human
beings cat and drink such diet every day withoutr being in the least
affected by itching, while on the other those who really suffer from
pruriginous diseases abstain from uU this forbidden food either by
their own desire or by their physicians' order and yet are not a whit
the better. If we no longer look upon itching from this point of
view, but explain it as a tmation peculiar to the »hn, capable of
being excited by nil those causes which actiug less intensely produce
B feeling of tickling only, and acting more so one of pain — so that
tickling often passes into itching and itching into pain — we shall
certAialy come nearer to the (rutb. Accordingly we shall not be
surprised to find that whatever can produce pain can also produce
itching : and thus, jost as jiuiii Tnay be ul one time the result of
external agents acting directly on the skin and at another of changes
within the body, so itching ia produced soiaetinies by a local irri-
tant coming from without, sometimes by a jirocess carried ou in the
onanism itself. It is scarcely necessary to add that the nerves
are of necessity involved in the process, as conductors of sensation.

If now we apply this to the etiology of prurigo, it will not be difficult
to maintain tbat the drop of blastema, exnded in a wrong place or in
wrong quantity, which composes the contents of a pruriginous
papule, will work as a constant irritant upon the nerves of the
papilla and thus produce continual itching ; just as in another case
a greater quantity of exuded fluid presses more strongly upon the
subjacent cutis, and no longer produces the feeling of itcl^Qg, but
that of pain.

TiifATJiuin'. — ^It is s tbankleaa task to diacoss the therapeatics

i)f aiiimuniblc iiuiludy, iimi ivs w*c have seen this tube tliu c:a*c with
jirurigo its treatment oan ojil> consist in alk'i'iation. W'c shall liuvr
dune all tliat can be expei-tcd uf us tf we succeed in su far initi-
yaling tbe patient's siifferinga as to make them no longer intoler-
nblc ; if M'e can restore biin the [lOwer of slei'p ; iiiuf so far niter
bis hideous appearance as to enable him to mingle with hia fellow-
men without feaiini^ to be nvoidcd or thrust out of human ^ocietv.

It ia true thai we finil in every book on llie subject n multitude
of remedies enumerated which, it is asserted, are capable of curiu);
[irurigo for a time at least, if not [lermanently. Hut when tried
upon au actual patient, the contrary soon becomes evident.

Many authorities have put the health of their patients to a severe
li'st by the use of horrible methods of cure. Mr. Hunt, for instwioe,
treated a lady, fifty-four years old, suppoBcd to be suffering from
prurigo, by abstracting seventy ounces of blood by venesection, and
tifleen by leeches in litlle more than six months, giving her, more-
over, by hia own accoiint, more colchieum, tartar-eraelie and putga-
lives, than he remembers ever to have exhibited in any other case —
iiiid his treatment is usually of tbe severest — and affecting Ler gums .
ouco or twice with mercury. But even this lieroic treatment \
nut enough, for in course of time he dosed his patient in addition I
ttith blue pill, colocyntli, senna, Plummet's pills, and a quantity of |
arsenic in the form of Fowler's solution. Other writers, as Rarer I
and WilsoTi, defend tbe practice of bleeding in prurigo, ihougli [
Uictt long ago declared it to be useless. For my part, resting upon I
my own experience, and tbe views on the nature of tbe disease |
which I have advanced, I venture to declare myself against every j
kind of depletion, whether local or general;' and must express my j
conviction that if really after large bleeding — according to Hutil,
he and others have carried it aique ail iMlquiiim — there bus ensaol ■ I
temporary cessation of itching, this result baa been more from tlie I
consequent depression of the nervous system than from any real j
improvement or cure of the disease. This view is supported by the I
fact that [tatients are relieved from the itching as well as tbe other i
ctfects of prurigo, when they are the subjects of »ome otIkT inter- I
current and chronic malady. We may explain in the same way tiu I

' I cannot but tiiBLtt upon tbe incfficncy of bolli ordiuar; aoJ drj oupjifi^ I
■nd or the modem B)iuuiiolieidt.mtt.bod iu tbe treatuenl at diaeues wbjdi I
heffii Willi itching of tbe *kin, and ui quiic cooviuccii tlutt tbty will w
ordcrvd b; auy ralloiwl pbjudaa ia fature.

TRRATMENT.

273

ition of (jlher Hi-prcssiiig moJca of IrealnieDt, such as that by con-
Imual pargiop. bj starving, and so on.

AJthough I have not seen good tesulls from the use of any
internal remedies iu this disease, I tbjnk it desirable to mentioa Iicrc
those wliich arc celebrated by other n-riters as liaving been of service.
Along with the purgatives already mentioned, are enumerated the
whole arrny of diuretics, diaphoretics and supposed purifiers of the
blood, ihc vegetable and mineral acids, sulphur, alone or wilii cream
of tartar, mercurial compounds, especially calomel, antimony,
guaiacura, copaiba, and lastly the " universal remedy," arsenic, with
its various preparations more fully recounted iu the chapter on
psoriasis. In the same way almost every writer lays great stress
won keeping to a particular diet, and we find in all works on the
dbject, without exception, salted nn<l smoked dishes, wine, brandy,

„ coffee, pepper and all kiuds of spices strictly forbidden,
^'Wben we compare thfse much lauded medicinal and dietary
jdes uf treatment witli the Dii»enihlc results which these authors
msclvcs, if they tell the truth, arc compelled to confess, there
8 a strong suspicion, even before trying them, that they are pre-
iribed only for the sake of doing sotiiethiiig. But their iiisutficicucy
wmcs unmiGtakcably evident to one who has the mournful duty
I specially treating many of these luckless patients year after year.'
By own ob.iervations in such a position have taught me that there
B tlo internal medicine and no siieciul regimen which can influence
I prurigo in even the slightest degree, cither for better or worse.
Bayer says in his oft quoted work' that, as a rule, simple external
treatment of prurigo has proved so effectual in his hands, " that,
except in a few cases tn which the eonstitutiou of the patient may
1 especial attention, be would recommend it exclusively." 1
! entirely with this advice, and would say in so many words,
mMetcrnal remedies ahne are o/any u»e in prurigo."
[ But cvnj of these there is not so great a choice as the praises
estowed U|)on thein in books would lead one to suppose. It is, for
', quite a mi!<take lo imagine that narcotics have the slightt'st
ect iu mitigating the itching of prurigo, whether used externally

■ I cannat bat taLe this opporluttit; of exprcuin^ my eilreme regret llial
dicnl wrikrs nro so often cnnleut mcrdj to nprniluCR the Mirrtioas of their

jdeccMon and couteoiporariu, williout crilicuiug llicm iu tlic Icut ur

bLIj kdiliiig lilt! reaulls of llicit uwa BxpcticDoe.

274 PRURIGO.

or internallr. Neither opinm^ nor henbane^ nor chloroform^ nor
ether^ nor Liquor anasfieficus iolfandicus, nor hydrocyanic acid^
do the patient the least easement. If large doses of opium or
morphia are exhibited^ so as at last to stupefy the patient^ sleep will
of course be obtained ; but, instead of being quiet and refreshing,
it will be disturbed by dreams, in which the malady will play no
less a part than when the patient is awake. He dreams that lie is
condemned to brush clothes, or to scratch at a wall, or to sweep the
floor; and so we may see him while fast asleep rubbing, and
scratching, and tearing at his own skin.

In fact, the only applications which have approved themselves to
me in this disorder, are those which produce a iofienxng and removal
of the uppermoit layers of the cuticle. These diminish the formation
of papules, or even stop it entirely for the time, and thus relieve the
itching. Since this result may be obtained in various ways, there
is of course no single remedy to mitigate prurigo, but many which
may be employed at pleasure.

To take the same order which has been followed in previous
chapters, let us begin with icafer. This is one of the most impor-
tant of our therapeutic agents in this disease, whether used in the
form of cold-baths, swimming-baths, or shower-baths, or as Priessnitz's
"water curo/^ or as vaj our bat!:?, or, lastly, in the simple tub-
bath. 'Whichever i:> eir.ploveil, tlie water will prove itself efficient,
it its use be pers.vertvl in. JS.^ tliat every patient suffering from
this malady will lind liiir.Mlf r^liLveJ by the use of any baths, of
whatever chemical ijualitv, if lie inlv kn.; s to them lon^ enoutrh.

But the ol^iect in viov i< more ^r.iAIy attained if the treatment by-
means of sft icip, Uilly d;scr:-ij.l at p. 29S, is employed; only
rememberiuiz not to ex[\-^ct a l^:il!;a:it and permanent success
from a single cycle, even sh.-r.ld it last for six days. The pro-
cess must be rqieateJ several limes. a::J exactly as is described
at p. j^oi.

S:'fj,\::r is d service ::: ] nir:^>-, v.l:.:;:,r uivsolvcl in baths, or
in soaps anJ oiiitmcMs. ■ r i:: t!:o vr:.; . f f ;:::i^,:::jn : but, as with
all othi-r application?, i: inii^t V. u>..] f . r :: 1 ::^ li:-.,-. :.!il suillciently
concentrateJ. It i< in Kti.-: i,- i'..-. v::!^.;.'v . i" >::!;.l,i:r i:.:it we must
ascribe the confusion w:.:c:l >.^ : :::; lx>:l.: b.:\\\.,:i prurLro and
scabies: for the sair.e rc::uA' ; r.-liie .1 -00.1 risu'.is in both, with
this dilTv-rence only, thai s.m:.:;s \\;.< c\ireJ \Aiihout its necessaiy
return, while prurJL'o w..s L:ii\ a!(.\:.i:Ll i\ r the I

laEATMCST. 275

mploy sulptiur, either in the modifiecl form of Wilkinsoii's
otutmetit which I have devised, or aa TlemingVx'a lime and sulphur
eolation, and both arc attended with visible success.

In llie former case, I order the patient first to tako a bath, and
then, without putting on his clothes again, to lie, quite naked,
between blankets for at least six days and nights without inter-
rujition, while everv night and morning a sufficient quantity of
the ointment is thoroughly rubbed into the whole surface of the
body. VHicn this period lias expired, the patient leaves his bed, and
remains for three days without any further treatment, until the
epidermis boa been partly shed; and when, on the tenth day, be
wiuhea and bathes, he will, if the subject of only slight prurigo,
appear quite free from it, while even a severe case will be decidedly
relieved. The unplen^iuitness of this treatment will always be well
borne, because, during the whole time, the patient is free from
itching, and can sleep quietly. In fact, he ia generally so pleased
with it, oa very willingly to submit to a. second or even a third repe-
tition.

When I employ Vlcmingkx's solution it is very much in the
same way na in the "quick cure" of scabies. The jiatlcnt first
bather, washes himself with Noap, and rubs his'wliolo skin with the
solution ; he next tnkes a bath of at least on hour^s duration, fol-
lowed by a eold shower-bath. This plan is not so quickly effectual
aa th.at with Wilkinson's ointment, but ean be carried on more
easily without interfering with the patient's business, siuce any one
may be supposed to have at least two hours in the day to devote to
the treatment of his inaludy.

Biirensprung maintained that he could cure any kind of prurigo
with corrosive luUimate baths, but I am sorry that I cannot endorse
his statement, for 1 have kept my patients for hours in such baths,
frithout any greater result than would have been obtained from
jnple nnmedicated ones.
llJniiy writers extol the virtue of other preparations of mercury,

ecialiy of white prrapitnte, grey ointment, protiodide nud dcut-
flide. To ascertain their efi't'ct upoa. prurigo, I once made an

jeriment which is probably nniquc, and was publislied by Xcumann,
■ the ' Allgemeine Medieiiiisclie Zcitung " of Vienna, in the year
B6o. {Numbers 49 aijd 50.)

BSeaidc the object just mentioned, I also wished to nscertaiu the
LjflcrcHry upon persona who had never before been treated

276 PRURIGO.

with any of its preparations, and also to decide whether it is trae that
cutaneous diseases, resembling those which depend on syphilis, may be
caused by the use of this drug. I chose four persons affected with
prurigo, who had already tried different internal and external reme-
dies for their disease, but never mercury in any form, and for one
hundred days had a drachm of grey ointment rubbed in, just as my
syphilitic patients were treated. During this period they were kept
in bed and on light diet, and their urine and faeces were chemically
examined from time to time. After a few days' inunction, both
showed distinct mercurial reaction ; but at the end of the hundred
days the prurigo was neither cured, nor even relieved, nor did any
one of the four patients show the slightest trace either of so-called
" Mercurialismus," or of eruptions like those of syphilis. Although
this experiment was made four ^ears ago, and I have frequently
seen the patients since, there has been no change in their disease,
nor has any other affection of the skin ensued.

I have not found the highly-lauded powers of preparations of lead
and zinc, or of iodine, in the treatment of prurigo, borne out in
practice. On the other hand, tar and its compounds, including
creosote, must be admitted among the active remedies against this
disease. Their efficacy, however, will depend upon the mode of
application, whether the form chosen be commoxi pitch, huile de Cad^,
or oL Rusci, or the products obtained from them by distillation —
resinon, resineon, and resinein, or lastly carboUc acid. I have tried
pitch in combination with lard and with soap, with oil and with glv-
cerine,with alcohol and with ether, and in each case found its good effect
in diminishing irritation. The most convenient method of applying
this remedy is the following, which I have lately used with good
success in the treatment of eczema and psoriasis. One of the tarry
preparations just mentioned, or one of their products, as resineon,
is spread over the entire surface with a painter's brush, and iw-
mediaielif affenrarJs the patient gets into a warm-bath, in which he
stays from three to six hours without intermission, or as long as
ho can atVonl time. AVhile in the bath no fresh application need be
niaile, since the tar comes otY vt ry irra/iuaiiy. ar.,1 will not be entirely
removed even after six hour>' iinmer>ion. Tiiis ^.It'hJ-j^h is well
borne, it alleviates the itehir.ir. liiminis^lies the fonnation of |)apiUes,
anil thus leads to R*troi:ns>iv:: rf j.ruriLro, as well as of the other
cutamous diseases mentionevl above : so tliat its itkia need

unly be interrupted when there ensues either a vio ag

TREATMENT.

277

— aod lliis is most common after the me of resiiieon, — or an
outbreak of Aene p'lcu.

Having learnt the remedies which avail to produce if only a
tempotary alleviation of this terrible disorder, it will bo the duty of
the physician to select in each case ihoso which are best suited to
the intensity of the m&lady, and to the situation of the patient. It
is not every one affected with prurigo who has time and opportunity
to devote himself to the treatment of his complaint all day long,
and that for weeks nnd months or perhaps for his whole lifetime,
Tlut most will have a few bouts of the day, or, at any rate, of the
night at their disposal. Some again will make up their minds to
submit la a heroic course of treatment for a sliort time; but since
a complete cure cannot be thus obtained, they must afterwards con-
tinue to follow one less energetic, nnd demanding leas sacrifice of
time. Bearing these considcralions in view, 1 have, for example,
treated many of my patients for the first eight or ten days by in-
unction of soft soap, or of my modified Wilkinson's ointment; and
when the disease has been thus rendered more bearable, I have, to
maintain this improvement, prescribed a sulphur or tar-bath for one or
two hours every evening, or the inunction of the same remedies
during the night, lly such measures I have succeeded in keeping
I patient in a comparatively tolerable, though after all a pitiable

wdition.

CHAPTER XXn. .
ACXE DISSEMINATA.
'A*ci/>/ ■?. oKiui — lovio^^vanff.

IIiSTOHT. — Acne does not appear to have been rrcognised j
disease by the oKlest Greek physicians; it would otherwise be sin
that an affection so common and so often attacking the face is
once mentioned in the Ilipjjocratic writings.

Manv authors consider the name iv;v/.? to be derived from
Latin varius, and quote in proof of it a passage from Cicero
which lie uses the word thus in jest of C. Sen-ilius Isauric
" Mirainur cur Servilhut pater tini.Sy homo constant hsimits, te n
iam varium rcliquerit.''

Eveu Celsus, who also uses the term van/i to denote this affect
speaks of it as follows : " Pene ineptia sunt curare varos, leniie\
et ephiliihs ; sed eripi tamen femhiis cura cultus sui non potes
Yet he mentions remedies by which he believes the eruption i
])c best removed, advising turpentine, alum and honey to be mi
togctlier and laid upon tlic papules of acne.

('assius (a. I). loo)^ treats more fully of this disease; and inqaii
wliy it occurs in the prime of youth and strength, supposes that
nolilcst and best elahoratod nutritive fluids arc determined to
regions allVcted, and there stagnate and accumulate.

(ialou^ ijhows an accurate acquaintance with acne; he describe
shortly under the name vuri, and says that the Greeks call it "lovi
that its papules consist of the thickened fluids of the body and \
they may bo cured by the use of emollient applications and j
gntivis.

Ai'tius, of Amida* (\.D. 543), who is well known to have coUec

• Mrii. hb. Ti, CAjv ,-,.

• *('rt>ii l»tro5ophi>t,T IVM. Mril..* I/'psIa*, 1653.

' F pi tome K\a\k\\\ IVrcAnicr.i opcruin, etc., * De comp. Me J. secniK
looa.* l.lv i\» )v w^;,. Arjrrutor.itnm i,StriMlMUf)i 1604.

• Trlr. i. 5crm. ir, cap. 1^^

OISTORY. 279

e ineilicnl writings of his predecessors, likewise inentioiiB timt tlic
GrLTks used the iinmes ukvi'i mid Tov0oc to denolc t)iis disonac;
niid cari, as papules chiefly affecting tbe face, are referred to both hj
Puuliis ^E^iiieta' and Oribasius,'- who was no expouudcr of the doc-
trines of Galen and of those current in his own time.

With these exceptions there is scarcely a notice of acne to be found
a nijcient or medimvul medical literature : not even snch works as
e of Mcrcurialis and Ilafeiin-ffer, specially devoted to the subject
t cutaneous diseases, make tlic slightest mention of this: nnd
'i scorch in vniu iu their writings for even its ancient names.
:> is not till the etst«cnth century that wc find it agiu'n noticed,
Oorrwus," who Hays : " Acne is a small bard papule in the (ace,
led by the Greeks lovdot;, by the Latins varus, tt is so called
»\1K it does not itch and so does not make the patient scratch.

s says tliat lovOo^ and ai:vr) arc thi^ same."
V jMssage of Scnncrt/ vrho lived Iu llic following century i» often
mtioncd by later authors. Tims Sanvagcs, when describing acne
idcr the beading " Pi'ydracia," writes ;' " Ptyhacia, acne Aefu,
vari Semifrti, lonlkoi Gnecij, gallici ISoHTgeoiit, pt^-
tciit connala iunt iubercula faciei, vari dicta, ait Senncrtaa ;"
\ furtlicr — " Sunt tcilicet tu»u)rei exigui, rubri, dun, ferlinacet,
r nnqvam sappurantvr, nee dolcnt nee pruriunt, tt lantitm
I detuTpant, maxime dittincti a tuiet-culit frontii, <U qttibat
I ia G'ltla Rjiea typhilitica ; neotoit all KUjthantiati, qua
ueedine, faciei injlafione et tuberculit, iailio ruirit, incipil."
es adds lliat these " tiibercula" are ascribed to tlnckncM of
I nutritive Uuids, and that they ufteti lust untU adult ago and
I disappear. 'ITic question whether this eruption be identical
h the Qutta Kosea of those given to wine, he leaves others to
} and refers to the obovc-citcd passage of Senuert for its
Ntment.
■Xony" speaks more at length of thit disease, disctuaing the
■ Lib. iii, csp. 2q.
* Lib. ir, Mp. 31.
* Joli. Gorrci Paruteaiis D<^I. Ued.,' Ub. uir, Franeofoiti sd Manam,
8. p. .6.

•Sonnertl pnel. Med.,' lib. t, c*p. 33.

' Noiologia m*Uiodica tiUteiis motburMm clauoi joila Sjilcnhivmi menlfni
~«taiiicoriini cniinn, nuctorc Boiwicr da Sauvojct,* Amatcluijsnii, i;68.

lassed.H

i mar M

280 ACNE 01S6EX1XATA.

changes of nomenclature it tas nndergose, and insisting upon
not affectiDg the general system. His words are: " jl^itudineat
vix conatUuvnt, cum po»sit homo cum Ha recfe talcre." Notwilh-
standing this, in further discussing acne and the diseases he classed, i
with it — myrmeciff, acrothgniioK, aeroehordon, retmCir, &c.-
contradicts this assertion of its innocence by stating that in m;
cases the indiscriminate use of caustics in the treatment of ruri majr
cnose some of llicm to develop into cancers. For the rest he recom-
mends alcoholic compounds and generally local measures.

It is remarkable that after this Plenck' appears not to have been
actjuainted with the name aciic ; at least it is not to be found io
work. He confines himself to repeating the accounts given of
disease under the titles ' Vari s. lonthos,' by Galen, and the ot]
writers mentioned above, and refers to the treatmoit
by them. His only original observation (and it is of little worth)
that vari are connected with the spermatozoa — and accordingly t1
tliey are cured by marriage.

In Bateman's modification of Willan'a system he makes the temubj
vnrtii and acne so far interchangeable ns to describe the disease
under the latter name. Following WiUan, he distinguishes as
species A. simplex, A. puiicla/a, A. injure/a, and A. rosacea ; and
describes the first of these as running a pretty definite course in its
appearance, its progress and its decline, duriug from three to four
weeks. I mention this particularly, because many later writers, and
especially Devergie and other French authorities, repeat this state-
ment as if it were correct, without considering how little it corresponds
with the reality. Even Bateman's four species of acne are not
justified by his own description: indeed a careful study of his
account of Willan's species shows that he was aware of the close
relationship or rather identity of the first three. It is only
between A, rosacea and the rest that he draws a true distinction by
showing the former to depend on a really distinct pathological
process.

Although Bateman treats of aene at considerable length he only
mentions with hesitation its occurrence on the back, where it is cer-
tainly much more developed than on the face. So that in the former
situation he must have taken it for something else. He does not
content himself with the simple etiology of acne offered by the

' ' Jos. Joe. Flenckii Doctrici do Morbis Cutaaeis,' and ed., Vieaua,
p. 60.

HISTORY.

SSI

tu9, who witli Galen or Cassias ascribed it to some thickness
of the nutritive juices; but prefers kss simple explanations,
mill (ieiiuces acne from drinking cold water when the bod;
I M heated, from emotions nnd disorders of digestion, in short,
Ktrom the most diverse and opposite conditions. Notwithstanding
hll this, \iv does not dvny that the disease is essentially n loenl one,
■snd accordingly recommends chiellj local measures in its treatment,
ntid es[iecially soaps anil other substances ca[>abtc of dissolving fat.
Mn Willdn's ' Delineations of Culaueous Diseases,' published by
^Batemaii in Is 17, we alw find corresponding reprcscnlations of
Kd. timpUj and ./. //unclata in one plate (No. 62), of J. indurata
i(pl. 63), and A. rosacea (pi. 8+).

W Plumbe, ia direct opposition to Wiitnn and Bateman, aasociates
E^. timpUx with A. punriafa as one variety, and shows conclusively
Etbeir community of origin. Dut while he also unites A. indsraia
tgnd A. rosacea (" couperose") he does not regard the variety bo
Hbnncd as altogether distinct from the former, but maintains that
Kt is only a further development of it.

I KrasmuB Wilson, on the other hand, has got free from this four-
Bbhl division of Willan's, which even I'lumbc substantially preserved,
und describes the first three varieties {A. tmplcj; punctalit, indU'
wtala) under the siiecific name of A. vnlgarh, and only separates A.
mrotaeea from them as a second species. He makes ncne to ansc from
D certain elaggishncss of the ncrvca, and want of activity in (he
nkin.' Curiously enough, Wilson believes that both the forms of
Rhc disease described by him [A. cu IjfarU and J. roiacea) occur more
nnen in women than in men. Although he admits ignorance of
Buy internal or constitutional causes of acne, and moreover advises
Rbat tlic skin in these cases be excili^d by local stimulants, he yet does
not disdain to bring now and then into play against it such remedies
n> bloodletting and purging.

■ lliomson' also accepts tlie division of this disease into two
necies and calls them A. aimpUjc {A. vulgarit of Wilson) and

B ' [" The presence of acne indiaites ■ disordered slmtc of cutaneous innerva-
■ton and contequeotij of tbe vascular action of tlio tkiri : m some in^taoces it
mt iniluoed lij direct coogettion of tbe integumeal, wbile in otber» it would
Etem to depend on torpiditj of the capillar^ circulation and cbstrucUoa of the
BBrrcnt of blood b; suiliicn and iirrgolar eieitilion." 'On Uiseaae* of llio
■ftin,' 5lh ed.. p. 667.— Ed.]
B ' 't'nolicul Treatusc on DiKucs allecting tlic Skin,' London, tSjo.

X ramm. Oa ia ftiolqgyhe ■■■■li tfat Me » aoatqitm
dmiTedin posoKof a cxitaai dander of ikm peeabr to fhow
of bnnpiiBtk teapemDrnt* In, pde nd eool to tfe frorh^ ud abo
m UiMe of »<alkd stnBOK dbikas. latfelinrtMEBtlie Ins
gKat v«%jii vfOtL kecpoBfto a CHcfUh- akeUd die^ awoiliw fidi
sah pniTisioBs> &e.

AH tbese vmers » ml » Hni» Gna lad o^n^ n-|am-l
acne »a dseKv coEisssnK m ibe idbKBitiaa of th^ fiJKrlro of
tlie sidii, or mocv soxclr of iis xhi c e oa s^ ^ladbL Hmit^ p|,|^^,
acae unocg tb^ mVecsii, aad vl& iDKpds^ WiDaa's rabdiTisioii%
admits tbe KiACiT ctf tbe &S tbw ^ J. ^ia^iej) aad looka on the
fottitli ^J, r,*:.-^^' » wi^y a niHier dcrdopaeat of tboii. We
HUT Kmuk of linKa/ vix\ iike aidss of bis pwJet caams , xufics
aeae among the Pi2s;ii^;r, ^^ be vas t2)e axst to insist that f'^irmii
oat ihc pustules or oTx:ii» tie:a viih the brncct b the hert and
the quicker: anxie ox treiizaesi:*

AlihmV view;» of acoe w\kv essstsitiiLlT £Saaii from ihose of the
£i^:lish dwiutol«.^^:i$» jos; nasaed* His accoent of the diaene ia
hononUr distiaguisbed mm tbeir sapcz&ail sutraicata faj a aaoia
thoioiigh iavesl^auoa of its aiaroTTiical cbuactors aad ctkdogj';
bat be is ]c>l asmj into r.^fctir.g as tiraecessarr and anjoslifiafale
subdivision oi its raneu^^. a:::i th:is bj his nuneroiis namci and
classes depart* far lc» advasrawxsslT fcoa ibe ciaplidtT of the
English whtew, Whi> the r.a»c a:=e bai is England loi^ saper-
setlcd that of tanis for the dis^ax ksc^ar. in German as "Finne,**
AUberi, viib his thoiongh lr.oaa\\ge o: asdeat medical liteiatnr^
ptv:Virc\l to bring ihe oM r-ame iu:o ::5e again as the generic tenn
for this grvnip of afliVt;v>ns, a::.l i."x\«oa of all disonlers of the ghn.
Jular siruotuivs of the skin un*Wr this o:^e name. His species are

}\ timmi^,:th^^ )\ /i.;,> '•a<?\:» ?\ uf^rj/rj. This classification
cause^l much iuvv::\c:;:f r.cc ; aui AMb;rr:*s U'iciisgs en acne fonnd
fe\r disciples ci;hcr ia TraLce o: clj^whcre. Uvea the cameTanis
was not aoceptod by anv o: his su.\"^fs*jr?, all cf tbem, except
Duchesne^Dupajv, pn^ferrir.g ?he :cr::i aciie,

> Traciical Ob$errat:or.$ on \\\c^ W\)i\o^ aai I:taUMat of
Diseases of the Skin/ Iav, 00:^. I5vi:.

- Tr&»$]ated into iK^rmAn *nd j^ulCisliea «t Wt ;svAr in 1S36L

* Biron AUl)cri'$ Leoiunti^ cvvieetci br M. L\Taar»
Gtrcjui by Dr. Biodl, Leipti^« 1S3:

■ niSTORT. 283

L Bictt end liis foUon-crs, Caxenavc aud Scbedel, describe uudei the
Bwnca A. timpUx and A. vidurata, those inanuim.ntions of the seba-
Beous glands of which I shall speak &a true acne, and also use the
Herma A. punctata and A. tehacea to denote the abnomuditf of
■necretion which I have already described (vol. i, p. loo) under the
K&lDrc correct and generally understood title, seborrhcca or steato-
Hrlitca ; tbia no doubt often accoui|>anies true acne, but is caused by
K dilferent process from that to which the latter owes its origiD.
H I'hc later French authors, as Gibert, Pevcrgie, Bocharl, Uazin,
^^jogcy, have been able to add but little of importnnce to the doctrines
Iw JJ)>^tt, and cho!ic rather to ntn|;c acne in new positions, among
bubiTules or pnstules, or, as Hardy iias done, with ' Maladies aeci-
H^tcUi's dc la Peuu ;" or else to udd fresh and unreal xpccicA (o
^Boae already iuslitulcd by WilUn and Bictt, such as V. puttulotiit
HDucIiesne-Uuparc}, subdivided iuto t. forma aruminata aud Kjbrma
^Keiutota, A. varloloiile (Uuaia), A. ombitique (Piogey), A. sant el
^meec iypertn^Aie dei Jblliciitcs (D«vcrgie), A. titfierculmde, EcdeT'
^bo^/miV (Ilugnier), A. h^pertropMrjue (Kocburt).
K Uayer is a pntscworthy exception among bis countrymen in
Bevotiiig himself to a correct d(3criptiou of acne rather than to
Hpsnufacturing new species of h.

K In the works of Qcrmaik writers a proper appreciation of this dis-

H^ring malady is unfortunately not to be found. Joseph Franlc,

^guch» and Biccke only otfer tho most superficial and inacca>

Hnle remarks. Thus I'rank descrilcs aenc as P»i/draeia a plethora

WmdA states that it arises in young persons who live chastely or after

Hirst connection ; Uiecke reproduces, pur el gimpl«, tho accomits of

Blench and English authors ; while Kucha conceals the reid cba>

Hhct^T of the di^a^e under the adornments of a butunical nomen-

Hiaturc, which has so place in the science of medicine. In a work

■Oklied 'A full account of Acne,' Brcndcr lays before tlie profession

the obien'tttions he made on the subject in Paris and Lyons.' He

divides it into A.juvtnilii, A. virilU and A. tenilu, aud at the same

time preserves Willim's classification, identifying these three species

' \ A. timpUr, A. induraia, and A. rotaeea of the English author

Mpectivcly.

1 Gostav Simon alono declares lumself against all further sub>
n nf this disease, and moreover expiain? pretty fully itf anatomy,
^ Gregor Breoiier, ' AiuTubrlicbe Alilisadlung ub«i Aooe,' Frcibarg im

284 ACNE DISSEMINATA.

remarking that '^ in each pimple^ where no pus can be discerned
under the epidermis^ there is yet always a point of suppuration deep
in the corium, which may be evacuated by a puncture/' Thua the
origin of an acne-papule in suppuration of the true skin was pro-
perly explained.

In the year 1845 I put forth my own views on the seat and
symptoms of acne in the journal of the Imperial Society of Physicians,^
oud I have now no essential alteration to make from what I then
wrote, l^ut the explanation of the origin of the disease has since
received some additional clearness from the advances made in all
directions, and especially from the doctrines of the cellular patho-
logy. Professor Virchow has, in his description of tumours formed
by retention/- taken occasion to mention acne, lie says that when
an irritative process is set up around a hair-follicle by the retention
of its secretion, and assumes a true inflammatory character, ''there
result tlie various forms which, since Willan's time, have been com-
monly associated by dermatologists under the name of acne. Ac-
cording as the fulfilled and occluded hair-follicles produce more or
less severe eflects upon the surrounding tissues, the character of the
acne will difler. AVhen the occlusion is suj}erlicial, the follicles
ai)pear in the form of comedones, and J. jiuncfafa is the result : when
it lies deeper, and i lie neighbouring structures swell, when the blood-
vessels bocumc diluted and varicose, and when pustules appear, wc
call the appearance A. rosacea (Gutta rosacea, Couperose, Kupfemase):
lastlv, when the skin around becomes thickened. A, ijidurata is pro-
duced.^'

We shall presently see how fiir these views, which have been
chietly formed from observations on the dead body, are confirmed by
what is seen during tlic patient's life.

Before, however, passing to the description of A. disseminata in
detail, I will remark that while there is in many respects close rela-
tion and likeness between this disorder and other forms of acne, to
be afterwards treated of under tlie nanu'S A, hicntajra s. Sycosis
and A, rosacea, or couperose, there is notwithstandint? a clearlv
defined ditlcrence between them : so that 1 believe I am justified
in i)lacing each of these three forms by itself as a distinct maladv.

Definition. — Acne disseminata appears in the form of red,

» • Zeitschrift der K. k. Ges. dcr Aerztc zu Wicn, Zweiter Jahigftng,' vol. 1,

p. E44.

» 'Die Krankhaficu GeschwulaU'/ vol. i, \\ 221 {1S63).

DEPINITIOS AND VABIKTIES, 285

nical or bemiaphprical cEevalioii or nodules, varying in size from
hempseeds to beans ; sodic solid, others filled with ^a; mostly dis-
crete, but occasionally arrnnged iii groups or iu liiiei ; found every-
where except upon the palnis ami soles, but chiefly affecting the
idcin of the hce, the chest and the back, and, in the majority of
KB occurring iu young persons.

Varieties. — ^This disease is frequently accompanied by other dis-
orders of the sebaceous glands and hair-folUcles, which are known
as comedonc)!, milium and scborrhcca, and have been fully described
ia the sixth chapter of this work. But the tubercles of acue may
[present themselves without any compbcation, either as a consequence
of an external irritant, or when tlie inflammation of the fullicle
[depends on some internal disorder. We may therefore divide acne
ijnto an idiopathic and a symptomatic form.'

Tu works on cutuneous diseases ue usually find that form of acne
ine described which occurs along with comedones and seborrhteu
the face, chest and back of young pcrsous. But since wc have
;ady shown that not only iu these cases, but in many other con-
ions, precisely similar pheni>meua may occur in the same tissues,
but running a dilTerenl course, having a different duration or other-
wise distinct, it secnis to tuo more advisable to form several sub-
divisions of acne, and to treat of each one separately.

(a.) The ordinary form of the disease, A. vul^arU of Fuchs,

itJwuys appearing niong willi seburrha-a and comedones, is that

r^dcscribcd by C'elsus, and afterwards by ricnck and Alibcrt under

name tana -. it is known in Germany as " Finnc" or " Pfucken,"

^in France as " Boutonv," and in England as " Stonepocks." It is

^mclerised by alTecling almost txclusively the skin of the faec

chest and the back, where it presents small red papules, sur-

landing the comedones and rising but slightly above the level of

skin (A. j)UHcla(a), and also larger papules or nodules (" tuber-

i"), which either contain a comedo, or else more or less pus

putlnloaa). Again, these jiapules may he ranged side by side

so lose their hemispherical form and assume the shape of a

lin of barley or oats (a, lioTiieolarii) ; or they may increase so

ich as to equal a pea oi bean in size, yet without showing their

ituitd until they arc opened, appearing to be only eolid protubc-

{A. ill dura fa).
' Fer Uie moauiiig of Ibcac terms u cinplojcd b; Trol, Uit)rs, Ke Tot. i.

280 ACNE DISSKIIINATA.

{b.) A seoon^onn is that which aene assmnei when it affceti
f oreheadi cspeoUSy near the hair^ and invades the scalp alao to a
extent; it then presents flat papules as large as iMmp-aeedsi,
assumes a postuhur form at once. In the latter case^ no oomed
to be seen, but each pustule acquires at its summit a flafc disk
crusti which adheres fast to the subjacent partsti and heoomes at
so depressed that it is surrounded by the rest of the papolea in
form of a raised edge or limbus. When this scab afterwards i
oiTa scar appears^ corresponding in size with it and also deeper t
the surrounding skin.

Tills Yariety of acne, which much resembles the emptioni
variola and syphilis, corresponds best with that designated bj Bai
A, ruriolffwrmh. It might from its ahnost exdosiTe oceonmoe
the forehead be called A./romtalU.

(<*.) In cachectic persons, and especially with those wbo I
evident marks of scrofula (such as enlarged glands, cariea^ j
fatty excretion in the shape of so-called Pifyrums iaieteemiimm i
P. icr^loionim, more properly called a universal seboidicai)
those iJected with the disease known as Zicim MmfUoMnnm, \
in patients recovering from scurvy, when each papule of acne appi
surroundtHl with a livid, hiemorrhagtc, purplish border — ^in all tl
ooiulitions eruptions of aene may be observed, which contain
comedo, and are not confined to the face, chest and back, but ap|
over the whole surface of the limbs as well as of the trunk,
this respect the eruption resembles that produced by sypl
(5. r«^iJi<fj/ir/}s/L?#ii\but is diitiuguished from it byits further coa
and especially by never producing specific ulcers. This vari
misrht be fairW named J, cackicticor%m.

(rf.) During the use of various remedies theit! may arise inflj
mation of the glandular structures of the skin, and so an eruption
prcilacevl resembling those just described.

Thus it is well known that ii;:inv persons, ii thev tiike iodine ini
luiUv. are atToerevl with an outbreak c: r.v.ir.erous T\:ru'cs of acne
the facv\ vv.v;?i ani bavk. ^V.ivl: ::: ;?o:r.o cases .Tuuklv ohamn
i^ustu.es, m etiiers reii.a::: : r a : r.o iin.i.UTw:, i.x\ er:ea j
vcnr rer?e\ t mnoe in il:e c\*.:V :::.:: cfa uu\::n::::c c:::ervi:>e i'^dical
and quickly disapyear en its vli^'or.ii-uar.ce w::hcu: leaving s(
behiuv).

Another less wdl known cause e: t::is kir.i o: acne is the k
pflkation of tar. I have beiVn: nieuiiccxd ihai aia^y peiaoaa i

YAKIKTIKS AND C0VK3E.

sar

ring from a complnint, sncb aa psoriasis, for vhich tar ia indicated,

I eannot use iu preparationa, brcaase every application is followed

" )r an outbreak of ted papules of the size of hemp seeds or beam,

'i of which shows at its summit a black point corresponding

irith the duct of the sebaceous gland or hair^follicle, and caused hy

^c tar having lodged there.

t beside these causes, wc may observe the same effect iu the
1 of iTorkmen who have to do with tar in the preparation uf
a, pariifliu, grease for carriage wheels &c. They do not
f come into direct contact with tar, but living in an atrao-
qilicrc strongly impregnated nith its vapour?, sucli irritation of the
lliin is produced tiial iiiflamniatioii of the sebaceous glands follows
n the shopc of acne. It is not surprising that iu these cases the
disease docs not conHne itself to certain regions of the body only,
but occurs everywhere, both on the trunk and limbs.

To denote this variety produced by artificial irritants we might
use the term A. artiJlcialU, or more particularly A, « pice, criodo &c.
CouBSE. — Each of the kinds of acne we have described follows a
^different course.

(rt.) The ordinory form {A. vji/^ari») only slowly develops into an
Btcnsivc eruption, for as a rule but few follicles are inflamed at
aud go through regular ingravesccnce from the stage of
I, punctata (o that of A. irtcfunita. While this is gomg on, others
c still only filled with their ordinary schaceons secretion, aud
Buring the metamorphosis of these last into acue-nodulen, a third
t begin the same process, and so on. Since, again, the developed
ruptibu docs not continue in the singe it has reached, but goes
irough retrogressive changes, while fresh outbreaks of the disorder
jcat at other points, the result will be that tlic whole course of
Rrolutiou and retrogression of acne may be observed at the same
me and in a single patient.

It follows from this that llie characteristics of n fully-developed

%A. vulgaris cannot be taken from the appearance of a single eruption,

mt that in every ease we must look for the comedones in which the

scasc originated, the nodules of various sizes, the pustules and the

tabs formed by their desiccation, and lastly for the scars whicli

riipi>esr after these have fallen off. Nor must it be overlooked that

1 skin between the aiTected follicles will always exiubil an oily

nppcarance, or in other words tlm condition known as seborrhcea.

*n hcu to this description wo add (bat the disease a almost exdu-

288 AC!CK DISSEXISATA.

mt\j confined to tbe >kin of tbe £mx, cbe dheil and the hmA,
learaur tbe icsl of the bodr iniacty ve lave d a gnoBti c ■■!¥■ mimgh
to dislingnwh thb Tuktrof acnefroa theioly » wdl m» finm
other cnlaneoiis iffiectioiis vhich msr icscmhle it.

(i.) X r»ni0/j}^&nti# pwjeim » saufaor tjrpiai come;, baft tbe
amount of eniptioa is usoaDr greats, and deqp aeais RBaia mm its
icsnlt. Tkb TaixtraeldoBtRaiRfbraloB^tiaKyaothithrta'^^
seveial monlhs saj be fitcqveBth- ob a ened betveoa its

(e.) A dilfcteiit eoane, bovcw, is ob a ened bjj.
Here a mnhiliide of diTcne eniptioiB appear
whole sorfMe, those abndr derdoped nwm much kagcr
aiqparent change, and after the nodnks or poatnlcs have dB^pooedL
thne remain for a tot lonit time maculs rcmarkaUe br thor livid
pigmmb^" In isolated cases^ espedaUj in thoie of scsrvj,
of the proper emptioa maj be replaced bj an nkeiatiii^
readilj bleeding, and sozioonded bj s IiTid border.

(J.) Tbe habit and doradon of artxlidalacQe depend apoQ the totem-
fitT and continoance of ic« excxcins: ciose, and aldot^ no dooht, apom
pecalLiritws of the izLregumeat afeoced. Aoae prodaceJ br tbe
use of iodine is not oqIt per$i5rerLC <o Io3^ as c!i« in^ is emplored,
bat aIv3T? IasC3 a loEU^r or <'::orter cixe alter 1:5 di^scoatmiiaiKr.
That vhich results trozi tar will ktep vh pr:Jaciac it^ hArd, red,
shoe-like nodules vbeu the ccaiacc 0: the irrl:a:inz sabscazKe vitb
the skin has alre;idT ceased ; §0 tha: this Tarletj takes tvo u> fosr
weeks hefors it i$ per:e\:clT healed. d:sa.pL<*arln^ at last, hoverer
withcat leaving behind either maculzxf cr soars.

DiAG^osTS. — Although the characterstio carks of tae sercnl
forms of acne have teen alreadj mentioned, i: mnst be remecnbeicd
that there are rriinj ni:rc:d coziiti.-ns in the c.:*ir^ of wnicj^ arse
in!Li:nnia:icr.5 of the hair f.lliol-rs ar.I 5t::a:ecu< /unis, wiuhoot

•-'-J. -ir: — ^ j.-.r t^.- ^c^..liI.c I-.r v. ■.. I^ ■ >r. _. .J.^ acnilo

C-va-o---* ..-^? ► - V. "— -* JvT- . c*»." . .-1. .",..;. v.. • ._..: 1 ^ "1 »"•-,:■

• « » .- . . .

L. . .•-0?C^« its »A-.*-— I V. « ?• ^ :, >, .^..'m* -..'v i.>v -■, ■...■.•*»" < * ~-- ^

•• . ::^- — -»--« AMk'jt DC

IS but port c: the wh.lo uh<:x<<: : • " :.:. v:hir.i::c::<:::^ ^,f
maladr shool-I t< tj^^n i:::o cvi-si/itrr.::-. M.:..7^r. the
inpottant differences between such allied fornis viilj cc:;:e oafc ■
the hUr stages of the disease, and th-is continued cbserraiion m

DIAGNOSIS AND ETIOLOOT. 289

D enable Ibe pbyjician to arrive at n correct diagnosif, wlucb, at
^ sight, irouli] liBve been impossible.

"SriOLOGT. — No one liaa yet succeeded in discovering the exciting

of acne, lu fact, with tliu RKcqitiun of a few cutaneous

tant?, which appear to work only under ccrtiiin conilitious, and

lin persons, we know very littlo of what will produce it.

IruH lliat in works nn cutaneouii medicine we fmd mentioned

cs of acne ccrlniu articles of food, strong emotions, iniiilnl

, morbid innervation, or torpidity of the organs of the skin.

t lUe^c utateintnla arc mostly lubilrary hyjiothcses unsupported

uiy biisis of fact.

considers certain trades to be especially injarions "in
1 ibe bead must be kepi bent, and at the same time exposed to
i{t;h tcmpcruturc." ^Vilson lays the blame in some eases on
iking cold water when (lie body is heated, in olhers, on the
! of irritating washes and cosinetics: while Brender thinks
; tobacco is a cause of the disease. Knyer says that acne
s among youtba who practice onanism ; Atibcrt, among persons
devote themselves "aux combinations speculatives," who
gamble all night, or who live in constant anxiety ; while Fuclis says
he baa often seen it accompanying gout; and PIcnck expresses a
nolioQ widely spread among the common people in the words,
"Juventibus victu crasso utentibus ct sprrmaticis sunt familiarea
vari ; circa adolescentiam cvanescerc solcnt."

How far these hyjiothcses can he substantiated, we must now aeo;
and I will use for this purpose statistics founded upon the numerous
coses of this disease which I have myself observed. It appears
from these that acne does not oftm occur before puberty ; that
persons of cither sex may sull'tir fronv it after the age of fourteen,
but that it most frequently occurs between the rightecotb and
twenty-fourtli years. Inflammation of one or more sebaceous
folliclrs may be observed from time to time in the later periods of life,
and there arc persons who sulFer from acne all their days. The fact
tha t wc find coses equally in all climates, and among all nations,' at
y season of the year, and in jiersons of the most diverse occu-
Ibns and modes of life, in the rich lis well as in the poor, is surely
ipg evidence that none of the con<.litions supposed to be produc*
I of BTDC are its rral cause,
kbovc ail, I tnuft express my utttr disbelief of tlie liypotbesis

I r-VrPrw

mlliiiltL d« Oii(

,' Etiangcn, 1)147.

:!W ACXE UlSSkMlKATA.

thit atae tuj be prodnccd hf the oje of cettain food — of salt
oucd fitfa, cspttaaSj barings, of smcAed taaa, strong cheese,
nlad, or uf dnh oonUiniDg tiaegaiar pnpnol vitli tiat condi-
MHnts, as prpp«, capacnin annmini (Hangsiiui paprika), ^ger,
■nd K) on. Xor i> the usertioii better foimded that the excessive
nse of •kobolic dtinks m a csoae of this disease ; it has arisen no
doubt from tbe too common confoondiog of nmple true acne [A.
ii m t aunata) witb A: rotaeta, vlikh maj do doubt be the result of
ialempoance. Tbe fitci u that dram-dr^en possess a most beauti-
ful, smooth, and ddicate skin, vilh the ducts of the hair follicles
acarcdv visible, and, of course, noslopt br plugi of sebum : hence
tltey are tittle disponed to iaflame and produce acne-nodules on
the bee, breast, and back. At the same time, there may be in
these cases a splendid specimeu of " Bacclua " {J. roiacea) on the
nose, cheeks, and chin — an additional proof that these two maladies
ure not produced by the same causes.

The circumstance that acne appears most of^ about puberty,
when certain changes in tbe system accompany sexual development,
was probably the origin of the opinion that a certain alternation
ekiets between the evolution of acne and the eiercise of the gene-
rative functions. But the results of unprejudiced observation do
not at all support tliis view; there are cases enough of persons of
each sex addicted to excessive veneri', ivho exhibit not a trace of
acne; others, again, who show more or less of it in its favorite
regions. On the other Iiand, we find the skin of the face, chest,
and back sometimes perfectly clear, sometimes covered with erup-
tions thick as the starry heavens, in those who are unmarried and
have never practised onanism; this apiilies to both sexes, but is, of
course, more easy of proof in the case of women, I cannot, there-
fore, iigree with Plenck's dictum, " Matrimonium varos curat," but
would rather say, " Tempus varos curat ;" for, in course of time,
this iuflnmmntiou of the sebaceous glands and hair-foUicles,
occurs mostly about puberty, will reach its end, and that just
suroly witli bachelors and vestals as with married people.

It is, however, indisputable, that collections of sebum on the scalp,
face, chest, and hack, together with formation of comedones, and
llieir necessary result in acne, frequently occur in connexion with
disordered menstruation, and disappear when this function again
becomes normal. But w*c cannot mention any definite afTection of
the uterus or ovaries which would cause the more or less frequest

:ime,
'hidij

KTIOLOOT.

291

B of acne. Indeed, the fact that acDO is met nith ju<t a«

ireqacntly in men as in women, n-jtUoul the slightest irregularitj'

I the MxDal functions bting observable, would nlone forbid our

wing any coiiclusinn a5 to the d<'|)endence of the one phenomenon

mpon the other- I, therefore, simply register the occurrence I have

tnentioned aa a coincidence

I must not omit to mention in this connexion an observation

^hich Professor Riglcr (now of Cratz), who lived for twelve years

D Constantinople, made at my rcqaest and communicated to me by

It is well knonii that the inhuman cuslom stilt exists in the

ut' of castrating, while still youiig, those intended lo serve in the

{fauem; and of these Professor Rigler remarks : "I very rarely saw

me in eunuchs," while be also states that acne disseminata is

rery widely spread in the East, tiiid may be frecjnently observed

^nong the dark races as well ns the whites,-

We have then only to mention [ireparationa of tar as certainly
Mpahlu of exciting acne by thctr action as idiopathic irritants, while
lymptomatic acne may be produced in the coarse of certain general
iiieascs — scrofula, scorbutus, syjjliilis in its specific form — or hy
\hc internal exhibition of iodine.

jVn ATOM Y.— Careful ob»crvation of the origin and course of a
ingle acue-uudule is enough in most cases to lead to the con-
Enction thai the seat of the disease i* the hair^fullicle, together with
fttiie sebaceous glands which open into it ; for either a comedo may
: seen in one part or other of the eruption, or, if not, a hair-
Ibllicle opens in the eeulre of the acne nudule, from which, firsti a
Jilug of st-bum and epidermis, and then a little drop of pus may b<:
' cooncr or later squeezed out by moderate pressure. This view ix
also supported by the following observations. Acne is often accom-
panied by comedones wiibout so itifiammation round Ihem, ond by
^Olher alTectinNs of the sebaceous glands, as seborrhoia; oAcr an
Ittock there remain depressions in the skin, like the scars following
mallpox, whieh, of course, do not affect the epidermis alone, but
^int to a loss of substance in the corium itself, with dettmctioo

* Etod at Romo it wu tli« custooi to csotrtt* eliiidrcn, ia oHor to prcaorre
eir *iHcct for stuging nl S. Pettr'», .os lale as ilia time of CleniBiit XtV,

kid iIioueIi this [lOpe forbad Ike prseticc, it coiiliuueil lung oTicr in vatioua

}>tls al Ilslj.

' ~ ' Die TtUkcl imd dertn Bewolmer,' ij Dt. Bigler, Vivnon, i8g>, vol. ii,

AONK DISBBHINATA.

of the hair-foUicle, so that no hair grows, aiiA no scbni
upon these spots. Laatly, acne has its seats of predilection
those parts of the skin wliere the fuUicles sre largest and most
numerous, while it companitivrlv spares other regions less sbundiuitlj
supplied, and never appears where they are entirely absent, as J
the sole and the pdin.

The inflammation of the follicle appears to be caused by the d
tents of the gltnda being hindered in finding their way out, aad 1 .^ .
like say other foreign body, causing irrilnlton, which in its tum
leads to a disturbance of nutrition in the cntaneoas tissue surrotind-
ing the foUide. The suppuration which foitows explains the r
and pain of the iiiUatned spot and the otlier phenoinena accoinpi
ing acne which have been already detailed. The pus, I repea^l
notj according to my bchef, the result of iufiauunation, bat, OD I
contrary, the redness and swelling of the acne nodule ore CMsedV
suppuration in the substance of the cutis. This
the simple fact that long before any pus can be discerned in fl
uodule even with the hdpof aleus,its presence can be easily demon*
strated by a vertical incision through the more superficial layers of
skin. The amount of pus is often but slight, so tbnt it can only be
recognised by microscopic esamination of the blood exuding from
ihc iucised nodnle; but in every case, without exception, there will
be found on repeated iuTcstigation more or less of the detoestaa'
pus mixed with this blood and sebum.

What has been here said applies chiefly to those forms of ■
vhicii 1 have uieuttoned under the names A. rm/jarit and A, o
formu, where the cause of the inflammation lies in the secrcttoB
aocamnlaled tn iu own gland. la J. tadtHkonim en the conttary
this sebaceous plug is wanting, and ben the epidermis Uuing t
follide appeal? to be abaormally derdoped, and »o to t '
irritatioD, which leads to inflammation of the parts aroand.
artificial forms of acne, and especially in "Tar-aroe," we ob«
that the place of the comnto is occupied by a minute qoantil
which mechanically slops up tbe excretory duct of the hsir-If
and has probably penet rated Jar enough into it to set up it
imtatiun. But how acse b produced by tbe i
what rdatioB the druj; whru takca intercaily hem i
of tbe skio, and cspc<:ially to lU ghmds, I a

1*800X0919. — AcDC is a' "
naey, and from its li

bere wrjll *
noestaoFj

ioTb^I

LmHUH
s«:rettnR ■

D qmteu
ingaBbe'
ftud mewtd oQibt

AVATOMt AND PROOSOSIS.

293

curt

^F 1

!ed a cousidcrable time for its coniplctc involulitin, U uiaj be aaid
genernllji tlmt rcBistauce to remedies, and long conliiiu&nc« of tbc
disease, will be directl,v as tbe nmoLint of eruption ; so tlmt cases of
A. vtdgarit or d, caeieclicorum, Bccompoiiicd by a smnll number of
[lapulcs and j)u»lulea on the face, breast, and back, vill not last so
long as those in which they are u«mefou». In A. arlifidaUi, on
the contrary, tbe amount of eruption has no such importance, fur
it usually is spreading in one place nhilc it heals in another.

As fur us tlie iinal result of Ihe disease is concerned, the prognosis is
always favorable ; for it never eiidiuigers life, and in the great
majority of caaes, after lasting for a CCTtain number of months or
years, dii<appears either completely or leaving cicatrices which show
there has been loss of substtince. Ts'or does the occurrence of acne
in the course of scurvy, tuberculosis, or any other cachexia appear
lo modify the Utter for the better or the worse.

But since it is not everyone who will patiently await the spon-
taneous result of an attack of acne, the physician is often ex-
pected to fi^ivc some information as to the probable duration of the
mftlady. Under these circumstniicrs it is well to remember that a
favorable prognosis will rarely be justified by the event. A rapid
cure can only be promi»ed in those cases at the utmost in wbicb
^ timplej! or J. rarioli/itrmit has not reoebed too great an extent,
those caused by known external irritants, as iodine and tar.
all other cjise* both doctor and patient must fortify themselves
ill a proper amount of endurance, retnembering that aeiie is, from
frequent rehipscs, one of tbe most troublesome and obstinate of
itaneous diseases.

Theatwent. — When we read the sort of treatment recommended
in works on dermatology, we might conctnde that nothing is easier
than to remove a folhculnr iiifliimmation which deforms the human
skin, and to banish acne from the face where it so sorely tries the
of youth. But as soon as the measures which are so much
ted come to be tried in practice, we arc quickly forced to the
»ite opinion, that there are few tasks more difEcult than to get
r the divers forms of this disease. The true conclusion to be
a from Ihe dictum of Cclsus, /jene ineplia tunl curare raroi ;
the advice of Plenck often given to young men troubled with
!, by physicians accustomed to cnre internal complaints by help
virtue," malrimonivm xaroa curat; and front the dccbiraliun
surgeons that it is ridiculous to trouble onerelf about the

cure of " piuii)lcs" — is, not that this disorder is wth^r tiui^
or harmless, but, poru-ly and simply, tiat tliese writers renily t
know any certain remedy for it, and so sre accustomed to hide t
ignorance under an affectation of superiority.

I must myself confess that, in spite of many efforts, I hove D
ancceetled in finding u rcmeJy by which ncne can be prerented f
developing itself or quickly got rid of when once established.
object of oiir art sltould be here to reduce tlie cutatieons glandt
tbeir normal function, so as to prevent their taking on that iafli
matory action which lies at the root of the disease. For irlico t
an acne-nodule is formed, it soon comes to an end of it«df ; '
few of them fail to uTidergo involution, by suppuration c
liou or Gxfyliation. But I repeat that I know of no men
ternal or eslerual, for even retnrJinn; the formation of acne-a<
At the same time I do not despair of such a remedy being some i
discovered : and this is the move probable since ive know that 1
arc able to produce inflammation of the follicles (by the i
iodine fur instance), while on the other hand excess in spirituous
liquors leads to such a state of the sebaceous glands that their con-
tents are kept liquid, and thus do not accumulate in the doc tx
This will of course be unfavorable to the development of acoe, i
accordingly we may set down alcoholic drinks, and brandy espedaf
aa internal remedies against acne dlsscminala.

I have, however, always found the drugs commonly reoommei!
in its treatment to fail miserably : such ns emetics, piu^nlid
Arsenic, the freshly expressetl juices, extracts or decoctions of tiiu
coucli-grass and dandelion, whey, sulphur -waters and antiphlogill
and derivative remedies generally. Onlv in the case uf A. *r/^
Mrum can I conscientiously recommend the inteninl use of cod-ln
oil, since I have made repealed trials uf it, uncomplicated bj •
pjitcnial application, and liavc always found tlie practice <
with success. In the same way, when acne occurs in scorbutic pBti
u treatment directed against the constitutional complaint wtU a
lead to the disappearance of the cutaneous discitsi

The uselcssBcsa of internal remedies against amr compels ns"!
resort lo local applications. It is obvious that n
fici:J layer of epiJprmis, wluuh ia do»ely i^onnci I
the cnlaneooa glands, will also lead to tho remo^.
so make tlie duct» at t he bair -follicles agiiin {iilcnt, a
aaoe to the nocumuIn||fl^^Ht nml (hud at lemt i

TREATMENT.

29S

taini

■ a„l..

source of tlie diseape. All applicationa which soften the cnliclo
influencing its chemical composition, and which exercise slight
imolus on the papillary layer that eccrctes the ppiilermis, will
ffer this ohject.

Accordingly the regiecitetl and prolonged me of ordinary hatlis in
me of acne affecting the brrast, back, &c., and of vapour-balhs
the fpjiip is also atlnclccd, with soap applied as usual iu washing,
commonly he attended with some success. So for as mineral
have any elfect at oil, it is not to be ascribed to (heir conslilu-
I, of nhiitcvcr kind, but dimply to the softening influence of water
U upon the epidermis,

the various applications generally used in (he treatment of
!, I will first notice the diiferent forms of aoap. When ordinary
ip is used in washing, Ibo free alkali always contained in it will
cIbc coHMdcrablc power in softening the cuticle. The choice of
fort rather than another should depend either upon its greater
convenience and mildness, or upon the presence of other eonstituenta
which in the so-called medicAled soaps assist the action of the alkali.
Liquid soaps can be more conveniently and uniformly applied than
solid, and those made with potash nre more active than those con-
taining soda : hence a soft potash »oap is the best that can be used.
"lie preparations known in commerce as fluid gljcerine-sonpa or
\ultne- cream, and the alcoholic solution of soap which I have
ed Sjiiri/ii* MjKmaliit alitiiinni are particularly valuable for
reason ; as are also the medicated soaps which contain sutphnr,
sulphur ami pumice-slone [Sehwe/el-SanilKtife) or sulphur and iodine.
But whatever kind of soap is used, it must be thoroughly rubbed
into the skin in order to attain its object. For this purpose it is
best to use strips of flannel, upon which a lifjiiid soap must be
.1, or a solid one rubbed aTler being moistened with water,
anoel must then be nibbed hard over the skin.
cfTect may he increased by leaving the dissolved soap in
form of soap-Buds upon the skin fur some time, during tJie
;lit for instance. Only it must not be forgotten thot all soap not
softens the cuticle, but uho irritates the true skin, and hence
not be employed for an indefinite length of time, unless it is
ided to produce escorlution. It will therefore be advisable to
soap regularly for three or Cour days and then to omit any
application for an equal period, until the epidermi!) sofi«nod
has been east ofT in flakn.

I The <

ACXr, DISSEMINATA.

Wheu

n(. tacks extensive

r^ons of tlic boiJr, batha coutn

soap arc of valae. But e\-en tliea the cffi-ct of the troatment i
be much increased if the affected paiLa are rubbed with soaped
Uniinel while the patient is in the lath.

Sulphur, which is so celebraleil \a the tj-talraeiit of ncne balh ia
the form of asoaj) and aconsfituent of aaturul or artificial baLbs, bu
I am sorry to say, not proved to be of the service its partisa as would
have UB believe. Stilt, we must often use it, because experience has
not tangbt us anything much better. Iodide of Fuliihur f'Brit.
Pliarm.,' i86;] acts locally as a strong irritant, and was esteemed ai
a remedy for many cutaneous affections, but particularly for bcuc, by
Alibcrt and Bielt as well as by later jiiiysicians {Cozciiave, Scbedel
Kayer, Veiel, Wilson). It is indeed trno that lliia compound prodi
rajdd desquamatigii of the epidermis by setting np a supet^oi "
Hammation, and thus often acts favurably. But inasmnch ;

cannot prevent the formation of fresli acne-nodulcs, it has rro t

to precedence over the applications already nieutioned, which set
in the same way.

The corrosive action ot percktoride of mercury uiion the skin J
earned it a not undeserved reputation in the treatment of een
cutaneous diseases. According as an aqueous or alcoliolic solul
is employed, according lo its degree of concent ration, and to its
plication as a lotion or by means of compresses, will this prcparatij
vary in the intensity of its action. As a general guide in it»|L_
we may lake a strength of a quarter to half a grain to the ounoa3_
suitable for lotions and bandance ; and this will not affect man: tlian
the cuticle, the superficial layers of which will be thrown off iu the
form of minute branny scales, If a more powerful action is desired
the proportion of corrosive sublimate in tbe ounce of water, alcohol
or collodion may he raised to five grains ; but the solution must tbca
be used with great care, and only wlien the pliysieiun can be present
to apply it himself and watch its cilret¥. The parts which are to be
deprived of their epidermis should cither be painted several limes in
the day with the solution, or covered with bandages soaked hi
it for a time not exceeding four hours, if ihe same eiftct is to ba
attained quickly. By this means the epidermis will be raided into
bhstcrs of varying size, nud wiU m ti short lime be culird/
st'parated from the snbjuccnt cutis.

The effect of thin pn'p;iratioii in curing ge^^HttA||Mn) il> sepa-
rating from their attachment* the epidrni '

TBBATMBNT.

297

see
I Alt,

tliu hair fullicles by ile3trDyiii<r the siiperfieiul layers of cutioir
bich, as is well knowu, tbey ore closely united. Hence if the
:lu3ioii of tbe hair-folliclca Jepcads upoa abnormal coUcction of
ibum nnil e[)iilermi9, they will be set free by this process, and so
ic anatomical conditiou which has led to tbe occurrence of acno
ill be removed. But seeing that this trcatineni gives the patient
lore trouble for a time than his disease itself, especially when the
incentrated solution is employed, that it is always jiainful, and that
cannot produce radical cure of the acne, it is well not to have
Kcourse to it so often as to the metboils ro be presently described.

The oricnlats arc accustomed to employ a combination of corrosive
sublimate with albumen' to beautify their skin : and as the former
ingredient is only in small quantity it dues no harm and often is
most successful in ita effect. How far ita repealed and long-con-
tinued use may lead to further ill results, my own cspetience does
not enable mc to decide.

The action of tindare of eanlharidc* and lincture of iodiiu re-
sembles that uf concentrated solution of corrosive sublimate, i.e.,
their repented npplienlion dcitlroys the superficinl homy Inyer of the
lidcnnis. Thry have also the same disadvantageii, since tliey are jast
unpleasant to tbe patient and do not effect a permanent cure.
The good effect aliieh the ordinary mercurial platttr has in
diminishing tumours and eruptions, of whatever size and whether
or no syphilitic in character, explains why this application hiu been
nsed ill the treatment of acne. Dr. Uidor Neumann bus made
trial of it in these casca and found tt to be of service.'

SocharJ disputes with Hardy the priority in emplovittg prepara-
tions of iod'tiU of mereury i and uhile asserting that he recommended
as early as the year 1847, keeps still the opinion he then expressed
it very successful results have bc^eu obtained by the use of oint-
its containing the prutiudiile or tleutiodide of mercury, according
the formula given at p. 4^. I must, however, confess (o my

' Tbe fonnuU is as follows :

P HjilrBr^jri perclilnriili, Jj \
AiuicdcalilUtit, Jiv;
Ovorum xxiv *ibuni«n ;
Sueci cilri (f. t. UiIk Medicr), Jtij ;
Succbari nlbi, Jriij. U.
Eigna Aqui enmetiCu arienlali!.
' rU* ' ZeiliClirift der k. k. QeselUoliRft dor Arnte.' Vunna, 1864.

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r.'^Ay.itT zj 13 icccc-t :c 'Ji!» ziuiiea :£ :r*arx]ec£ wifca I hare

In lit inz 1 j«, ev^rj':*:!!;. izii scsc cc al & person aflected
x>.;. ac-f^. •/.:ali 'i*^ cariiil :■: k-it^r: Li* skin scr^pil-ruslT clean, and
r.'.r ".r..- v? :- :.•: ■! :: tij;, :'-.r iizi* ilzze. ':i: ilio :"_e :'jce, and
T?. r. -•-.-■• '/.- "..-: V::£ -iz: :;.■?>: i.« t^I'. 1: Ifjs: :r.:e a dar. and

.',..;* ',.- ^j.',''f>--> f.cj,.r^:'ii '-'*■■ '■. ■ *, cr .".r.v s-i'ivl s.:;ip preferreJ,
;j f I ' r '!:;;■ i r. '/ i * a > o i .'» v ^ :« : r. T;. r- :1 1 :. n- ■ I t r. ■.:? i ■ r: pregaatt d ir it h
yo.'ip ri.'jiii'l \if x\\\i\jf-A fjS'.r iLe ?k:n, ar: 1 l::.it Irisklv, since the
iu»f.\.;xu\(:\\ \,T( -yMTi: i? of coiisi'lfrr.'ib'.e service in rtmovirg the pluss
tS wl,iirri \\\\\(\\ ob-trrjrt tlio f'.lliclfs. IT.e soap should then be
Ui'j l.'vl oir wiih wfitr-r; aiifl to prevent the tension of the skin
V. liirli iri.'iv foLo'-v, t\\\\fT ri litil': I'lvrt-rin'-, cold crt-nm, or anv simple
i,\\\\\i\i-\\\ .-hould \if ;j];p!irrl, or if tiii:* is ikjI well borne, some eartliv
|»o\\dirr-nr|i JIM pumicf stoiw, Vi nice tjilc, (>v ],nlii.^ ahunhiis jjlinnosva
(;i' Im-.1(ih;. It i.i l)r>t to \\\iA\ jit ni^'lit, h(causc the redness of tlie
ikin viliirh is jirodiirid hy tin- rubbing with flannel, takes some
jittlr tiiiif to (lisiijipcar ; and many ];atients dislike this in the
rnriitT Iioiifh of the day. The application of oily prepantions is
I I iilfin fffoniinrndi'd n't Im' nblc to the pat' Voglf

TREATMENT.

In cases wiiicli need something b^ond mere wasliing with aoaj),
tkU should be followed bj the application of the following sulphur-
paate, bjr means of a cnmers-hair brush.

El Licliaa
Potusn

M«<

in pr(FCipi(ali) ;

Gljcemi;
Aquie lautoccnii ;
Spiritu* villi Gdlici, ana 5>j.

^^^P Thix shoald be left all night upon the skia, and washed off next
I morning ; not with saaji, but with aglulinotis lotion, obtained by

pouring hot water over brutFcd almonds, and used lukewarm. After
this pflsto has been applied a few days in succession, slight reaction
follows in the form of mild PUffrianU riihra : it must then be intcr-
milled till this has disappenrcd, and meanwhile Wdsou's zinc-oint-
mcnt may be used as described above (j). 149).

While this treatment is going on, tlie ucue-nodulus should be
scarifled in good timej before their contents become yellow and
purulent. As soon as a red tubercle appears, it should be incised to
the depth of one or two lines and allowed to bleed.

The u.*e of ordinary baths or, whin the disorder altacka the face,
, of vapour- and shower-baths, will he of imporlnnt service in assisting

^H^o measures.

^^HT Another method of treatment is by sulphuretted sand-roap or
^^^Hbdiscd sulphur-soap : a piece of one of these is moistened and rubbed
^^^6lto the skin until a lulber U formed, whieh is nlluwrd to rtuwin all

night and only washed off next morning nitli bran-water.
I III using corrosive sublimate, one of its sohitioua mentioned above

^^Hifaould be applied once or twice a day with a camel's- linir brush or
^^^Bb piece of sponge, until cither an eruption of vesicles follows or
^^^Bunpla desquamation. Then all treatment should be suspended, or
^^^Vilsoii's zinc oiutmcntmay be used. Mercurial plaster mny be aUo
applied during the uight, followed by washing with soap in tlie
morning.
£ut whatever special treatment be adopted, it can only be snccess-
1 if, when once begun, it is sedulouaiy persevered in according to
I rules above laid down, and with such intermissions as the state
Ithf skin mnv from time to lime demand.

chapteb inn.

5TC06I5.

HiSTOEY. — The tersLs sjcoeis, &k»x5« menugra, bchai menti^ are

found iu maziT cf the vcrks of aixzent and medneral vriten. But
from their descriptiozLs it is quite eridcnt tliat tbcj do not refer to
the same affection vhich at the present dar is known bj theK
names. Thus, Celsos, vho devotes the third chapter of his sixth
book to sTcosis, merelj says that this disease vas named 96Kwaic by
the Greeks on account of its resemblance to a fig. He expresslj
states that it occurs chieflv on those parts vhich are covered with
hair, and especially in the beard y.^ixLu im iariii). But his detailed
description of svcosis disa^ees eniirtlv with the affection which we
know bv that name. Celsus applies this term to hard and round
sores, or to moist and uneven ulcers, secreting an offensive matter
in trreater or less quantity.

Pliny states (Lib. xxvi, cap. i,) that in the reign of the
Emperor Tiberius a disease which in Latin was called mentagra, in
Greek lichen, was introduced into Italy from Asia. But both
from the works of Pliny, and from the satires of Martial, it would
appear that this complaint occurred chiefly among the higher classes,
and that it was propagated by the habit of kissing (Kiisswuth,
lasium, hasiare)}

Galen,^ after describing acne ('l)e Varis'), passes on to speak of
tumours resembling figs (* De ficosis tumoribus '), and of other
cutaneous diseases which attack the chin ('De lichenosis in mento
tumoribus,' ' De raenti tumoribus ') . But his description of these

> Cr, ' Mart. Epigr./ xi, 98. " Ad Bassuro de i^pQCtnil bisiatorilms."
» • De Comp. Med. sec. loc./ lib. v.

STCOGIS. 301

iffectioiu is quite aphoristic j and, if it were not that tliey have a
sjwcial seat, hia account of them would be just as applicable to any
other cutaneous diseases.

It is very ]>robRbtc that njcosis wns formerly coiirounded with

certain syphilitic affections, niid eaiweially with those which arc now

known by the name of "plaque/i muqiiemfs" (flat condylomata},

I tnd which arc really not nnlikc the tubercle? of sycosis. Botli

nvlicr and later Latin writers very rre<|uently speak of ficosis nnd

ifcoais in connexion with piles;' and Aetiua and others mention

e disease as occurring ad anum.

Piulus .£gineta, again, describes tuider the name of sycosis
iffections of the eyelids, lo which the name of rpa\t»na had been
iplicd.

Xone of the writers of the Araliiau School give an accoant of

■ntagni worth quoting. The phyeictnus of the 17th and i8th

centuries — Mcreurialis, Lorry, Sauvagcs, — in their definitions and

descriptions of the disease, merely follow the writings of the

ancients.

Plenck says of muut«gni, " Est jfeciiliarU »cabie» circa nicnlum
Wfua ill critttU abit." We distinguisliea a M. venerea, M. leprosa,
~'. infantum, M. Pliuii; bat no one of these varieties answers lo
' oar sycosis.

Even Willnn has left to us no direct account of the disease. It
was Thomas Bateman, his successor and the editor of his work, who
first gave an accurate description of sycosis. Hia ligore of it (pi. 6 j)
represents a disease affecting the chin and tho region of the lower
jaw, and characterised by the formation of tubercles and pustules.
To this he gives the name of tycotin mend ; distinguishing it from
the fycoiis capillUH, ri-presented in plate 66.

In the German translation of Bateman's work by Caiman (edited

^by Blasins, with additional notes), wc find at p. 379 the observation

" the eruption sometimes attacks the external genitals." From

BliB remark it is quite evident that Bateman was thoroughly familiar

■ith the nature and seat of sycosis.

T Alibert describes it under the name of "Dartre pustuleusc men-
■e " {tltrpet pvslnloitta MentiiQra), aa one of the species of his
mas "Dartre pustnteuse" (flerfien yHe/u/onini) . But although be
1 plate 20, a pretty nccumli: SguK of the disease, it is qniti;
Hd^nt, from tlie corrcapondmg letter-press, that he had never care-
' Cantontor tamiilie meilico liJente mnriscie,' Jlarliol.

30'2 SYCOSIS.

fully observed its peculiarities. In his later work, ihe ' Monographic
des Dermatoses,' translated by Bloestj he mentions it as the sixth
species of liia genus Varus, under which name he groups together
the affections of the sebaceous gkuds.

The later English and Trench writers have adhered to the vieTts
expressed by Bateimn concerning sycosis. They have published
but feir original observations or investigations in reference to it.

I may, however, quote the following passages from the work of
Samuel Plumhe :' " It (sycosis) really consists of a number of small

abscesses Every little tubercle should be punctured at its

first commencement, and every hair extracted from the part, which
may be removed without mucli pain. This practice striclly followed
up, is capable of removing the most protracted and troublesome
cases without the use of any internal medicines beyond alterative
aperients, and any dependence upon internal remedies unassisted by
it, will inevitably lead to disappointment."

Unfortunately, neither the countrymen of PJumbe nor his foreign
contemporaries paid much heed to his observations. They have
chosen rather to adhere to views of the diagnosis, etiology, and
treatment of sycosis, which, although they are commonly held, are
nevertheless entirely incorrect.

Thus, in the ordinary descriptions of sycosis, — and iu reference to
this matter I will merely quote two well-known English dermatolo-
gists, Mr. Hunt,^ and Mr. Erasmus Wilson,^ — we read that it is met
with in both sexes, that it is not confined to the hairy parts of the
face, but attacks likewise the eyelids, the scalp, and the axillte, and that
the pustules of this affection have a special form, contain a pecuhar
kind of pus, and are to he distinguished from those of impetigo
and of ecthyma. The origin of the disease is ascribed to the use
of blunt razors, and to other absurdities. The treatment from which,
according to these writers, good effects are to be expected, consists
in the administration of iliternal remedies (principally arsenic and .
ciJomel), in venesection and the employment of leeches, and in the
iipplication of poultices.

As a rule, the same may be said of the French dermatologists.
These made no searching investigations so as to increase the existing

' -A Pniclicul Tioaliae o
1837! pp, 65. 71.
■ Oi>. cit., p. 105.
* Op. cit., p. 7li.

i of iLe Skill,' second eJiiioii, Londoo,

IknowIeJgc of tbc rcul nature of sjcosis, nor wen- tlieir views in
Kxegardio tlieeliulo^yniidthc treatment of the dieease &t all in advance
P-of those professed by Samael Plumlie, wliom most of tliem very
unjustly depreciated, ^'eitlier Biett, nor bis pupils Cazenave and
Schedel, nor, again, Rayer, Chausil, Duch'.'sne-Duparc, Gibert,
Bocbard, or Devergie made any considerable progress in regnrd to
the theory of sycosis. Almost all these writers denied that the
affection had ita seat in the hair follicles. They also drew distinc-
tions between its tubercular and pustular forms. In fact it is quite
1 evident ttiat they had no well grounded conception of its nature,
■Their attention was mainly directed to triHing alterations in its
KMme, and in its place in their classifications. They made no clinieul,
' microscopical, nor anatomical observations, on which a successful
plan of treatment could be based.

In the year 1842, Dr, Gruby ' [mblishcd his observations on
vegetable parasites, and stated that he had found in sycosis a fungus,
to which he gave the name of " Meiilagropkyte," while he de-iig-
nated tiic disease " Phylomentagra." Tlie fungus he described ns a
peculiar crjptogamic plant, growing round the bulbs of the hairs of
I Ihe beard, and particularly those of the lip, chin, and cheek, and
I penetrating into the space between tbc root of the hair and its
sheath. * Tlie affection caused by this parasite was said by him to
consist in the formation of grey or yellowish scales of epidermis,
somewhat convex in their centres, sbghtly depressed, and irregular
at their margins, and traversed on nil sides by the bairs. lie further
stated that these scales " are but slightly attached to the subjacent
ekin, but adhere firmly to the hairs, so that wlicn one removes a
scale, the hair comes out with it."

It is evident, however, from the description given by Gruby, that

I the affection which he had obsen-ed, and to which his investigations

refer, was not the sycosis that wo are now concerned with, but most

probably a macubr form of Herpes tonsurans {Trichophi/Uni tomu'

rans, Malmsten), a disease which, as is well known, may occur ou

iany hairy part of the body, and is not necessarily confined to the
Wilp.
Bazin, again, is of opinion that sycosis is caused by a vegetable
barosite. He' speaks of the complaint under the name of T. men'
I

tj'

0», Mod.,' 1641, 37.

Rcdierolioi tur la Natare cl It Tmiicmciit ilos Tcigact,' f ttu, 185^

SOl SYCOSIS.

tagre ou tr/cosiqite, as one of his five species of Teigntt. But the
affection described by bim, instead of being identical nitb that of
Gruby, is, on the contrary, precisely what is ordinarily called sycosis,
at least if one may judge from tlic ligiire which he gives of it. He
repeatedly mentions, too, that pustules and tubercles sre formed,
and that the hair-sacs are inflamed io this disease. Turther on '
he states again and again that he has extracted many of the hsirs
in cases of sycosis, and that he has detected the presence of the
peculiar fungus. At the snme timr, he admits that all the
hairs in cases of sycosis are not affected wiib the parasite. Finally,
he remarks' that the fungus in mentagra alters the hairs themselvesj
that it is not to be recognised by any outward appearances, but
that it is "complicated with pustular inflammations, and (in its
later stages) even with fungoid vegetations round the base of the
hairs." I must confess that my reasoning powers are unequal to
the task of reconciling the discrepancies in these statemeuts.

The views of Baztn have found warm supporters in Anderson,*
of Glasgow, in Robin, Hardy, Peftis, among I'Vench dermatologists,
and in my own countrj-man, Kiibner.* From the works of these
writers it would appear that they conceive themselves to have been
the discoverers of the fact that herpes and one form of sycosis
(sycosis parasitaire, biotige Trickomi/cosU of Kobner) are generated
by the same vegetable parasite.

Now, although I have no desire to appear egotistical, I am com-
pelied to draw attention to a paper by me on Herpes Tonsurans,
published so far back as the year 1 8 j4, in the ' Zeitschrift der
k. k. Gesellschaft dcr Aerzte." In this communication I quoted b re"-
mark of Plumbe's, that " to describe them " (spots on different parts
of the body, evidently of the same nature as the disease of the
scalp) "more particularly would he to copy very nearly the account
of the first form of herpes circinatus by Batemaii." I showed, too,
by microscopical evidence, — and I believe that I was the first to do
this, — that there is a macular form of lierpes tonsurans identical
wilb the herpes circinatus. It is clear, at any rate, tbut I antici-
pated the researches of the writers above named, at least so

' Op. eit,, p. 70,

« Op. cit., p. 71.

' 'On iLe Puraiitic Affeelions of tlie Skin,' 1861, London, p. 58.

• 'Klinbclic und ei peri men telle Miuiiriiiingcu aus df r Uermnlotoeie uod
SjphiliJologic,' Erlaiigcri, 18G4, p. 13.

* J:iltrgnr)£ ■%, band ii, p. 473.

' «P o

HI9T0RT. 305

concerns ibc relation between Herpes tonsuraiis and H. cir-
ciimtus.

In the paper just referred to, I stated that 1 had repeatedljr
looked for an BfTpctton of the hairy parts of the face, in the cases
of Herpes tonsurans (Cazenave) which had come under my observa-
tion. But neither before I wrote this, nor up to the present time,
have I ever been able to diicover sach an alfection. And, indeed,
even were a case of this kind to present itself, I sbotild not diagnose
Si/coii» paratilMTe," I should sicriply call the disease a Herpes
lurans, exoctlj as I do when it Attacks the scalp, axilla, pubes,
any other region of the body. The only alTection to which I
lid consider the name of " Sycotta jiaraai/aire" applicable
luld be such as has by Kubncr been termed Folliculitis barbtc, —
one in which tubercles and pustules traversed by hairs should be
present on the hairy parts of the fac«, and in which a microscopic
fungus should be found in the hairs themselves, or iik the epidermoid
lamella; rouud them.

Nor have I hfcn at all more successful in mceliiig with a case of
the tubercular Trichomycosis of Kobner, although I have zealously
looked for it not only in Vienna, but also in the hospitals of Paris
I of London.'

CoDsidering, therefore, how easily mistakes are made in micro-

lical investigations, and that many works on cutaneous disieases

as « matter of fact, conlftin erroiieotis statements, [ shall surely

no offence if I continue to exprrss a doubt as to the existence

of a Sj/eo»la Paranitica, until I have myself seen an instance of the

nff«:tion at some period of its course. In this opinion 1 am

igthened by finding that my own views accord with those of v.

nsprung, G, Simon, Wed!, and others, Kobner, however,

idled lb«! disease very carefully, and therefore 1 must not pass over

researches in silence, bnt mnat state what his conclusions were.

irding to this writer, sycosis presents itself iu two forms. One

' Dr. Kobner oaa pouibi; hare had under hb obsemtion liea
'ted and liirty catct of Sfeoih parotUiea is a xnjilaj wLlcli I cannut
At >n5 rate I cniy liis op|<ortuuitiet, ia living in a ihitrid M ricli in
Witb reference to llio amount of muterial wliicli ii »t mj f»mnian>i, T
y Bij lint, ■ltlinuf;li I ersry jcnr S«c belwcen three unil four Ihtmwiiit »km
:i iLe Gcueril UubiilUI bI Vicuna, jut anioii): ill tUr^e Ibcre arc, Hi
E outride, not mure tbui twelve eases of sycosis sliijuhIIj. Ueno«, during llio
' '\a period of mare tliin twenty ■jrm, during whicii I have lipid mj nppoinl*
L, I tuTs Dot been kble to ttiidj more iban 340 riBni|ilts of tbediwaie.
SO

30(i 8TC09IS.

of these, the afTectioii which has been known by that name
the time of Willan, is described by Kobner under the title of
Folliculitis barlxe. In it no parasite is necessarily present, although
a fungus mag be found at its commencement. In the other form
the affection at first presents the characters of a Herpet tonaitrana.
Subsequently, in addition to the original red spots or rings, there
appear scattered red tubercles or pustules. The hairs which pass
through these present even to the naked eye a certain loss of lustre
and want of colour, their condition thus resembling that observed
in Favus. When these haira are magnified 350 or 500 times, tlie
ordinary appearances cliaractcristic of the presence of a fungus ara
plainly seen.

Another work on Sycosis to which I must here refer is that of
Dr. Gustav Wertheim,^ Primararzt and Decent at Vienna, This
observer has suggested the hypothesis that the disease in (juesfion
is due to a disproportion between the size of the hair aud the
cahTjer of its aac. This view is based on the resulta of measure-
ments of sections of the follicles. The limitation of eycosia to the
hairy parts of the face is attributed by him to the fact that the hairs
of this region have a much greater diameter than have those of the
scalp.

Definition. — I define sycosis as follows: — A disease of chronic
course, non-contagious, attacking the hairy parts of the cutaneous
surface, and characterised by the development of papules and
tubercles, continuous thickenings [xmammenhdnjieHden IxJiliraUn),
and pustules of various sizes, all of these having invariably hairs
passing through them.

The atfection generally commences in the beard. There first
appear a few semiglobular papules or tubercles, like those of an or-
dinary acne, having a little pus in their summits, and traversed by
hairs. These successively develop themselves, at longer or shorter
inten-als, until considerable numbers of them are present. Some-
times they remain isolated, at other times one eruption follows
another, so that they become crowded together and form thickened
patches (lufiltraten), always strictly hmited to the area of the beard,
on which grow long, thick hairs.

When the disease has reached this stage, there is no longer any

appearance of papules or tubercles. Beneath the cuticle covering

I ' ZeitBChrift der k. k. GcsclJBcliiift dcr Aeretc,' r86i.

SrUPTOMS. 307

pas keeps formiiig, so that ^<^w pustiilts are coiitiiiuuUv
■aring, each traversed by a hair. The pus may either he dis-
U|>on the surface, cliiefly when the pustules are opened by
le finger-nails or in other wnya, or it may dry np into tbiii yellow
or brown crusts, which, like the tubercles and pustules, have hairs
running through them.

The characters of Mycosis therefore vary to some extent, according
the eruption consists rather of solid tubercles or of pustules ; and
according as these tubcrcl» or pustules remain isolated, or are
iwded together and confluent.
'Hii; appenraiice-s obser\'ed in this disease arc hkewise modifletl by
the nature of tbe patient's beard, wlictber strong or wcsk ; and also
by ihecJrcumHtunccof bis being accastomed to shave, ornot adopting
that practice. If a part affected with sycosis be closely shaven,
or if the hairs be cut short, there is of course an opportunity of
icing accurately the ehnracters of the disease in its different stages,
in all t)io modiGcations througli which it passes. But when
affected re^on is concealed by a long and close beard, it is only
separating the hairs that one can tliorougbly eiutuiiie tbe disenscd
'ace, or, indee<l, obtniti a view of it at all, so as to si^c whether it
covered with crusts, or presents other changes.
In ci-rtain cases, the progress of sycosis is ac<.-ompniiied by nppear-
;s differing from those hitherto described. Sometimes tbere nre
led eJevations (knollige Hervorragungen], not unlike the mucous
ihes of syphilis ; or htUe tumours appear, which might be taken
boils, were it not around them one can always find smaller tuber-
papules, or pustules, traversed by hairs. In other instances
arise, partly as inde|H;i)dent formations in the lower «tra1a of
the cutis, partly by development from the tnmour-likc eminences
just referred to, or by the coalescence of numerous pustules, them-
selves deeply sealed, a number of abscesses dJMliarging their con-
tents by many small openings, and thus resembling a carbuncle. In
a thin) cIhm of cases there ap|>ear fungating growths, convtitulirig a
sort of 'Cam lur%rian»' These, like the earlier tubercles and
pustules, always have hairs running through them ; aiid when a httle
pre.^sure in made on their sides, points of pus may be seen near tlic

However varions, Ihesc appearances are always nceompnnicd by
I, which are characteristic of sycosis. A diagnosis may, there-
, bo made almost withont hesitation, if one carries oul in all

■iile (if looking for every sjmptom

308

rnten tlin
llUriUM;.

If u ■^coiia u left to itself, to run its course withoat interference,
tlie |in[iulcii, lubcrcldt and larger elevations successivelj sapparate,
•ci llml tliL-rc arc formed pustules of greater or less size, wldch may
i-vi'ii ninoiint to sbsceases. When tlie contents of these are dis-
olmrKcd, llie hniri which remnin ore found to occupy little escoriatioDs
or dciireMniDnR, corresponding to the canals of hair-sacs, which hare
loil tlicir upidermicliningB. The connections of the hairs themselves
nro thu* loosened, and they subsequently fall out, — this process
being fiillciwed by Ihn spontimeous cure of the disease at that spot,
and atten<lcd witit the formation of a permanent cicatrix, sometiiues
flnt, aometiraes raised, on which no hairs afterwords grow.

TliuB, llien, after the sjmntancous involution of sycosis, the part
affcotctl ia elLhiT entirely bald, or covered with but few hairs. The
discnce, however, lias no tendency to destroy other structures, nor to
spread from the hairy to the smooth regions of the face.

But before the complaint subsides of its own accord in this iraj,
a very long period always elapses, occupying many months, or even
reaching twenty or thirty years.

The regions which are most frequently attacked by sycosis
those parts of the face on which grow the beard, whiskers, and
moustache. The eyebrows likewise are commonly aifected, and the
free edges of the upper and lower lids, from which the eyelashes
spring. Next to these come the pubic regions and the mons veneris ;
and, last of all, those parts of the ajiillBC which are provided with
hairs, and the scidp. On the head, however, sycosis occurs only as
a sequela of eczema ; whereas all the other regions are liable to it,
as an independent affection, not preceded by any eczematous
eruption.

Just within the nostrils, where the vibrissEe exist, an affection fre-
quently occurs, presenting all the ordinary characters of sycosis.

Since, as a rule, men alone are provided with beards, the disease
in question is met witli neither in youths nor, on the other hand, in
women.

Diagnosis. — Among the diagnostic signs of sycosis are t^ be.
enumerated above all its seat, its limitation to male patients inwhoiB'
the beard is developed, and its characteristic pajiules, tubercles, and
pustules, witA hain runn'mg through them. Another important fea-
ture of the disease is the absence of ulcerations, of oozing from the

DIA0N08I8. 301)

mrroce (niisseii, madidare) nnil of itching ; for this affords a Tcady
diftinctioa betwc-eii sycosis ami commou acne, eczema, or any of the
(iy{)hiliilfs, — with which affections it certainly iniglit be confounded.
Tile characters nUove ineiitiuneil should therefore be always taken
carefully into consideration ; and wbeiievpr aiiy part covered with
hairs presents {lustules or crusts, these should always be softened
and removed, no <liugnosis being given until the exact state of the
skin itself has been ascertntned. For, in a case of this kind, the
presence of red, rooist patches, denuded of their epidermis, indicates
that tlic ntfection is an eczema. On the other hand, if there be more
or less profound destruction of tlip cutis, if cruets adhere to the
diseased surfaces, if the ulcers have sharply-cut edges, and if Ihelr
shape be that of a kidney or semicircular, or present sc^^ncnts
of circles, — under such circumstances the case is on« of syphilitic
ulceration.

Hut if isokt^d papules, tubercles, or pustules are seen, alt per-
forated by hairs, — or if wc observe those little deprraaions with
hairs projecting from their centres, described above as being left
when the pustules themselves have perished, — and if these characters
arc confined to the region of the beard or tu parb covered with hairs
of a similar kind, — the disease may safely be diagnosed as a sycosis,
and in fact can hardly be confounded with any other ofTeetion,

ProffHotii. — On this head it will sulBcc to say thnt the oidy cir-
cumstances under whicli an unfavorable termination could be appre-
hended would be if, after suppurative action of long stAnding, inflam-
mation of the skin in the neighbour I mod of the parts atfected should
arise, and [uiss into an erysi}ie)as. Under all other conditions, hon-
ever protracted the cose, no ill consp<iuences result, beyond the con-
tinual repetition of the morbid process which constitutes the
disease.

I£noLO0T. — According ns the contagious nature of sycosis has been
pserted or denied, the causes to which It has been attributed have
neu various. Some, including Pliny and Foviile of Rouen, have
bieved it to be propagated by & special contagious principle;
pbcrs, from Gruby to Kiibner, have ascribed it to the development
■ vegi-tabk' parasites in the hairs. Again, like all the forms of acne
fad indeed mnxt other chronic affections of the skin, it lias been
supposed to arise from the presence of r morbid principle in the
blood. Others have imagined that loeiil irritation may produce it ;
I usert that it is evprcially apt to occur in cooks.

310 SYC08I8.

fouiiiiiT", lugiir refiin;™, .itoki-ni, «nd other pCTsons who are sabject
t» tho loDg continued ojieralioii of beat. Krasmus Wilson attnbulea
it to exjioMire to the night air; and it has also been ascribed to an-
cli-aal; liabit«, to povcrLj, nnd tu the use of blunt razora. Among
l\\i' iritiTiiiil oonditioni which are said to jiro^luoe it are over-feeding,
and indulgence iti ipirituoua liquors, or in highly seasoned disbes.

As I have already mure than once intimated, I cannot, either from
my own yxpt^rienco or from that of my colleagues. Bay anything'
to the finistcncc of a conluffiout form of sycosis ; and particnlarly
to whether the fungus which produces herpes tonsurans is, or is
likewise ntpnhle of giving rise to the affection with which
now concerned. It is iint for me to cast a doubt on the obaervatii
of other writers; and therefore I must leave this an open questi
to Iw sellled hereafter, if more favorable opportunities tho\
ari«e.

Itut as for the action of cutaneous irritants, I cannot admit
these ever give riro directly to sycosis. I have never seen such an
Direction product^d in the first iustntice, immediately after tlie appb'-
cation of an irritant to the skin. I allow that aU the characters trf
sycosis may be presented by an eczema of long standing, when it
alTcots Uic hairy parts of the surfaco. But this is true, whatever t)
('HUSO of the carina ; whether it may have arisen from some intci
affection, or general condition of the organism, or merely from somt
pxternal nnd local inlluenec ; and in the latter case, the extematJ
irritant is only indirectly the cause of the sycosis. Thus it is, so
B}ieak, only tlimugh the mtdium of nn eczema, that we could explain
the prtHJuetinn of ayccwis as the n-sult of ex|X)8ure to heat or cold,
or of the action of n blunt raxor. liut 1 must confess that, although
1 have hud a very oousidemblc number of cases of eczema and ci
syonsis under my observation, accident has by no means favoured
me in this matter. Amimg all my patients with the hitter complaint,
not one has attributeil it to heat, or cold, or to shaving, or irritation
of any kind ; and from my own experience I should even be inclined
to maintain that a much more frequent cause of sycosis is precisdj
the bahit of UtliHii tie beard ffrow. Tlius, I have seen the disease
far less often in those individuals, and among those races, whose
cuflom it is to use the razor daily, than either in the orthodox
Polish Jews, who on rchgious grounds do not shave, and who re-
move the beard (if at all} by a paste of orpiment and quicklime,
in the llungarians of the better cluas, who from their youth avi

'ouS

Hr""

shoi

ETIOLOGY. 31 1

in order to preserve in their beards the fineness at the
origiiinl down. A decisive ftrgumeut in favour of this opinion is
alsoBJlurdrdb; the fod, to which Ii<liiil] advert further on, that cnrcful
shaving has proved to he an effectual ranedy for sjcosis.

As for tlic statements that the disease may be set up by dyscraain
or by internal disrases, sach nsseriians are Biniply untrue. Nejtlier
syphilis, nor scrofula, nor any other disorder of the system can be
reji^irded as causing sycosis. In bvour of the notion that the disease
is due to ihe deposition of n ncrn/vhut matt^rial (Schiirfe), some may,
perhaps, urge the fact that it is frpciuently Bccuiupaiiitd by ii
blt^phnrndeiiilis, an atfecticm which has always Im-n reg.irib-d as an
expression of ttiP scrofulous state. The fact ilsclf is beyond dicpiitc-;
but a far more reasonable explanation of it serms to mc to bo tliat
intlammntion of the hair-vaen and sebaceous glands wbii^h
coiinlituU'S sycosis is not iieccesnrily confined lo the bcnni, but
ly attack (ither regions (snch ai tiie edges of the eyelids) at wliich
iponding structures exist. Such on explanation would ace-ount
thf nssociolioii of the disease with a blt-pharndenitia withnut the
:er affection being regarded as nccesssrily a sign of M-rofula.
That sycosis has notliing in common with nypAili* is sufficiently
shown by contrasting the features of lh« former disease with those
yphilitic tubercular cmplion. But I may furlbiT state that
rlieii tlie two afTections occur together the syphiiilic tubercles can
removed by spproprisle treatment without its producing the
htest change in the appearances proper to the sycosis, these
yielding only when recourse is hud to the remedies which ex>
perience has shown to be cffi^ual in tintt disease.

The above remarks may be summed up in the statcmntl, that I

sycosis as a local dinfMt, tchkk cantuU essenlially in an

\mmation of tie icir-saa, but <^ Kkote eaute we- are absolutely

The hypothesis that it mar, perhaps, be immediately

to a perversion of the pnteess \»y which the Imira are normally

[eicfd ia one of which I can adduce no direct proof, baaed on

itomical or microsco])ical observations. But such a notion is to

■rtuin extent favoured by the fact thai in this iiffcetion it is

mou to find within n single hair-sac two hairs, one thicker and

irally of greater length, -the other thinner and usually sborter.

Now the researches of FrofMwr Langi-r mIiow that the way in which

fresh haini arc furuted in the beard is tlic fallowing : — From the

buB of aaa of the long sacs, Foittaiuing a hair, there grown a

STCOSIS.

new sac of smaller size, which is placed a little to the side of t
mother sac, and somewhat more deeply towards the subcutaoeoiu
tiasae. Li this oew sac a ininute hair is formed, in exactly the
same way as when the hairs- are originally developed in the foetus.
Tliis litlie hair, as it grows, parses iulo the old sac ; and, under
normal conditions, it pushes out the former occupant of the sac,
and t^es its placi-. One can, therefore, imagine that in exceptional
cases both the old hair and the new one may remain within the
follicle, filling up its entire cavity. Thej may then, perhaps, exert
a mechanical pressure on the adjacent structures," and in this way
set up an inflammatory affection of the hair-sac itself, leading to
suppuration, and also to the formation of a red tubercle, through
which the hairs themselves will pass.

Each tubercle of sycosis, in fact, always contains pus in greata-. J
or less quantity, even at a time when no yellow point is to be aeen. 1
at its summit. Sometimes, however, this pus does not escape until
the one or more hairs which close the mouth of the follicle have
been extracted, together with their root-sheaths, which in these
cases are loosened and swoUeflj so that they can often be removed
Bt'parateJy.

Anatomy. — Itwas shown long since by 0. Simon, that pus is invai
ably present in the tubercles of acne, so soon as the slightest elevation is
to be seen. He did not, however, make the same remark of »i/cosi».
Of this he treated in his chapter on " Parasitic Diseases," choosing
not to contradict the statements of Gruby, although he had not
himself discovered a fungus in the hairs extracted from the tubercles J
in this disease. I too have repeatedly looked for, but have never 1
succeeding in finding, the parasitic plant described by Gruby, and J
subsequently by Bazin and Kobner, as being present in sycosis.

Wertheim^ has proved, by his investigations, that every tubercle I
of the disease under consideration contains a metamorphosed hair 4
follicle, and that this follicle in fact constitutes a amnll abscess.

As I am not able, from my own observations, to confirm every-
thing that has been stated, concerning the morbid anatomy of the I
disease, by tlie writers above referred to, I will pass on and remark ^
that when sycosis has existed for some time the structures between |
the follicles become involved in the inflammatory change, as well a
the follicles themselves. The connective tissue elements undergo I
proliferation ; and this leads to the formation of a number of semi-
' ' Zeitsclirifl det k. k. Gesellscliaft der Aente,' i86i.

e
s

I ■

ion iB^I

AN'ATOUr.

813

globular condjlomntous elevations, which may lutvc somewhat the
appearance of raspberries (Frambcesia) . These, like the ordinary
tubercles of the tiisease, arc traversed by numcrou? hairs, and contain
■ nniiy iJottils of sujijiuratioii, wliit^h are liiscuvrred on npjilying
pressure, or on piiUing out the hairs one by one. It vra§ the
peculiar apjiearance of these growths, resembling aomcwhat the
ranular inside of a fig, which led our forefathers to give to the
Hisease the rather fanciful name of Sycogit.

I'uEATMKNT. — So long 83 sycosis was regarded as the result of a

■eneral disease it was a matter of course that it should be treated

p; internal medicineii, namely such as were regarded as andctygrranica.

Bt is, therefore, not very xurprising that the remedies most highly

ecommended for it in the various ancient and modem works are

t same as those used in psoriasis' — the so-called anti-dyscrasic

Hccoctions of woods, the pui^tivea, the supposed sperilic medicines,

md above all, ancnie. But it certainly is remarkable that the

Lsures, which we now know to he capable of curing the

mplaint with certainty, should formerly linve been regarded as

Itjurious, and ebould even be consiilcrcd so at the present linic by

writers. Thug, according to liayer, the first principle in the

umsgemeiit of a case of sycosis consists " in using a pair of scissors,

Qstead of a razor, to remove the beard, for the. razor is invariably

found to increase the inflammation."

Now what I lay down as the first principle in the treatment of

e disease is the exact contrary to this; — that the beard should

rely be cut short with scissors, but should be carefully shaved

y Hay. It is true that without the use of the razor it is possible

■to cure a sycosis ; but the treatment takes a much longer time, and

is attended with far more pain and discomfort to the patient when

shaving is omitted than when it is regularly performed. I have

repeatedly tried the two plans, and shall now proceed to give in

"i the results of my cxiiericnce.

1 have already on more than one occasion pointed oat that in the

reatment of a cutaneous affection no single method of procedure

btn ever be applicable to all cases- The reason for this lies not so

Buch in the differences of character presented by the disease itself

I different instances as in the fact that the occupations of the

ntients are various, and their social conditions uueijual. These

' Fut* p. 19 of lliii Tdlume.

31 1 SYCOSIS.

circum stances often render it quite impossible to carry out a method i
of treatment which may nevertheless he both the most speedy and
the moat certain. It is to the interest of the patient, as well of the
doctor, that due attention should always be paid to such points.

These remarks are applicable to the treatment of skin-diseases
in general, hut they are pre-eminently so as regards sycosis. To
certain persons the temporary loss of the beard, while they are
under treatment, is hy no means a matter of indifference. Various
considerations prevent some indiriduals from altermg the appearance
of the face in this way, whereas others ore able to indulge the fancy
of the moment as to the kind of beard they shall wear, — at least
within the liuiits prescribed by nature herself. The method of cure
ado]ited in cases of sycosis must be modified according to these
circumstances.

Thus, if the patient places himself entirely in our bands,
certainly should without delay adopt that treatment which is botkj
the most rapid and the most certain. The hairs should he remore^J
at those spots which are diseased.

If, however, this is not practicable, we must endeavour to elTcctl
a cure without having the beard shaved. The possibility of attaiuin^ W
this result is sufficiently proved by the experience of the older, and |
of some hving practitioners, who have been strenuously opposed to J
the use of the razor jn sycosis, hut who nevertheless have succeeded |
in curing it. I have myself repeatedly had to treat cases in which j
the hairs of the affected parts could not be removed ; when tha I
disease, for instance, has been seated in the eyehrows, or when the-V
patient, ^m affection for his heard, or from any other cause, ha»|
objected to losing it.

Under such unfavorable circomstances, the plan I have adopted
has consisted in making small incisions into the different abscesses,
so as to allow of the discharge of the pus contained in their interior.
The separate cuts, of course, sometimes run together, so as to result
in superficial wounds not less than an inch in length. The instru- j
menl which I use in making these scarifications is a very narrov I
two-edged bistoury, having a short blade. With this I make a
number of incisions, separated from one another hj a few Hnes, and
carried through the most superficial layer of the cutis as well i
the cuticle.

In adopting this procedure one need have no fear either of I
destroying the hair-follicles, or of causing scars which might pro-a

lighl

TRKATMENT. 315

9ace a pcrmiinent disrigiirement. Such incisions, into parts of the
akin iiililtratcd with inflammatory products, heal so perfectly and
so speedily, that in a few days no tracts of them can be discovered.

This little operation is genrnilljr followed by somewhat frtc
hteinorrliaftr, which, however, does good rather than harm. If
necessary it can with certainty be arrested by the ap]ihcation of
charpie, dry or dipped in tlio liquor ferri jKirchloridi. 'Hie iron not
only acts us a styptic in checking the bleeding, but also contributes
towards the subsidence of the tubercular elevations.

When the greater number of the abscesses have been opened in
the manner dt-scribrd, and whni tlie number of new papules and
pustules which are formed begins to diminish, wc may proceed to
ilcetroy, by means of canstics, those which are left.

Tlius the summits of the individual tubercles may be touched
itli a glass rod, moistened with concentrated acetic acid, or nitric
«etd, or with an aqueous or alcoholic solution of corrosive sublimate
{one part to two), or with chromic acid. When any of these sub-
stances are used, it is a good plan to apply water dressing or rags
spread with lard to the affected spots, either constantly or at least
during the night, so as to macerate nud soften tliem.

When tite. face is so tender that caustics cannot very well be
employed, we may substitute for them an ointment of red or white
precipitate (one drachm to the ounce of lard), the unff. Siiciardi,^
the itHff. tvlpkuTU iodidi, or, lastly, the lae tulphurit, recommended
by Prof. Zeisal.' But to attain the desired effei't from any of these
applications, it is net^essary that, instead of being merely ruhlied in
lightly with tlit^ ^nger, it should be spread upon strips of lint, so as
to make a sort of plaster, which must bo kept all night long in
contact with the'alTeetcd parts.

Ordinary washing is not sufficii^t to cleanse a part which is
sent of sycosis. What is culled a face-douche (Oesicbts-
douche) must be used. This a very like an eye-douche, only that
the tubes should be connected to a fixed support, and should be of
greater diameter.

The rc^lar use of the local appheations above iiameil will cure

the disease, even thougli they are. employed only during the night.

These methods of treatment are, therefore, to be recommended for

itieDts who, by their occupation, or by otlier circumstances, ore

ndf p. 48.

Zdtachrtn der k. k. Unelbchah <l«r Aerate,* Wien, 1855, |t. 805.

316 SYCOSIS.

prevented from subjecting themselves to an uninterrupted course

energetic treatment.

If, however, such considerations do not interfere, it is
betler to adopt the following procedure, because it effects the ci
of the disease most speedily and with the greatest certainty.

The tirst thiu^ is to soften any crusts that may have formed,
hairs shoulil, therefore, be cut short with scissors, so as to t
one to get at the disease ; and oil should then be forcibly rubbed
into all the aifected parts of the beard, after which they should be
covered with pieces of flannel dipped in the oil. By this the greater
part of the crusts will in about twenty-four hours be loosened, so.
that the diseased spots can be washed with soap and water, aii4'i
then shaved in the ordinary manner. Tins proposal, however, ia '
often objected to both by the patient and by tlie barber. The
former dreads the pain of being shaved, the latter doubts the
possibility of shaving a part in so diseased a state. But " t/rau Ut
alte Tkeorie." The patient does not experience the sufi'ering which
he feared; the barber finds no particular difficulty in using hit-'
razor. In fact, a person with sycosis can he shaved just as well
one who is healthy. No doubt a few of the tubercles will be cut,
and a little bleeding will ensue. But these inconveniences are quite
trifling, when set against the benefit of the operation in facilitating
the cure of the disease.

The diseased surfaces having thus been exposed, it is sometimevj
necessary to scarify the part in the manner above described: in
slight cases incising each separate tubercle ; making long cuts in
more severe ones, where there are large patches of the disease.

In other cases, however, we may at once have recourse to the
method of epilation, a practice which was long since recommended
by Plumbe, hut which had fallen into obhvion, until it was re-intro-
duced by Dr. Gustav Wertheim. Epilation is often objected to
by patients ; and, indeed, it is an operation from which some medical
men would shrink until they had made trial of it. But it may be
effected without difficulty, and without causing very much pain, if
tlif attem])t be made with courage' and confidence on the surgeon's
part as well as on that of the patient.

In the first instance, those hairs only should be extracted which
run through pustules, or emerge from the summits of tubercles.
Gentle traction will be sufficient, the forceps used being such as are
employed for the removal of eyelaahes. The hairs at the periphery

e
e
■i

B -

TREATMENT. 817

•^t the diseased patches should be first pulled out, aiid cara must bo
taken to seize with the forceps only one Imir ikt a time.

The extraction of the hair is very often followed by the discharge
of a little pus from the interior of the hair-sac, or by the exudation
of a Iraiispareiit fluid, which collects as a minute drop upon the
cutaneouH surface. In olher instances, bleeding occurs, and some-
times rather more than one would eipect to follow so shght an
injury. Either exudation or hemorrhage may at once be stopped
by the npjdication of a little charpie, dry, or dippt^d in a solution of
chloride of iron.

At the first few " sittings," then, the operator may content him-
self with epilating those spots over the diseased surface which arc
roost severely alTected. It must be borne iu mind that the jirocedure
has Ducessarily to be gone tlirotigli every day, and, therefore, that
there wiil ho abundant time and opportunity for going over the
ground a second time, au<l removing any hairs that may have heeu
left on the Grst occasion.

After each epilation, the whole of the surface affected with the

disease should be covered witii strips of rag, smeared with some

inttiient, such as my vn^. diarAyfi,^ or the unij. lUAary^ri, or the

. tinci oxidi of Wilson. Whichever of these be used, it must

e kept always in contact with the surface by means of plasters or

Provided that the circumstances of the patient and the engage-
« of the surgeon allow it, it will be wdl to repeat very often, —
Brhaps as often as two or three times daily, — both the epilation
1 the subsequent washing of the affected parts with soap and
:er.

Under this plan of treatment it will be observed that the tubercles
mbside, the pustules die owny, the infiltration diminishes; but
1 it is first commenced, one must be prepared from day to day
1 find fresh pustules continuing to appear round the short hairs, as
; first sprout from their follicles. In proportion, however, as
•, hairs which remain become frwer and fewer, the characters of
i disease will be less and less marked ; and by the time that the
jiilnlioa is completed, the sycosis will generally be cured.

But the success thus achieved mu»t not lend the medical man to
f&t his hands into his pockets, and discontinue further treatment.
£ must still persevere, and, in particular, muat strongly urge on
' r(a.p. 145.

818 STOMIB.

the patient the importanoe ot ahafing ngnlaify €v«f day. Hi
lesson has been taught me by my own eKpericnoa. After I hi
sncceeded in caxing a njoom, at the ooat of miuh one, ftienr
and taroable, I hare sometimea aeen the diaeaae xetom ao noii i
the beard has again been allowed to grow* Efea vhfln jetn ha
passed I have seen pnstoles break oat again witUn a hm weeks i
the time when the patient has been oTeoEcome hj the temptatiim t
try the experiment of leaving off the nae of the mor.

As I have already stated, sycosis la often aooompaamd hjm aandh
affection of the follicles in which grow the ejebahea^ or those c
the eyebrows, the axills, the pnbes, or even the aea^ When tin
is the case, the same treatment must of ooune be adopted. Ih
qnickest way (for instance) of curing a tinea cilionuBt (Hlephaio
adenitis of certain authors) is to poll oat the haiia of ths psi
affected, so often as redness and infiltration show ihsmselvea^ am
postoles are formed. There need be no apprehenaicm leak this pro
cedore should cause a permanent loss of the hairs. On ths cob
trary, these subsequently grow with eztraordinaiy liquidity, so fhs
it often seems as if the new hair most have been fonned within th
follicle, and have been ready to emerge before the old one vsi
extracted.

One may, therefore, feel perfectly confident tiiat the plan abovi
recommended will cure sycosis, without leading to permanent bald
ness of the parts affected.

HiHTORT. — Neither the works of the Greek, nor those of tlie
liiilin writers on medicine contain any account of &cue rosnccn. It
would seem, therefore, that, being unflttmded with pnin or itching,
it was not rcRarded M & ditease, the redness of the faec to which it
» rise being simpl; termed iVpvBpot: In the writing;* of the
tomitn poets, on the otiier band, ne find piissages whicli show that
iiey were accustomed to sec red noses, and knew something of the
fi of such an api>carani^e. At leant, the follow ing^epigram
s to lead tn this conclusion : —

" Pampiiio eil naimt niiioi Int Itmffiu tl mhn
l^lut, el iiiKC muna Hngit uUrq»t tripks i
Adnnt *t Ivrrti, Baeekta gnat eoitdidit ipt,
SI miuio linelai wyw« rabrrt dfdit."

"Yhe complaint is distinctly mentioned by latej writers, snch aa
yde Cbautiac, Fenidius, Nicolnus Florenlinus, Amhnise Pnr^and
Letruc, — the first of whom advises that veneescctioo of the frontal
, leeches to the nostrils, and eptspastics should be employed
scure. Fernelins' dislin^ishm between common acne and acne
XB.. " Rubor faciei," he says, " tel simplex et totitariiu, et Pel
e pHftuHa vel putiulaa ctmitet Aabel. U<t pmtulif H intentum
fubi>rft» kabent, gvfta rontirea vocanttir; *i duraet eriffva exfrigiHo
e craxta humore, et relut in callunt crmere/ir, pari nominantur."
I Florentinus divides the affection into three grades, the
I consisting in a simple redness of tlir face, the second being
ipanidl with an croption of pustules, and the third with the
matioD of ulcers. Pnr^ gives a similar account of gutta rosacea,
g that he has »xa it sometimes with, sometimes without pus*
Sennertus,' lastly, speaks of a man, living near Dresden,

' ' UaivecM Me<Jiaa«,' 1679, p. 443-
* ' Piact. UetU* i(i>9t lib. t, cap. 2 1 ,

... ■">• f-Td

'. r

820 ACNB B08A0BA.

who was obliged to have some poitknis fA hii doss eat o^
its size interfered with him in reading.

Among the Arabian authors there are some who
more or less plain terms to the disease with whibh we axe luiw
concerned. Avicenna speaks of it under the name of BedechcsBAa^ a
name afterwards converted into AbedsamoL Gkdielmoi de SeKoeto^
calls it ^^Buzieagua "' or " Awra cervina/'^

Astrac, again^ distinguishes three species of it, the firat appeariBg
as a simple redness of the skin, the second being aoeonipeined
with an enlargement of the veins, and therefore described hf Urn
as '^ varicose/' and the third beuig characterised by the tamalkm
of scales, and consequently named ''scaly."

The most early and complete description of acne meacffaj haW"
ever, is that given by Lony/ who was fully acquainted not onty
with the symptoms of the disease, but also with its cmace. ]^
treats of it in two chapters, the one headed ^ OuUa rageu/^ Om
other *'Be rubore et tumoribua in cute narium/'

In the work of Daniel Turner,^ which appeared in the eighteentk
centary, it is dealt with in the fourth chapter, which, h o w e rer j ia
devoted, not so much to the description of the diseaaej as to a
comprehensive account of its treatment.

Plenck, under the second order {Macula rubra) of his first claaa
{Macula) of cutaneous affections, speaks of a comphdnt which he
tennit ffulfa rosacea, and which he states to consist of red spots^
nrraiiKiMl in oluntcrs (doldenformig), and seated on the face and
noHo. 1 1 diNtiii^uishes nine varieties of it : — Gutta rosacea simplex /
(fnopotatorum a. bacchia ; hydropotatorum ; fArilie ; pemianatig ;
herpetica; Byphiliiica ; lactantium; variolosa* It is evident^
but rather from the names given to these varieties than from their
definitions, that he was fully alive to the causes which produce the
contplnint, and to the fact that particular classes of patients are
liable to it.

> Chir., lib. i, c. 18, f. 309 r.

' This imiiic is equivalent to " wine-cask/* being derived from cagua, CaborSp
" a wino of Bordeaux," and l)uza, "a cask."

* This means a '* pack of winc<skins/* the word aura being the same aa
arrrfit, " a sailille-lMip/* and cfmna being an abbreviation of eella vinaria,

* Op. cit., p. 640.

^ ' Treatise of Diseases incident to the Skin/ 8vo, London, 1714. Thir
work reached a third edition in 1726. The reference in the Germaa editip
appears to be to a German translation published in 1766. — [Ed.]

IlISTORT. m

Willan and BatRmnn apealc of the disease as a species of aciit^,
calling il acne rosacea ; and the latt«r of these writers duscnbea with
tolcruble accuracy its different forms.

Ahbert, in the first edition of his work, gase in Plate XXI a good
representation of the com])laint, undcrr the title of ' Dartre piiittuleuae
cou|ierose,' clasaifying it among the ' Dartres ' or ' UerpeU»^ But
he subseqaently adopted the opinions of the English writ«rs of his
■ dftj, and placed il among the apocics of Varus (acne), the different
I forms of wliich he collected together to form the second genus
of his 'Dermatoses Dartreuscs,' He then admitted six kinds of
Tori : Varni sibaceun t. earned, V. miliaria, V, fronlalit, F,
hordeotatuf, F. diMentinatan, F. jjutfa ituea, and F. menla^ra.
He thus agreed with those who think that aaie rosacea helongs to
the same famUy as those affections which consist in a perversion of
the functions, or in an iDflaminatioD of the substance, of the seba-
ceous glands.
I Biett, and with hiiu Cn/.enave anil Schedel, admitted four species
I al acne: A. simplex, A. indurata, A. rosacea, and A. sebacea.
Thcsd writers, in fact, adhered to the views of Alibert.

liayer continued to place acne rosacea between A, simplex (Varus
s. lonthos) and acne mentngra (Sycosis). But he nevertheless
renounced the opinion that these three diseases stand to one another
in the relation of species to a genus.

Krank' took a different view. He grouped acne rosacea (Kupfer-

liandcl) among the exanthemata (HnDtri>then), at the snme time

I lemarking that the disease presents dr; scales (trockene Blitttchen

I oder Hit/.blattercheii) as well as tubercles (Imubenartige Wucherun-

gen), and that it is also in part n moist eruption (auch fenchto

Bliilhchen entstehen).

Fuchs, on the other hand, adopted an arraiigtiment similar to that
wliich has bepn spoken of as hann^ bei-n employed by English and
French writers. He divided acne (his sixteenth species of cutaneous
diseases) into three varieties ; A. vulgaris, A. meniitgra, and A.
ntaeta : thus including the latter affection under tiie general head
^^ of acne.

Alibert bad already recorded the fact that one of his pupils.

lanvei^e de Volensole, had taken the opportunity of examining

" Varus gutta rosea " in a fatal ease of apoplexy, with the follow-

; result : — When one of llie tubercles was cut across in wi early

' Op. cit-, p. .11.

ihiC the eertie of tbe tabcnfeUt hnd snd too^ and seeaed to
tatm • Hrt of ken^ The trdaem gndnOj diannisfanj fron tkt
cntn (onrii the peripfacfj, iC bngth aannK altogetho-. Bat
wiicn tbe tnben^ «m alraadj tuf f aat hig, Uk appeanncn «cr
■HPrmiti "Hie kcred in the «BtR wta icpbced bj a drpoeit at
pu of ft eonial (nn, fa>Ting iU bmat in MOtaet intfa the onder
HU&ee of the cutis. TbeaaDa of thn Itttk abscos were sorronodcd
bj red and mAamed ttam^ the mliKa> gradoallj disaj^ieanng at ita

A aimilor ohaemlioii is recorded bT G. Sudml' This writer wn
once able to exanune a dmnkard's nose, which was corered with
moderate]^ Urgt tabtrda of acne rosacea. These during Life bad
beeu of a dark red colour, and toj prominatt ; bot in the dead
boJv there was verj tittle redness, altbongh the sweilii^ of the
akin was still plain!; noticeable. The thickening was doe to the
presence of perfect!; developed connective tissue, in quantitj greater
than oaturaL

Plmnbe, Anthony Todd Thomson, Hunt, Erasmos Wilson, nod
other Eogliab writers, for the most part coincide with the views
of their French and German coiit*mporariea, and regard acne rosacea
aa allied to ordinary acne, and aa essentiallv doe to an inflammation
of the sebaceons glands.

In the following accoant of the symptoms, coarse, and etiology of
this disease, I shall maintain a ditferent opinion. I shall laboor to
prove that between acne simplex or A. disseminata on the one hand,
and A. rosacea on the other hand, there is only a partial analogy,
dependent on the similarity in the estenial appearances of these
diseases, and on the circumstance that they both affect the face.
I admit, indeed, that they are sometimes seen together on the same
patient, and that the presence of the one is perhaps favorable to
the development of the other. But I am, nevertheless, convinced
that these two ao-called species of acne are entirely distinct diseases.

So far burk as the jear 1845, in publisliiiig a classification of
'Diseases of the Skin,'" I staled that acne rosacea, instead of
arising in an inflammutorj process, in fact consists in the formation
of new vascular and connective tissues, and therefore, that allhoogb

' Op, oil,, p. 36J,

' ' ZoilMlirirL dcr k. k. QeHlkchaft Jer AersU,' Mai, 1845, Bud 11, p. 145.

SYMPTOM 8.

933

a assoeuted with scne ilis^miDBU, it ougbt properlj to be
luwed among tfie new growths.

To the news wliich I tlien fxpreased I still adhere. But in the
present volumes I am endeavouring to arrange cutaneous diseases
ill groups, based on t!ie prinnples adopted in natural history. I
no longer classify alFectioiis of the skin according lu aay one set of
E^ohanicters, but tuJcc into consideration all points of resemblnnce or
Mgrcement in their symptoms ; and coiiseqiirntty it seems most
■Donvenient to describe the coinplaiut in this place, after the other
HfttseiLscs wltich are known uudcr the name of acne.
H I repeat that 1 am atiJl Grmly convinced that iiiQaminalion of the
HMbaceous glands and other culnneuus tissues is not an essential
Bcharacter of acno rosBce*, but that when present, wliich is no doubt
Hnquently the case, it is merely an accidental complication. To
Bvoid repetition, I refer for evideiica in proof to the following
Becount of the symptoms and course of the disease, based on re-
Bbeatcd obfcrvations which abundantly justify the view I have taken
Bonccraing it.

B Syufioms. — ^The roost imiKirtant of all the diagnostic signs of
Hune rosnrea is its itTecting a particular region, the face. No one
nrould think of givii^ this name to a disease seated on the thigh or
Kio trunk of the body, although it should present exactly the same
Characters.

H 'ilie parts of the face cliidly attacked by it are the nose,
PWieeks, forehead, and eliin, In very excrplional cases, however,
r b may cover the whole face, and even (hut generally only in persons
f'Vbo arti bald) encroach upon the scalp. Its fuudfuuental fenturv is
mjtn intense rt^ddeniiig of the skin, without iiiuoh swelling or tension.
WOa close examination the deep ret! colour is found to depend oo an
Hljection of the blood-vessels of the affected part, these being seen
Bgenejnlly eveit with the naked eye, but stdl better with a lens of
Bioderate power) to form a number of serpentine lines. 1'he appli-
Bktion of forcible pressure with the finger, if continued for a short
B&ie, causes the redness to disappear. When the finger is removed,
Wtn vessels which had been emptied may be observed to fill again
Hletty quickly with blood. The vascular twigs are puticutarly
Hnmeraus, and strikingly evident, on the sides and bridge of the nose.
B This condition forms a ground npon which other appearances
Hevclope themselves : — sometimes the tubercles and pustules of ordi-
^hw MMl in atlig flMM) protuberances of greater or less size,

824 ACNE ROSACEA.

of firm consistency^ and without any pornlent contents. These,
again, according to their duration, and the differences in their aeatj
present various forms, which will be subsequently described.

Other features of acne rosacea requiring mention are a certain
persistence and obstinacy which characterise it, and its occurrence
at particular periods of life, those of growth and decay (die Evolu-
tions- und Involutionsperiode).

Course. — The varieties in character presented by this disease have
led writers, not altogether wrongly, to describe it as passing through
several stages. Unfortunately, however, these various characters do
not, in all cases, develope themselves in the same order of succession,
sometimes one, sometimes another, being first observed. I therefore
prefer to speak of it simply as manifesting itself under different
forma.

One of these consists merely in a more or less intense redness
of the skin of the nose, cheek, forehead, or chin, without change
of form. In such a case, if the tip of the nose is alone attacked,
the patient often ascribes the complaint to cold, thinking in fact
that the part is " frost-bitten." (This is a matter to which I shall
hereafter return, when speaking of the exciting causes of acne
rosacea.)

In addition to this abnormal redness, however, the part aflPected is
generally the seat of an excessive formation of sebaceous secretion,
so that it has a shiny, greasy look. The patient also complains of
experiencing a sensation of warmth, which, however, need not be
constantly j)rescnt, but perhaps comes on several times in the course
of the day, and especially after a meal, or in the evening.

These symptoms, increasing in intensity, bring us to that form
of the disease in which the whole countenance acquires a deep-
red colour, and the abnormal vascular ramitications can be seen
even with the naked {'so, \\\ such cases the exact hue of the atTected
parts is liable to considerable changes, beinir lighter or darker
according to the external toniperature, and also according as the
|jati<:nt hni)j)cns to present himself to the doctor in the niornins: or
in liie cveniiii:, before dinner or after havintc dined.

If with these cliang(\s there is combined an intlammation of the

sebaceous glands — in other words if an ordinary acne is present

this of course contributes materially to spoil the already damar^^d
comj)lexion.

Jioth the above-described forms of acne rosacea are most common

8TMPTOM9.

S25

" fair "sex; but there is a tliird variety which belongs mora

iailylo male patients, and particalarl; to such as indulf^ to excess

-itiious liquors. This third variety is rreqtietitly confined to the

where it sometimes manifests itself simply by an cxeeiisive

sion of the blood-vessels, forming lines between which the

n is of itA natiirul colour. In other words, the appcitroiice of the

B would be hcaltliy werr it not for the presence of these larjfe

Diifying vessels.

1 such cases, the temperature of the end of the tmse is generally

Qusly lowered. The part feels cold when touclied. It lias,

;vcr, a shining, greasy appearance, which shows that the scba-

s glands are in a state of cxc^asivc activity. This form of acne

Mcea ta commonly met with in those who imbibe braiulg.

I Differing from the variety last described, which is generally con-

JDed to the nose, is the one that occurs in habitual teini>-AnD^tn,

md in which the face generally i» of a dark red coIhut. In these

nibjects the n^driess is either universal, or, if conflncd to certain

parts, it is deeper than in those whose drink is brandy. The

affection does not consist simply in the presence of numerous voa-

* twigs; the surface of the skiu between the blood-vessels ii

iclf altered in colour. The whole face has a bloated appearance.

Vet another type of the disease is allorded by those eases in which,
f I may be allowed the expression, the modeller's tool »wms to
live been used, instenil of the colour having been simply laid on
Irith a brush. It might be said tliat the plastic art, as well as that
r painting, is concerned in proilucing tlie disfiguremrut. Under
a/omtafive, or rather dt^urminy agency, the nose acquires a pear-
: form, becoming nearly as broad as it is long, but presenting
Lher pustules nor protuberanceii. The ducts of the sebaoeoiis
lands, however, arc dilnt«d ; they may or may not be plugged by

n ; some of them arc iiidamed.
\ The vurielles of acne rosacea hitherto descrilted may all lie said to "^
•long to the first grade «f the disease. The disfigun-mcnt is due
itirely to vascular injection, serous infiltration, and slight infiam-
blion of the sebaceous glands.

[ But when acne rosacea has existed for a greater lengtli of time,
e diseased parte come to present semiglobular tumourii of invgular
nd form, which do not contaiu any pus or other secretion in
«ir interior, and arc in fact made up of a homogeneous tissue

I ■

>l 326 ACNE ROSACEA.

I ;
' i.

I I

resembling that of the healthy skin. The part thus affected becomej

,, of course much enlarged^ and great disfigurement results. T\u

I change is always more extreme on the nose than elsewhere, and theM

|i I ' growths have consequently been known by the name of " Flesbi

excrescences of the nose.^^^
So long as such formations do not alter the outline natnralh

i> ' ! belonging to tlie organ^ but give rise simply to an uniform enlarge-

ment of it, the disease has not gone beyond the second degree.
But as the acne rosacea advances^ the features may gradoaU;
become deformed and monstrous, the nose in particular under-
going enormous enlargement in one or another direction, or even in
all its diameters. This constitutes the tAird and most extreme degree

I' r of the complaint.

' In some of these cases the nose, without any increase in iti

breadth, will be elongated until it projects beyond the lips, and

■| even down to the chin, — reminding one of the turkey; while in

other instances the organ will expand in every direction, until ii

'• attains the size of the two fists (Pfund-Xasc).

Even when the nose has reached so enormous a size as this, how-
ever, the skin is the only tissue affected, and the deeper structurea
entirely escape. In one case which came under my observation the
alse of the nose were as large as the fists, and hung down so as to
conceal the mouth. But the nostrils were nevertheless of the
natural size; and the patient could take a pinch of snulT quite
cleverly, when he had raised the affected parts with his other hand.

In fnses of acne rosacea of the second and third degrees, again, one
sonietinu's finds that the mouths of the sebaceous glands are simplv
dilated, but nut at all inflamed, and that the colour of the skin is
almost natural. Whereas, in other instances, the parts affected are
infensclv red, and present numerous lubereles of acne, some just
funned, otliers already in the stacje of decline.

I nui*it nut oinil to montion one very remarkable appearance
observed in some casts ut' acne rosacea — that in which the excres-
cences as'-ume the form of the el;ij)|)er of a bell. At first semi-
irlohular :iii(l >e>sile on the surface ul th.* intcirnment, the protulxT-
anees increase in t-ize until ihey are as large as hazel-nuts, while
their woiirlit in the mean time draws out the skiii at their base, sc
that thev l)i»enm»' stalked, and mure and more crlobular.

But varied as are the forms und»r whi<h the disease presentc
' H'kitHi.skv. ' J^plirbucli d, path. Anat./ Rnnri II. pp. 52. 59.

DIAONOSIH.

327

lelf, the variations are always confined within certain fiii-il limits.
iTe never fiud it leading to extensive aupparatinn, nor to ulceration,
kar givini^ rise tii any considerable loss of substance.

In each form of gutta rosea, however, tlie spontaneous involution
of the disease is occasionally observed. Even the protubernnces
above described, which characterise tlie Linrd degree of the disease,
will sometiuies be fonud to undergo absorption ; while in other
Etaftses their blood-veasels become obliterated, they are deprive<l of
■wunshmeut, and conncqaently thejr die and fall otf.
B DuONOsis. — The variety in the appearances presented by acne
■naacea explains the fact that diiBculties sonietimea arise in the
Biagnosis of the diseute. The mistake most commonly made is
■liat of confounding it with the acne disseminata. This, however,
Buy be easily avoided by paying attention to the fact, that in the
Bkttcr comphiint there is no increased vascularity of the airected parts
BKi^i^Uy< iiut merely an acute inflammation of certain cutaneous
^plliclca, which quickly subsides at one spot, to reappear at another ;
Brhereas in acne rosacea the redness of the surface (especially at the
Bb of tl>" ntwe) is persistent, and the blood-vejisels ar« varicose.
HCoreovcr, ocue disscminnta is scarcely ever confined to the face,
Moth the chest and the back being, as a rule, likewise attacked by
Wk. But actic roaacea never ext^^nds beyond the face and lirad.
B I have already alluded to the fact that when acne rosacea is limited
Bo the nose [and particularly if its tip is alone aiTected) one is apt
Bd imagine that the part is froHt-bitten. But, in the first place,
B^e nose very rarely suffers in this way from cold ; whereas il is
Bery commonly attacked by gutta rosea, and particularly in ladies.
Hloreover the two atTections are siifliciently distinguished by the
Biircrence in the appearances which they respectively present. In the
■umrr, the colour of the diseased |iarts is bluish-red, the snrfucc is
Bhiny, the swelling considerable ; in the tntlcr Ihr skin has a bright
Bed hue, is greasy botb l« eight and touch, and is scarcely at all
KroUen.

B Venus, again, as well as Bocelius, gives rise to an affection of the
^mw, and the various formB of Input attack the same part, and
^bbject it to their destructive action. Uence there is sotiietimes a
B|ttie dilTiriilty in distinguishing aenn rosacea from tluit disease, nr
BlDiu syphilis. But mistakes may generally be easily avoided by
Bearing in mind that acne rosacea never leads to ulceration, nor
^■eitroys the tiasues of the nuac, that its pustules always undergo

ACNE BOSACEA.

iuvolution within a short space of time, and that ^ the other

of the cutaneous surface, aud even the mucout mevibrane of the noae

itself, are invariably spared by it.

Feoonosi8. — lu acne rosacea the prognosis depends essential I j on
the cause of the disease. As a rule, however, it is unfavorable.
On the one hand, the internal conditions which sometimes give
to acne rosacea are difficult to remove; and on the other ham
when it proceeds from evi! habits (such as indulgence in apirituou
hquors] treatment is almost sure to fail, unless, which is seldom
possible, the patient's character and mode of life can be changed.
Still, its cure is by no means an impossibihty. We sometimes
succeed in removing it by skilful management ; in other instances
we liud that the disease subsides spontaneously. One may at least
say that, however long its continuance, however uninterrujited its
course, there is no danger of its forming the starting point of any
other local or constitutional malady.

Anatomy, — With the exception of the investigations of Dau-
vergne de Valensole, Gustav Simon, and Rokitansky, {to which
investigations I have already referred,) medical literature is very
poor in observations upon the morbid changes, caused by acne
rosacea. For this, however, several reasons may be found : — firstly,
one seldom has an opportunity, even in advanced cases of the
affection, of examining the parts after death ; secondly, experience
shows that in the course of a protracted constitutional disease
sufficiently severe to prove fatal most of the signs of acne rosacea
gradually disajjpear, so that in the dead body one may search for
them in vain ; lastly, not only in this, but in all other cutaneous,
affections, the appearances visible after death afford but a feebtft
notion of those which had been observable during life. Nevertht»
less, it may be taken as proved that the anatomical changes in :
rosacea consist essentially in an excessive vascularisation of
affected parts, in the growth of new connective-tissue elements,
in an hypertrophy of the cutaneous glands — all these changes being!
far more marked in the hving than in the dead body.

ErioixiGr. — In men, acne rosacea is most common after the
fortieth year of life, that is, just wlien the bodily powers are fitat
beginning to decline {zur Zeit der Involution) ; in women it occurs
principally at the two periods of puberty and of climacteric change^
Hence we are driveu at once to the conclusion, that the causes
acne rosacea are nut the same in the two sexes.

ETIOLOGT.

329

This is coiifiriued hy the fact lliat the appearances of tlie disease iu
wotiien pre^nt constant differences from tliosc observed in men. In
the former acne rossceii never goes beyond that condition which I
have described as conatitiiting the Artt degree of the disease. In
the latter it rcpiches the secoud and the tliird degrees, but these are
invariably preceded hy, and occur solely as further stages in, that
form which is common to both the sexes.

Again, tlie occupaliou and habits of life of the indindunl have an
unmistakcable inflnence on the development of this complaint. It
is less common in countrjr-folk than in those who dwell in towns.
Persons olio nr<; Itrinjierate in their habits are less liable to it than
those who indulge in the pleasures of the table.

But although there can be no question that the disease is far
lore frequently caused by conditions arising within the body than
f some of those eit*.TDal and local agencies to which it has been
ribed, it is nevertheless true that acne rosacea may result from
intiuned irritation of tbe skin.

I Thus, we see the complaint in persons who constantly expose tbc
; in all weathers to the inclemency of wind, cold, and rain — in
cbmen, cab-drivers, huckster-women, day-labourers, and others,
reii tliough tbey may not be particubirly addicted to drinking, and
Irithout there being any reason to suppose (hot the parts affected
have been " frost-bitten." In sucb patients, acne rosacea appears ai
a very dark redness of the whole countenance, not affecting the nose,
forehead, or chin, more than other parts.

Another class of persons in whom the face often displays an
intense red colour are those who have placed themselves under the
cold water cure for a very long time, and with great perseverance.
1 do not, however, think with Plenck that it is necessary to give (o
the disease a particular name (guttn rosea At/dropotatorunt) on tliis
■econnt ; nor do I agree with him in advising such patients to
" ik wino, as a sort of antidote to the water.'

inother cause to wbicli acne rosacea has been ascribed is llic
ition of high degrees of heat, continued dnring a long period of
This, however, I cannot admit. There are many classes of
■n, — such as bakers, smiths, stokers [of steam-engines), and
s-blowers, — whose occupations constantly expose them to inl«nae
toll, but in whom I have never seen acne rosacea, unless thry
'Plurcs curari siudeado ut Tiuuni bibnre iacipiaat.' I'lenrd, np. cil..

« ■

* 1 f.1 h^

880 AGNK B08AGIA.

were alao in the hibit of diiokiiig to eiOMi. NorcHiIi
tbfb oompbint ever arim (as Wikon^ ha stetod) ^bam tibe ^m of
oold dnnJcs in s hasted state of the body, and fkon the loeal apflU
cation of irritating aahstanoesi'' Boch aa ooanMtiea» I noat aJoo
express my dissent firom the Yieir that it may nsnlt from over appli-
cation to stndy, or from emotional exeitemeDL

The following are the only cauaea whieh^ aooording to nqr dhaer-
▼ations, are really capable of giving rise to acne roaaoea.

(i.) Excessive indulgence in qpiritoons liqnon. It ii^ hmrem,
to be remarked that no strict role can be laid down aa to tiio
absolate quantity required to produce this eflbet. Mneh dnpenda
on the individual predisposition*

I have ahready noticed the fiust that penomi who drink faraadj
are aflected with a form of acne rosacea different from thai vUbk
is observed in those who imbibe wine or beer. Of all alqohoBo
drinks wine is the one which gives rise to the most intense ledden*
ing of the nose and other parts of the hee. The aone roaaesa whiah
is set up by the imbibition of brandy is generally confined to .the
nose. Be^ drinkers are comparatively seldom^ attacked by iba
disease. There is no doubt, too, that some kinds of wine tend non
than others to produce it. This is the case^ for instance, espeoially
with the Austrian and Bhenish wines, which are poor in alcol^^ but
contain tartaric acid and ethereal oils in abundance; while the
disease is much less likely to be set up by the more fieiy and moro
highly spirituous wines of Hungary and Spain.

(2.) Disorders of all kinds in the special functions of the £emale
sex. For the sake of brevity I choose this general title, which,
although lacking precision, is, I think, sufficiently intelligible.
It is to be regretted that our knowledge of the disorders in
question is not accurate enough to enable us to define them more
closely.

Careful inquiry has shown that, whether young or old, women
who have acne rosacea generally suffer from menstrual disorder.
As to the exact nature of this disorder^ we are for the most part
obliged to remain in ignorance. The reasons for this lie partiy in the
impossibility, or at least difficulty, of making an examination in the
cases of unmarried women ; partly in the fact that one seldom has
an opportunity of keeping the patient for any length of time under

* Op. cit., p. 668.

BTIOLOGY, 331

obKiTvat.ion ; partly in the circumstance that lier own statemeiita
ore oftfii mftccurate, and of hut verj- Utile vnlue. 1 will meHy
rpinark, by way of example, how seldom one Rcts satisfactorj' and trust-
wortliy answers when one bfIib a young woman whether the meiiBes
r are regular or irregular, painless or attended with pain, scanty or
I abundant. According to my experience, she most commonly sayn,
in the first instance, that she is perfectly regular ; whereas she may
subsequently acknowledge that the exact contrary is the fact, if she
is questioned more clowly, when she and her medical attendant are
on more intimate terms. This, however, is very natural, and must
be attributed rather to the way in which the inquiry is m&de, than
to a desire to deceive on the part of the patient.

A question framed in gcncrnl t«-trms presupposes, before it can be
correctly answered, that the patient herself knows exactly how and
wlien the menses should appear, haw long they ehmild last, and how
great should be tlui intervals. But this is far too much to require
a girl. The proper way is to put precise and definite questioDS,
mcli as tleee : When were you last unwell ? How long did the
fjtow continue P Aflir how many days doej it generally return ?
Is it preceded or accompmnied by pniii ? Do yon suffer from leu-
corrhira before or afterwards, or even throughout the whole interval P
What is tbe quantity, nature, and colour of such a discharge p
I "When do you expect the menses to appear ngnin? — and so forth.
|rhe result will generally be to show that women themselves know
nery litUe about these matters ; but this is the only way to gain
Wie informutiou which we require, and which, for their good, it is
ptccessary that we should obtain. The doctor should tell hi* patient
i observe carefully the various points referred to in the above qoes-
pions, so that after a time he may be able to determine what should
! the normal condition of the sexual functions in het particular
;»!ie, and to prescribe accordingly.

It will, then, be found that in yonng girls who suffer from acne

Osaces the menses are not invuriubly suppressed or scanty, being,

Q the contrary, quite as commonly excessive or too frrqucnt.

Moreover, menstrual disorders arc well known to be themselves

'merely the results of, and secondnry to, morbid conditions of the

urgaus of generation ; and it is therefore incorrect to regard sucli

I fonctional disorders as the cauttt of tbe cutaneous affection under

consideration, The first object of Uic Kientiflc physician must be

D discover what is the nature of tJic primary morbid condition ; for

332 ACNE ROSACEA.

it is against this that his treatment should be directed. But here^
as a rule^ the inquiry breaks down. It is but seldom that one can
determine the presence of any actual disease of the organs of genera-
tion, the symptoms being generally little more than distension of the
abdomen, pain in the position of the ovaries (sometimes extending over
the whole hypogastric region, and even to the regions of the liver,
spleen and stomach, and to the sacrum), sensations of bearing down
(as if a heavy body were falling out of the vagina), and such like.
If we are able to examine the parts with the speculum or with the
finger, it may be sometimes found that there is a malposition of the
uterus, an anteflexion, or a retroflexion, or that the vaginal portion
of the organ is considerably indurated or excoriated, or even that
there is ulceration of the os externum.

Physicians, however, have for centuries lamented the inadequacy
of the means at their command for the diagnosis of diseases of the
internal organs of generation in the female, and have consequently
admitted the existence of uterine disorder, or " Hysteria,'^ *' cum et
sine materia" Now, to those who are acquainted with this fact,
there will appear nothing absurd in the notion that acne rosacea may
arise from such " hysterical " causes. As an additional argument
in favour of this view, I may remark that changes in the intensity
of the cutaneous affection are often distinctly observed to be con-
nected with varying states of the functions of the generative organs.
For example, acne rosacea is in some persons present only during
the week which precedes menstruation, in others only during preg-
nancy, in yet others only when they are not in the family way.
Sometimes, when it has existed in an unmarried woman, it dis-
appears so soon as she is married. Sometimes, lastly, it first breaks
out when the patient becomes a widow, or at the approach of the
climacteric change.

Thus certain cases of acne rosacea can be traced to causes of a
more or loss definite kind. But in other instances we can discover
no condition to which the disease can with any probability be
attributed. In both sexes, and at all periods of life (except, indeed,
during cliildhood), it often enough appears, without the slightest
ground for ascribing it either to drink (in male patients), or to
disorder of the sexual functions (in females). In such cases, the
cause of the complaint remains to be discovered.

For my own part I confess freely my ignorance upon this sub-
ject ; preferring to take this course, rather than, with other writerSj^

TREATMENT.

333

c over and over again names and phrases wliicli are either
iniugless or unsii[)|)or|:ed by [iruof; such aa stasis of the portal
\, plethora ahdiyminalh, scirrhus vcntricuii (Puchs), congestion
c bead, consttjiation, hsmorrboidal affections, bubiluaL errors in
diet, indulgence in acid, smoked, or highly seasoned viands, eating
cheese or fat pork, kc.

B I hove already stated, however, it is a fact that acne rosacea

1 be set up by certain injurious influences, ajTecliug the skin

eetly. Among these are protracteii mid repeated exposure to cold

' e open air, and the cold water cure. On the other hand, I do

not admit that the disease is ever a. conaeigaencc of tiie nose having

been partially frost-bitten (gnKa rosea pe.rmonaliii) , for I ascribe to

Iter causes (those ena me rated above) therednppearanccof the tip of

B or;i;an in some young girls and women. Nor, again, do I allow

lat acne rosacea can be caused by the use of bad soap, or by the appli*

n of cosmetics. I have known comic actors who for many years

nd plastered their faces every evening with different substances,

irithout any injury to the skin. The writers who have attributed lo

Itch applications an action so dctrimeutal seem not to have known

V^v cosmetics are nscd, tliat they arc not laid directly upon the

[ cntatieous surface, but that the face is first smeared over with a layer

of grease, which is thus interposed between the colouring- matter

and the skin.

Tbbatment. — In this complaint very little can be looked for from

internal medicines. It is true that all medical works which treat of

^ acne rosacea recouimend purgatives and laxatives, and restrictions ia

[• diet ; and that good effects are stated to follow bleeding from the

Lreiiis of the feet, the application of leeches to the ala nan and

behind the ears (I''uchs), and the administration of arsenic and even

i emetics. Other medicines bnve b«en vaunted which were supposed

D be purifiers of the blood, such as Viola tricolor, Coehlearia olHci-

is, Tnfolium flhrinum, Nasturtinm aquaticum. Dulcamara, and

ardana. But, in my belief, no one has ever seen tht^e remedies

Kceed even for a time, however long the patient may have continued

D take tiiem.

When, however, there ia amenorrhcca, or the menaca arc scanty,
f when the bowels are confined, aloes should be prescribed. But
e drug would of cnnrse be given under such circumstances, even
1 no acne rosacea were present ; and upon this the aloes has
D direct action, affecting it only ia so &r as it may arise from the

334 ACNE ROSACEA.

abdominal disorder. According to some, the cure may be aided by
the use of vapour and douche baths, artificial or natural sulphur
baths, or douches of sulphureous water.

In previous paragraphs it has been shown that acne rosacea
presents itself under different forms, and may depend on various
causes. It necessarily follows that the proper treatment cannot be
the same for every case.

Here, as everywhere in therapeutics, the indicatio eausalis ia of
the first importance. Those who drink wine or beer, or eat to
excess, must be ordered to live more temperately. Those who have
been undergoing hydropathic treatment must be advised to use
water with greater moderation, although they are not (as Pleuck
suggests) to be urged to imbibe wine. In the case of female
patients any disorder of the sexual functions must, so far as
possible, be removed.

But none of these measures go very far towards restoring its
natural white colour to a reddened nose; and, according to my
experience, remedies applied directly to the affected parts are the
only ones from which a cure is to be expected.

These must, above all, be adapted to the degree of intensity of
the complaint.

For acne rosacea of the Jirst degree, — in which the disease is of
recent origin, is unattended with considerable changes in the cuta-
neous tissues, and consists simply in a reddening and increased vas-
cularity of the parts affected, these appearances being slight and often
present only at certain times, — sulphur (as was taught long since by
Alibert) is the best application — and this whether the affection is
or is not combined with a common acne. I prescribe it in the same
way, and in the same proportion, as for ordinary acne, and for
sycosis ; either in the form of a soap, or of an ointment, or, again,
as a solution of liver of sulphur. The^e applications are best
used at bed-time. The part should first be thoroughly washed with
soap and water ; and the remedy should then be forcibly rubbed into
the parts affected, and should not be washed off until morning.

All such methods of treatment, however, produce considerable
irritation. Hence, after any remedy has been applied in this way
two or three times, the apparent effect is to increase the redness of
the skin, and to make the cuticle peel off in small scales. It is
coTisequently necessary to suspend its use for a time, until the
reaction has subsided. A good plan is to employ it only on

TRKaTMEKT.

335

certain days of the week, doing uotbing ou the oLiier days, or simply
Binearing the aS'ect«d part with cold cream or with some emdlient
ointmeat.

The efiicacy of sulphur in the trejtlment of acne rosacea hm heeu

irued to account in the manufacture of various cosmetics, such as

hhe ' Kummerfe 1(1' ache Waschwasser,' the ' lait Sioilieu,' &e. All

■these contain sulphur, and possess the virtues of that suhstnnce.'

Another substance which may be used in the treatment of acne

rosacea is Iodide of Sulphur. This was first recommended by the

Trench, It nmy he applied in the same way as for ordinary acue,*

jjut it is a painful remedy and unpicasnnt to the patient; and it

lofs not possess any advantages over the other preparations of

^ tlie local applications useful for ocue rosacea of the lirst

re also to be mentioned those containing corrosive sahli-

{-Rieh as i\i^ " oriental lotion" (Orientalische Waschwaaser).

It has already been described in the chapter on Acne,' and may be

used in the Bnme way as in that disease. This remark applies also

. to other mercurial prcj.arations there spoken of, and particularly to

the Emp. mercurialt, the wliite precipitate, and the Ung. Rnehardi,

|pSiade from tlie deato-iudide in statu noscenti.

It must, however, never he forgotten that all these, remedies arc
more or less of a caustic nature, and that the immediate elfect of
their application is apparently to do harm, and not to improve the
condition of the diseased surface. It is only nl'ter a little time that
Kithe good which they do becomes evident. It is thcn'fore advisable
that the patient should be forevamed, so that he may not be
I- disconcerted hy the seeming aggnvation of his complaint, lose
oonSdeuce in bis medical attendant, and fail to persevere in carrying
out the treatment.

In acne rosacea of the »«cond degree, attended with extensive

Lteleangeiectnsis and even with large excrescences, it is essential, in

bhe first place, to destroy the dilated veins, or at lenst to render

1 impervious. The quickest nay of efi'ecting this is to make

It Riny be remarked that tbej all giie b bUck colour to prFpuralion* cun-

aiaiug l«ad, from Ibe oonibinatiDD of the sulpbur wiLh the metal to fonii n

jiburct. Uraoe, while aaj un« of the Liquids id quLitioa is being

uiplojed, it is DEeutar; to avoid the use of ointmaals or pigiueuts in which

' a pretent.

• Vide p. Sd6. * Vida p. m.

336 ACNE ROSACEA.

a number of incisions with a sharp narrow bistoury or cataract
knife^ so as to cut the dilated veins longitudinally^ particularly
those of which the loops are plainly visible, being gorged with
blood. The blood should be allowed to flow for a little while, and
the parts should then be touched with a43rush dipped in the Liquor
ferri perchloridL The reaction which follows this procedure is very
slight, particularly when the operation is not too hastily performed^
but is done at several sittings, the larger veins being first incised,
and afterwards those which are smaller, until at length all visible
blood-vessels have become obliterated.

This method of treatment will often by itself diminish the redness,
and cause some of the protuberances to subside. When it is not
sufficient, the scarifications must be repeated, and any stalked
excrescences must be removed. In this way the nose will be
restored to something like its original form ; and any redness which
may remain must be removed by those same applications which are
used in acne rosacea of the first degree.

It remains to speak of the treatment required when the disease
has reached its third grade, the nose being greatly altered in form,
and enormously increased in size, although the bones and cartilages
remain unaffected. Even in such a case, one can cut off as much of
the thickened and hypertrophied skin as may be necessary to reduce
the part to a bearable condition. The method of doing this is to
remove a triangular piece of skin from the dorsum nasi, A longi-
tudinal incision should be carried down the nose to its tip, and the
skin on either side of this should be dissected off the subjacent
structures, so that two wedge-shaped pieces may be removed. The
edges of the wound should then be brought together along the
dorsum.

The operation may of course be modified in various ways accord-
ing to the circumstances of the case, as, for instance, when the
hypertrophy does not affect both sides equally. I would lay stress
on the fact that, since the subcutaneous tissues are healthy in acne
rosacea, tlie skin alone requires to be removed. The surgeon need
therefore have no fear of undertaking the operation, which is quite
unattended with danger.

CHAPTEU XXV.

PUSTDI.AK ERUPTIONS.

benujloKfs pualutoiif — Impetigo {Panteljlecite) ami l-'ci/ii/ma
{pAlcrilatfn).

UiSToRY. — The meaning now attached to tlie word " pustule " is
I Ycry ililTfrciit from llmt iulctideJ 1»j the niicieiit physicJuns, and
I bj' those (if the iniddle ages, At the present da/ iiotluug is called
I a pustule which does not contain matter, that is to say, fluid of a
I atraw-ycllow colour. But fortnt-rly Uie term was used very lavi»hly,
f will applied to almost every kind of eruption, whether consisting
I only of aoliil red, white or yellow nodules [luiervula), or of a
I yellow purulent fluid enclosed beneath the cuticle.

Thus wc find in Hippocrates a. cluiptcri)e puatHlis prur'iginotit,
which contains the aphorism laia pn»fu(a non admodum pruri'
I ginosit (ni vXaria i^av^itfiara oti wuvv ri KVnofiiiStu.y And
I tliia is explained as follows: — " Puttula lutte, tJ^attM, depreiitt ;
I ociiminttttr, tvblimtt, fiittiij'tafa." The eruption of measles as well
I ta thut of sinall-pox, is called pustular. The contents of the pointed
I and conglomerated pustales {acaminata, coac(ic) ia said to be humor
I b'Uiomt, calidut, teriuin, while that of the flat ones is described as
%j»itHi(o»vt, crattus elfngtiiui.

Galen' uses the term jtualula not only to denote an affection

of the Kkin, but also as synonymous with hi/ilatide«, under which

lillc lie describes a condition aaswcxiug apparently to pericardial

exudation.^ So that the name of pustule was in his time evidently

^ Dot cuuriiied to cases of cutaneous disease.

Wc find a section in Celsus Be putlalarutn generibvi ; and here,
■for the first time, the chaniclers of this morbid product arc fully

' S«i!lio Ti, Apb. ix.

■ "In cute IMC nunc pustulu eicitat, nunc pruritum moTet (m. excre*
Ivicntonini relcullo)." Gsleni Pvrguneni Are Mnlica, qvte et An Pura ilicilur,
Lugduiiii Balavoruin. 1561 (p. ijos).

' " Tcguoienti conlia puslulv, <]iiM, ^Di'a Icuui sqDiuoqae UuiDOro |>leua »uul|
Biydatidn appellaot."— /iW. p, 367 r.

388 PUSTULAR ERUPTIONS.

described^ so that the passage has always been quoted by succeediug
writers.^ He distinguishes four kinds of pustules.

(i.) Those which resemble the eruptions produced by sweat or
stinging-nettles^ and which are either red or not different in colour
from the rest of the skin.

(2.) Those which are livid, pale, black, or of some other un-
natural colour. All of these contain fluid; and on their bursting,
the flesh beneath appears ulcerated. They are called ^Xiicraivai

or cXk(JS€£c-

(3.) Those which are somewhat hard, white, and pointed, and
from which a sanious, or purulent, or mixed fluid can be squeezed
out. These are called ^Xi;^aic<a.

(4.) The worst kind of pustules, called iwivvicTiStg, either
bluish, or dark, or white. Violent inflammation extends around them,
and after they have been opened a festering surface {exulceraiio
mucosa) is seen within, of the same colour as the expressed fluid.

Paulus uEgineta clearly extends the term pustula to eruptions
not containing pus. For while treating of pustules properly so
called, he also mentions, as distinct from iXxest^ pnstula citra saniem
(op. cit., lib. iv, cap. i), and compares them with the Greek
iKZlfiOTOy tKZi(7fxaTa, irepiZifiara.

The Arabian writers distinguisli pustules as benignant or
malignant ; and each of the more famous applies, after his own
pleasure, some special name to the same kind of eruption. Thus
Avicenna ^ uses the terms as^eruj saire, and lotor ; of which essera
denotes pustules with more acrid and lymphatic contents, mingled
also with blood, while Lutor are those of larger size, filled with true
pus — characters which have led some authors to suppose that the
pustules of variola are here denoted.

Rhazes^ names pustules aptintas, but also speaks of them under
the title ;sera, Ilali Abbas, on the other hand, employs the term
sera nod is as equivalent to the iirivvKTig of the Greeks. But it
is evident that these writers did not confine sueh names to anv
particular eruj)tious, or even to cru})tions of the skin at all, for
Avieenna speaks in sonic passajjes of Ivtor pulnionis, stuuiachi cf
alia rum jnirtium.

Throughout the middle ages, we lind tlie same use of the word

' 'Aurchi Cornelii Celsii de Mediciua libri octo.* Lausaima?, 1772, lib. v,
cap. 28.
" Op. cit., lib. X. ' Op. cit., lib. vi.

33a

■pustule to dcDote diffi/rent culaneous aflections. Some writers, a»

Gorrteus, simply repeat the account given by Celsus, wliile Tenieliua

defines tlem as rounded elevations, nsing but slightly ubove the

^Jevel of tbR skin. Tliia nutlior further dbtinguishea two kinds of

BUstulcs — the moist {hvmida), which contain a transparent fluid

^kumor), or sanies, or pus ; and the dry {sicca), which dg not secrete

y fluid. He puts in the first division Bydroa, Ephdidti, Phiyctma

a. Pkli/ctidei, Epin^didei, and the crusts whiii form after these

have burst and tiicir contents dried up {icabiei genera). Among

y pustules he reckons some exantheins, pruritus, and certain kinds

t acne and warts {vari cl venucarum t/iiati/am genera).

We do not find any definition of the word in the works of Mer-
^rialis. Indeed, this writer generally denotes the diseases which
e iu classical times known as " pustulte," by the terms Porrigo,
iekor, Fai-ua, Tineu, PsgJracia, Helchgdna, LHailcula, kc.
Lorry, who, as a rule, is more careful than his predecessors in
lialiing the various forms of eruption, and who possessed a
^er choice of names ihnu they, describes in a separate chapter
e tumours which are developed into pus, or some other fluid.
; first treats ai puitula proper, and then of a second kind of
niption which he makes equivalent to the ^\ut,aKn>v of the
:kB, tlie ^\<>KTaiva and ^Xnicrfc of Celsus; including, under
latter species, yaXattt and 'iZpuia as well as i^av^Sfftara
■Ml'iivjutu^ia wffirtp vtfii Kovara (pustulas combustorum). He
' distinguishes as separate s|K«ics from both, ptiHitlic in-
temmatcrife, npfitvioi and irnvvKTiSft;. It is clear from this
Idaseitication that in Lorry's time the word pustule was no longer
indiscriminately to every cutaneous aft'cctiou, hut deuoled n
distinct form of eruption with [wculiar contents.

Plenck, again, defines the term still more precisely as follows : —
" pHttiiltt aunt itiuiitrei exlgvi, rutjri vel fiavi, quvnim apej in jim
il cTvtUim purHlentitm itiif." lliat he intended to limit the name
elevations of the cuticle tilled with pus is clear from the fact that,
B the section wliicli follows this definition, he treats of tlie pustules
f acue, of scabies, of variola, anil of varicella, and, in addition to
use, of a fifth species, " tcrminthi," which he describes asputluta
iifriatn/et el ardentti-
But Willan has beyond question given the most accurate and
> Op. oil., lib. rii, oap. g. " QuUquid nlundo Mliemata leuler ia cut«

340 PCSTCLAR ERUPTIONS.

precise definition of postole? in these words : — '* Pustuli ; an eleva-
tion of the cmicle, with an inflamed base, containing pus. Postnlea
are rarioos in their size, bnt the diameter of the largest seldom
exceeds two lines."

He distinguishes four rarieties of postnles :

(I.) P^^jzdcifiij, the largest; it contains pus, and rises from
a hard, circular, inflamed base, of bright red coloor. After the
contents have dried up there remains behind a hard, thick, and
dark scab.

(2.) PffJrjdumy minute and irregnlarlv circumscribed, prodac-
in? bnt a sli^rht elevation of the cuticle, and terminating in a lami-
nated scab.

(3.1 J'ior, an acuminated pustule of intermediate sire, contain-
ing a straw-coloured fluid, which has the appearance, ace zearlj the
consistence, of strained honev. It usuallv occurs abo;;i i^ head,
and is succeeded bv a thin brown or vellowish scab. Such pcstules
are called Cfria or F.:ri when thev approach the size of phlrzada.

(4.) Pi^yctU, a small pustule, seated on a circular, slightlv
inflamed base, and containing either a transparent, or a curdv,
whitish or pearl-coloured Ivmph.

Both rienck ar.i AVi.Ijj: used the definite and limited meaning of
|ni5tu!s' in crJer : > injke a group o: those afectfons of the skin
in i:ie course 0: wliicli rustules appear; and while Plenck, as we
have seen. liiviJts :':.:< c'.ass :r.:o five crenera. Willan and Bateman
in compleiiiig :::? work' have adopted a similar classifioaiion. ciliing
the five cviiera o: : us'.uhir iMseas^cs Izii>et:20, PorniT?, Ecthnn^,
^ anohi. a::i Soabit^.

T^is ass.'oiativ n o: r..\:ai::s diferlng in their nature as well as
in their lom: n:u>t be prj:;our.c<:d v^rj unfortunate. But it is still
more to Ve r>r::re::evi ih?.: Wi.lan a*:vi his sucoxss-rrs have not even
taken the trouble 10 exclu.;e frv?n: the sub-.iivi^iou? of the five genera
^cr::!^ ii:5ea5e5 \r':.:ch .ire c:n:V>>vr. :::: rustulir :;: -.ilh

• ft

4 « V ■ «

• V-^Vt- *• ■•* V, «•

'..i:. ^, .a (...M.' '. . / . ■ • ■ » . r>.

» • . • ■7-, • -

• * - *

i^ f;illt'] Iv Cizenave //:-;-:* :. ;r *: .*, Iv M-Cnt^tcn r.l : lif.*

^ » m - •

fo/fttrmi, but was never set n to produce pustules ; ^^ . P, J^A^jntm^

nisToai. 311

iffectioa witliout any other sym ptom tLan loss of Iiair, and Ijetttr

hiitnicd Alopecia areata ; lastly (5)^ P. faiviia of tlic head and face

Kpls. 41 and 43), in wUicli, no doubt, pustules and crusts appear,

rut also red and moist surfaces ; in fact, as 1 have already proved

!o), it must be rfgarded as £czcnin imjiHiginoauin.

But even tlic ossociation ofsueli beferogcneoua diseases as species

Bcf one and the same genus is not so rpprehenHible as the inaniier in

Ivhioh these same authors have described precisely similar alTcclions

Fonder totally ditTerent names. Thus, if wc compare the descriptions

»nd figares of impetigo, and especially /. tp<iT»a and I.fgurata, with

the nccount of Porriso /<ivoi(i, it becomes evident that neither of

these writers would have been able to point out any distinction

rbetween tliem at the patient's bedside, unless the dtlTefcucc of

lality were aceept^id as nuch. Or, again, compare the drawings and

rscriptiun of E^-thyma vittgare and A', faridum (pi. 43), with those

rot Scaliei ptimlenla (pi. 46). Tlie same large phlyzacious pustules

I vbich on the lover extremities serve as characteristic of ecthyma arc

I reckoned equwlly diagnostic of scabies when they occur upn llie hands.

The writers who followed made some nltcrotions in the arrangc-

■nent of these genera, but only increased the confusion thereby.

llius, even DHtetnaii had added to Willan's species of impetigo (/.

rata, iparta and tcaiida) I. erffiipelatodea, and /, rodent. Then

[ i'lrrrigo lupiitota, answering to our favus, was invented, and lastly,

I Ecthyma infanlUe, both of them quite unnecessury.

Plumbc dcsrribes pustular diecases under the heads Porrigo
\:larvali», P./avota, and Impeligo, and thinks he has improved ttic
I subject by explaining ecthyma nnJ rupia to be identical.

Alibert, who, as ne know, publisticd at different jKriods of his

ireer two distinct clBasifieution.s of cutanraiis diseases, funned in

8 earlier system a subdivision of the genend group of "dartres"

r hcrpetes, called Dartres pustulcuses. Tliis comprised the several

forms of ncne, as well as other pustular affections answering to

tbe impetigo of Willan. But, at the same time, in hta last class,

RPwra, he speaks of a Psoride pastuleuac, and describes Willan's

r ecthyma luider the title Psoride croAleuse sordide, figuring it iu the

I last plate (No. 53) of his atlas. In Abbert's second system, he

'escribes, in the fifth subdivision of the first class of Eciematoses, a

i»tular affection under the name phlyzacion, which he explains as

Ejnoiiymous with ecthyma of Willan; and further on he calls tb«

bird group of his fourth class mclitagrn, and makes it correspond

342 P08TCLAR XE0PTI0S8.

with the impetigo of Lorry, Willan, Plambe, and Bateman. Last
in the first group of his third class, Dermaloteg tineosa, he npealu
of achor as a disease vulgarly known bs "la gourme," Porriffo
//ircff/iff of Willan.

So that while AUbert made diven changes in the nomeDcIatare
of pustular diseases, he added nothing to the improvement of this
chapter in dermatology.

Biett reckons among the putiul^, beside variola and vaccinia,
ecthyma, impetigo, acne, mentagra and porrigo. He tliioks it an
important step to insist upon the accurate discrimination between
the characters of pustules. Thus, according to him, pblyzacia nre
charncteristic of ecthyma, pjydracia of impetigo, aud " favous "
pnstules of jiorrigo, while those of acne and mentagra are man
acuminated, and have a broader base. He admits only two kinds
of porrigo, P.favom and P. tmtulata, considering that these alone
show peculiarities which are not observed in any other of the pus-
tniar affections. But by P. favosa he obviously does not intend
the disease so named by Willan, but the Favut vul^arit of AUbert.

The views of Willan and Bateman upon pustular diseases, as thus
inodifled by Biett, were for a long time current, and are found repro-
duced by the later writers of all countries.

Rnyer changed Biett's nomenclature by substituting the term
Favus for Porrigo fuvoaa, but supposed that the affection begins
with pustules. He divided ecthyma into an acute and a chronic
variety, and insisted on its distinctive characters ; but he was also
the first to give up the terras tinea and porrigo entirely, describing
the diseases hitherto so called as impetigo or favus.

Fiichs, while keeping" to Willan's arrangement, added a number
of subordinate varieties of pustular affections, none of them, how-
ever, with really distinctive clinracters. Thus, it is impossible to
see how his Impeiigo faciei iactfa differs from an impetiginous
eczema, and the same applies Xa his Impetigo ochor muconu and
granulaius. What is meant by dividing ecthyma into an E. vulgare,
B. antimoniale, and E. paevdopsora, and by what external signs
these varieties are to be distinguished, Fuchs has not informed us,
and I cannot pretend to say.

All modem dermatologists are imbued with the same doctrinra ;
so that there is not a single French, English, or German work
devoted to the subject, cither exclusively or in jiart, whicli does not
admit ecthyma and impetigo as independent pustular diseaseg.

HISTORY. 318

Dszenave and Schedcl, Chausit, Ducliesnc-Dujinrr, Dever^Ie, Oibert,
Green, Thomson, ami Erasmus WiJaon, the most distingiiiBhed
English dermatologist, in the numerous editions and revisions of
his work — all of them offer us the same names, and the same cha-
racteristics. Mr. Wilson takes jiains to estnblish a distinction be-
tween the pustules which may be recognised as sncii from the first, and
rtliose which are developed from vesicles, and insists that the furmer
Lonly arc characteristic of impetigo. But 1 should like to know how
Ktine can tell by looking at a pustule whether it began in a point of
iQppuration under the epidermis, or contained at first a transparent
|<fluid which has only afterwards bt'comu purulent. This is, in fact,
nly one of t\iosQ pinitfi de dootnnaire with which unhappily we so
jeften meet in dermatology, and (to console us) not much less fre-
tquently in other branches of medicine — mere theoretical statements,
which only serve to puzalc students, not to advance science.

Tlie irnpossibitily of establishing a distinction between those
jpustules which Bit lach from the beginning, nnd those which are
meveliiped from preceding vesicles, or some other form of eruption—
especially in cases where both pustules aud vesicles are seen together
tupon the skill — renders it not only dei^irable, but really necessary, to
Hanite all such oases under the same bead as impetiginous varieties
jof ci'zcma; anil this is what 1 have endeavoured to accomplish in
hhe nineteenth ehnptcr of this work.

But ultlioiigli in tliis manner we get rid of a part of so-called

■mpeligo, including the species described by authors as /. eiytiptla-

foJfi, I. rrgtirmaika, l.fueiei rtttru, Aehor mticotut aud J. granu-

tafua — tbiTc sliU reinnin to be aceoiintpd for thoso cases of pustnlar

eruption which occur upon tlie extremities, and have been iiitherlo

QCtiHwn as Impetigo »}iar»/i nnd Ecthyma. Even tliese, however, need

c admitted as diseases tni gi-aerit only in very few cases, nnd under

dinito conditions; while generally I believe it to bo much belter

I view Ibem as verj- closely connected with certain morbid states

■pon which they depend.

To explain my opinions on this «ubject, it is necessary to inquire
mder what circumstances those pustular eruptions occur which
Five the character of psydracia and phlyzacia, cither discrete or
landing together in groups and heaps, and occupying the trunk
» extremities, bat uBualiy the latter.

. B/ far the greater number of such pustular rruplions appear
I the caur»c of discsKs which are characterised by otiier signs, and

844 PU8TULAU SaUFnONB.

not by puftoles alone. We found thii to be the caw with the pna-
tnles of eezema. Hose who would make a distinction between
B&sema eapiUUU and Impetigo eapUU from the crosts and pnatules
tfaej Me upon the scalp, I would beg to defer their diagnosis until
tiliej have by suitable means got rid of these and all other nunbid
products from the surfiuse. When it is thus laid bare, an unpre*
judioed observer will certainly no longer call the disease impetigo,
but will fed himself obliged to dedare it ecsema, and the spedes of
eoeema known as B. rmbnm. Any one who will repeat tiiis simple
eiperiment must agree with me that these are not cases of true
impetigo or achor, and that they are rightly named E. impetiffi'^

•'^

The same procedure in the case of the pustules and crusts upon
the extremities will show that what seemed at Qrst a genuine J.
figmtoia or /. icaUda of authors is really something quite different^
generally an eczema, and appears as such when the morbid products
which masked its true character have been removed.

a. Pustules are often observed as a result otpmrigo, but without
anything to dista'ngnish them from those occurring in the course of
scabies, ecsema, and other affections {ef. chap. zxi). They are here
devdoped from the prurigmous papules, and (pradually dry up into
crusts which are isolated when the pustules are discrete, but large
and continuous when they are confluent. Hence we often find the
appearance called by Willan LJlgurata, L icabida, in those affected
with prurigo ; but it would be a great mistake to look upon these
scabs and pustules as a substantive disease instead of a mere part of
the general pruriginous process.

Beside this form of eruption, which is usually observed on the
lower extremities, pustules are often seen on the arms and hands;
and were then no longer called impetigo or ecthyma, but Pwra
mteroeatpa, P. maerocarpa, Pieiidopsora, or Serpigo. But here
again they turn out on closer investigation to be only devdop-
ments from a primary eruption of papules or vesicles; and thus,
though reaching the size of lentils, and filled with fine, yellow,
laudable pus, they do not, according to our received nomenclature,
deserve the name of pustules.

3. Lastly, it has been long known that numerous pustules may
appear in the course of scabies; and this gave rise to the very old
name of S, pustulosa, or, as Fuchs called it. Psora mcrocarpa ei
macrocarpa. But no one has yet given us any means of distinguish^

rxJsrn.Ks in eczema, pncntoo, and scabiks. 315

bj; a pustule of cctiiyma or iiupttigo from one produced by acobifs,
nless we accept its localiaatioii ou tlic hands as diagnostic of I he
Utlcr. The result is tiiat we see, at the pre!i*,-iit day, as in Willan's
time, pustules on the hands pronounc<^d lu be those of scabii^,
while others of precisely similar »hapc, and size, and course, are
coiled by the same authors ecthyma or iirtjietigo, when they occur
I upon the legs.'

If now we attempt to explain the occurrence of pusiules in tlip
diseases Just enurnernl«d, the fact will beip us, which has been so
iftcn noticed, that any eruption, whether of papules, nodules
wlfubercttlti), vesicles, or blebs, may, in its further course, become
pustular, by Ihc solid or serous contents of these primary formations
dng transformed into pus.^

Tlius we see that out of the vesielcs of variola, the bhbs of

lemphiguB, the papules of acne, the nodules of boils, pustules nns

' developed which only diffi^r in their size and other secondary points,

but agree in this, that they may all be regarded aa ahseesaes, some of

which are merely subepidermic, while others are covered hy a ihickir

,. stratum of akin.

From this it follows clearly tbnt the appearance of a pustule
I always preceded by another morbid procfss in the skin, viz.
1 exudation, and that this exudation leads to the formation of
nis, and its collection under the epiilermis — in fuel, to ibc pro-
Eduction of a pustule. So that all pustules must be regarded as
*■ teeondary morbid products, and hence are not fitted to form au lu-

' Compire Willou'* 46tb pUle and tie 43Td in Bateau's "Dcliacitiotts*'

wilii tbc 461I) in tlie Uttrr work.

* In using lli» exprension 1 do not meao lo inipN tlial utj mDrbiil product i*

kscluallj tran«ronned iuto pus. I quite agree witli Vircbow*! doclritie llmt |iiis

taool; ba developed byprolJCcrntioafrorn pua.lbooghit mutt b« admilti»l tlmt

B first step, tbe formstion of the primary pua-corpusclM, depends on trniM.

formaiion oT otbet tissue- element), such u blood-discs, epidermic ccilt, atui

connect iTe-ti«siiB-oorpu»cle». Thus mj eipresaion, " trsnsforniBllon," oill

coincide with tbe "ccll-substitnliou" of Vircbow. And it seems to oid pnr-

i-^ulsrl; sppropristp, because it implies that m lornl procGsa goes oa with

relopment of ceitain elenjtiitarj furmations, wilhout requiring tbe >up|>'i.

a speoinl exadalion from tbe geoenl plumi. U Ibus serrei io

Mtc the change of tiow which in recent times hu led us no longer to regard

a molfria fieeeani wliicb is excret«d from ibe juices of the t)odv, but ni

■llic r»tilt or a local process, wilbont any close conneitioo *iUi gcucral outriiino,

Ud origitutfng in ihe " tnnsrorinalioa" of nnnnal tiisuc-elemeats into pu>-

346

PPBTTLAB BRUFTIONH

the unmH

dcpwident species of cutaneous diseases. There are, fherefore, no
proper postular diseases ; but only pustules which may occur in the
course or as the effects of many different affections of the skin.

We must noT inquire under what conditions it is foimd bj
experience that pustules develop themselves, or, in other words, under
vhat conditions does pul form under the epidermis P

In general we may say that in most cases this happens only when
some other morbid product lias preceded it in the fonn of a papule,
Q nodule [tHbereiilum), a vesicle, or a hleb. It is rare for pus to be
produced at once as such, and then it may be generally legafd^
as the result of metastasis.

But since external and directly injurious mfiuencea as tcD as
affections of the entire organism may both produce various eruptions
of the skin, the pustules which are the secondary result of these
may be divided according to their etiology into two classes, which
I will now examine.

{ I .) Pustules arising from primary eruptions produced by «
irritanti.

Referring to the chapter on eczema for a discussion of the i
in which these produce at first redness and then Bubepidermic s
exudation, I have here to add that from a further metamorphosis of
this exudation, or by the progress of the entire morbid process, a
pustular eruption may also be produced. It is, then, no longer
surprising that pustules may owe their origin to any mechanical
pressure, or to rubbing or scratching with the finger-nails.

Accordingly in former chapters I hnve explained at length the
occorrence of pustules in eczema, prurigo and scabies, and have
ascribed them to the scratching which the irritatiou of these
maladies occasions. But as we well know that not only these con-
ditions but many others produce an itching of the skin, aud so tempt
the patient to scratch himself, there wdl often be found pustules
where there is neither eczema, scabies, nor prurigo, but some oth
cause of continuous irritation.

A good example of this is offered by patients who are affeC
with lice. Those infested hypedintli capHh will, by their scratching;"
produce either an Ee;t^ia nibrmn of the scalp or, as a further de-
velopment of this, impetiginous eczema {Impetigo, AcltOT granulatw*
of authors). Again, the attacks of joet/icM^i' vesilmentorvm on llie
skin produce such intense irritation that the patient cannot resist
scratching himself; and the inevitable result of this is, beside more

nsiujes
e othoqa

or KXTKRSAL ORIGIN.

317

B escoriatioii, pustules of phlyzacious fonn. These, as the
Bcratching continues, QC(|uire a hiemorrhBgic circumferencp, and
thii9 present the cbaractRTs of Ecthyma vuli/are, E. luridum of
' in, Alibcrl's P»ori<le croiilfiiae lorditlf. Such pustules aro moat
n met witJi where the clothes are moat closely in contact with
skill, in places corresponding with the folds of the linen,
! the clothes-lice have their favorite aojonrn, on the back of
pe neck, in the lumbar and sacral re^ons, and on the lower
Btremiliea.
The more rare pedicuH pubU a. morpionea are but seldom found
I such numbers as to produce pustules by their irritation, and
pore often only lead to the formation of papules which resemble
pidamina. But in exceptional cases of an unusually large colony
{ lice, stnaJl psydracious pustules may be observed.

Those who like myself are accustomed to see many persona
Delonging to the poorer and abject classes, especially such as come to
Hjbiic hospitals, will remember how many of such patients, covered
rilh pustules on the back and extremities, apply for relief, and that
S every caan these patienla carry with them the »ix>legged causes
if these pustoles in their clothes or in thdr hair.
But beside lice, other insects arc known, which do not live
1 the clothes or hair, but in furniture, in beds, in picture and
niking-glaaa frames, reddish-brown in colour and of disgusting
idonr — bugs [cimice* Uciularii), which suck the blood of men.
Their biting and sucking cause papules or wheals, accompanied
r severe itching ; this produces scratching, and so leads to the
H'mation of pastules.

In the Hime way we must explain the pustules caused by meta-
jorpbosis of the slight exudation produced by the irritation of
t bites {Ctt/ij- pi/>mi«], or by caterpillars [Qaalropacia proca-
ionfa), which generally only cause whenls.

Farther, we must remember the practice still too frequent in
tedicine of producing piutulcs designedly by the application of such
KtanFous irritants as croton oil, mezcreon, and tartar emetic, with the
baiscworthy intention of thereby drawing out some m^Uria pfcena»
■pposed to be lurking in the body.

i but to a great extent at present also,

,il practice, and patients not only bear

I n their ignorance even ask for it. It is

" 1 to ontimony a peculiar action

I-

348 PUSTULAR ERUPTIONS

on the skin, and dermatologists have not scrupled to describe
the pustular eruption it produces by the special name of Ecthyma
antinwniale or Exant Aetna Autennetlii (Fuchs).

I cannot but take the opportunity of protesting against this pro-
cedure as absurd in theory and in practice useless, nay mischievous,
and occasionally even dangerous to life. Medical literature fur-
nishes cases enough of the frightful effects of the application of anti-
monial ointment, and there is probably no practical physician who
has not had opportunities to convince himself with his own eyes of
its iU results.^

^ In adducing some examples of the numerous cases which ha^e occurred in
my own practice, illustrating the cruelties practised on patients by this applica-
tion, my object is not to Gnd fault with my professional brethren. They acted
in perfect good faith, under the notion long before drummed into ihem that
by intense irritation of the skin they would succeed in delivering their patients
from still greater evils. I only wish to show that, in spite of these violent
revulsives, it is impossible to draw out the materia peeeans ; while in many
cases there is really none to be drawn out, and so the campaign, carried on
with such ponderous artillery, is against an imaginary foe.

I have frequently seen children with heads sharen and covered with pustules,
some having formed deep ulcers, and produced a horrible state of things, all
the result of repeated inunctions of antimonial ointment persevered in even
after suppuration had taken place. The object of this treatment was to cure
acute or chronic hydrocephalus or meningitis, or convulsions from serous effu-
sions on the brain, to favour the return of eruptions supposed to have turned
inwards, or to prevent the deposit of morbid products upon the intenial organs;
but not one of these results was ever attained.

Obstinate ophthalmia was formerly everywhere treated by counter-irritation,
at first of the milder sort, by mustard poultices, various stimulant plasters and
ointments, Etnplasium ad rupturas, or so-called " Fleischpech," and, if these
failed, by the inevitable Un^. Autenriethi, No doubt each time numerous
pustules were produced, which spread often beyond the spot where the oint-
ment was rubbed in, and sometimes covered the whole body ; but ophthalmia
was not cured sooner under this cruel and injurious treatment than at the
present time, when few oculists think of employing it. I have repeatedly
seen the whole thorax, frout and back, covered with pustules, as the result
of such inunctions, without ever being able to convince myself that the sup-
posed internal malady was thus arrested.

As an example of the lengths to which fanaticism may go in this direction,
I will mention a case which occurred in the practice of a celebrated physician
ill a large city.

In a family in which several children had fallen victims to tubercle, a little
girl still survived. With the view of preventing the development of a
disease, of which the presence in this case was not proved, this gentleman kept
up a continual suppuration on different parts of her body by means of anti-

OV i:tTEIi:(AL ORIQIN. 319

^■(l.} ItesiJe these pustules proiluccd by Iwiil irritants, arc lu bu

itiwd those wliich arc developed out of some otiicr eruption, itself

e re«>c/( !•/ ait ia/eraai affecti'M of the blood or nervous system.

KSIiu!', Zoslcr and all other kiiuU of herpes arc clmmcteriscd by for-

■M&tion of veaiclea; but the contents of these vesicles nmy become

f, purulent as iii any otltcr case; and hence a time will generally come

tin the course of hd nttnck of herpes in which pustules, discrete or

I agglomerated, may be wen on the face [IL/aeiads), on the gciiitnla

\{H. prosfnital'm), or on the trunk and limbs (//. Zaxler) — pustnlca

jrliii'h we know often alTect tlic akin deeply, so as to cause ulceration

xbA leave sears behind them.

' Hie contents of ncnc nodules, which b^an in the inflammation

r a follicle, from its duct being stopped up with sebum, will grad-

rioalty change into pus ; and the pustules so formed, thongh diH'cring

l']li shape and size, may be readily ilistinguislied from others by llie

t mixture of pus and »ebiim they contain.

The Uebs of pemphigus, when their serous contents have become

purulent, are frequently scarcely to be distinguished from pustules

originally such, cspecinlly at a time when no new and characteristic

I tilehs arc present, and when those already formed, even of a small

I dze, contain a puiiform fluid.

A similar transformation may be seen in Uie case of syphilitic
I'Sruptions ; and general eKperience proves that there is no variety of
I tiiese — spot, papule, nodule, scale, condyloma or bleb, which may not
Lend by becoming a syphilitic pustule.

Lastly, it is well known that the vesicles of variola, including
I ToriccUa, varioloid and vaccinia, become pustules in the course of
* c diacase.

In all these instances pustules arc developed out of some other
nption preceding them; but there arc also cases in which tln-y
^pear upon an inllanied surface in consequence of acute or chronic
'innnlitis, without any other eircumacribed fonnation having pre-
ided them. In ordinary erysipelas (Dermnliiia erjftAematostr) and
I phlegmonous inllanimntioa of th(^ skin, suppuration occurs, either

ftnUl ointment /ur Ikt 'jum qftltrrn yttiri. 1 mjiclf »nw licr, when tliitlrcn
sn dill, witboul, it is Irur, au; B;nij>[«iti of tulrcrculosii, but emaciated,
iducfd, and willi wateelj a spot on iiec bodj not tenncd. And liiicu in tlii»
pTorlunalit ca*e llie oiDlment liad most uoaccoutiUiblj been rubbt^il iu mer
ic joint*, Uie poor cLild Itiul licr liinbt coalncteJ fram Ibe cicattiutioo wbich

850 PUSTULAR BBUPnONB

circumMiibed or extennvej sapeifiinal or deep ; and wliit 18 called
an abscess when seated in the coriom^ becomes a pustule when
corered only by epidermis.

What is tme of a limited dermatitis, also holds when the same
process extends over the whole surface of the body; and the boili^
abscesses,, and postnles which are then observed, have all the same
origin, and only differ as the sapporation takes place in the trae akin
or on its snr&ce. This morbid condition, which may assume a mx»e
or less destmctive character, is often the resolt id known diseases,
especially of those dependent on contagion, as Puduia malifma,
infection from dissecting wounds, farcy, and glanders {MaUammi,
fioXfc)* But since I have already spoken of these maladies at
length, I will simply refer to that passage (voL i, pp. 351-4)* u^
only state here that the pustules observed in them may be either
phlyzacious or psydracious in form, and that they have no peculiar
characters by which a diagnosis as to their origin can be made.
Hence it is not enough to notice the pustules ; but the other local
and general symptoms, which will be found fully detailed in the
passage referred to, must be taken into account before a right
judgment can be formed as to their true nature.

Closely allied to these are the pustules which occur in other
diseases, produced by contagion arising, not from without, but from
some source of poisonous infection having its seat in the organism
itself.

Thus, in puerperal fever, in the suppurating stage of smallpox, in
severe pneumonia with great purulent infiltration or gangrene, and
whenever large internal abscesses occur, one may see pustules sud-
denly appear on various parts of the trunk and limbs, without any
antecedent eruption, without papules, or vesicles, or even redness.
Elevations of the cuticle come up una iciu, filled with purulent
fluid, without any red halo denoting reaction round them; generally
in small numbers, causing no pain, forming no scabs, not tense, but
only half filled with a fluid which has no disposition to coagulate.
They remain unchanged for a time, then increase in size, and,
without drying up, usually end by discharging their contents and
showing a more or less hsemorrhagic surface beneath. The fact that
they do not often undergo any further transformation does not
depend on any difference in nature between them and other pustules,
but on the fact that patients in whom the former appear usually die
from their primary disease.

01- ISTKRSAi, OBIlilN.

351

: must regard sucb pustules as metaslascs lu the skin, and
in{jarabte to other luetastBtic absceases nod purulctit iiifarHua,
g from them only in llie fact that tlie skin, instead of in-
mal organs, ia the seat of the morbid process. Their diaguusis
ests partly ou their offn characters as above described, partly on
' e coiicomitunt general disorder.

From what has been said it results — That the ptntular ajfectiont of
"10 akia deicriied 6jf authort under ike names Impetigo, EclA^iiui, Pot-
jo, Achar, ^v., have no eAetcace at independent dwasea. They
: only concomitatitg or se()uelffl of other cutaneous maladies, the
IBturc of which may be deterinlimlby oUii^r chnrnctmstic appcirnnces,
md generally long brfore any pustular eruption becomra visible.
Accordingly wc must not be content in practice to observe the
! and form, the number and extent, of the pustules of on erup*
, but must still inure carefully iieek to determine what is the
aary disease of which these are the result, Wc must especially
' in mind that a very large timnber of jmstules always points to
c previous action of some local irritant ; hence, in such eusca we

I ask ourselves whether scabies, or prurigo, or pcdicuH or
Iber epizoa, gave occasion for the eruption. It must not, bow-

, be forgotten that sometimes the cliaractera of the original
dy may have passed away or have been destroyed. Thus, the
is-runs of scabies, the vesicles of eczema, ur the papules of
rnrigo, may have disappeared, aud the pustules, which are often
' in undergoing involution, are left as tlio only trace of what
s preceded them.

CotJBss. — The development and retrogression of pustules always
take place after the same general t^pe. Minute points of suppu-

II under the epidermis are first noticed, in the form described by
nilan as achor and favut pustules, These gradually enlarge by

picreasc of the pus they contain, until they become what are called
''.a, with a more or le-^a irregular periphery. A red circle
ficrwards forms around eacti of tbem ; and, continually growing in
ize, they at last become blebs as large as a sixpence or a florin,
' I filled with purulent Uiiid, and answering to Willan's phly-

While still of the size of achores, ot when grown Xopeydracia or

lyzacia, the pustules may stop short in ibeir development ; instead

" icreasiug, their contents begin to diminish, the aiwx of each pus-

iulc falls ill, and it then dries up into a yellow or brownish scab^

-* L

. • • ■ - • . — — i

:• 1 . - ■- .......

' '«- •*■ ■•■■ ■ *■ - .

1 ■

THEIR COtlRSB AND DIAGNOSIS.

353

(ulea &re Buperflcial and affeet tKe «xtremities, they are often accoin-
Epatiied bj ttcliiag, wliilu tliuse more deeply seated and occnrnog on
■ the Iruok are geuerallj^ painful.

DiAONosis. — After having thua discasaed the definition and clia-
iTacteristicB of this form of eruption, the question remains for us,
1 whether there are any distinctive features by which tlie pustules of
ItlifltTcnt cutaneous affections may be recognised. In other words,
I can vc distingubh a single pustule of variola from one of acne, of
I Byphilis, or of scabies ? Are there peculiar forma characteristic of
linipctigo and ecthyma P In general we must answer in the negative.
fWcither ihe size, nor the scat, nor the contents, nor the shape, nor
lllie so-called "dimple" (l)elle) can be assumed as diagnostic
l^marks.

The last appearance, the depression lu the middle of a pustule,

ftirhicb gives it the so-called umbilicatcd character, and lias been sup-

I posed to he characteristic of those of variola, is really to be found in

all cases in which pustule:! nre developed out of pre-existing vesicles,'

but only so long as the contents of the pustule arc not purulent

throughout — that is so long as it is not, properly speaking, a pustule

l«t all.

It follows from this that the anatomical appearance of a pustulor
keruption is not sufficient for its diagnosis ; its course, its metamor-
Iphoses, and the number, distribution and seat of its several con-
I vtiluents, together with the concomitant symptoms upon the skin,
must oil be taken into account, in order to decide the eruption to
^ iu one case to soabies, in another to acne, and in a third
[to variola.

It remains true, however, that pustules do not only occur in the

curse of other primary diseases of the skin : they may also be found

Iwithout being accompanied by the signs of scabies, or smallpox, or

Phcdc, or eczema, or prurigo. Is it correct, or is it convenient to

follow Wiilan's and Bateman's nomenclature so far as to allow to

Uuch pustular eruptions the names impetigo and e^ihyma, or oogbt

e terms to be abandoned ns altogether superfluous ?

If nothing further were intended by the name impetigo than

limply a collection of psydracious pustules, occurring either sepa-

t»trly or in groups upon tlie trunk, the face or the limbs, and if

Ktbyma meant only on eruption of Inrger phlyzadous pustules con-

liied to the extremities, there would bo nothing to be said against

' C(.. »ol. i, p. 337.

IIA r^ 1 lit '^ TT. • n«^/^ 7

•r Cd. Hi:

'■*-

- _— ~f^ -L = T. .JZ^'. T- 2. .r iinc^v

.'I "Lit T a*u:* _
;, IJr: :SiU=* ill.

'•m :. • u= riias rmr*-

•■ ■ • .- ■

r". .■.^:t :I T _ .1

l:*'':.!'l 1 rc L ^." !Li

/ ■ ', '^ ^ ' ^ ' ^-- f— "...^ , ? , ^_^. «?»? .... 2*T . . J i •

* ■ ► •

; •. /...•/ :.','.•■•,';.:.■ \..- ■ J..: •:. .r.j :. .: :-.^>^■. a:J:r.:-

ETtoLOor. 865

'smift, denoted by red [1P3S {Erythema tranntatienm)-} thiaisofc«o
I succeeded by serous exudation betveeu the cutis vera and epidermis,
wheuls ;' and in other cxses by the sigiia of more intense
l-inlliimmatory action which denote an idiopathic dermatitis {D. Iran-

These undeniable facts assumed, the produotioti of h pustule
I under the coDdltioDs given is explained by the ordtnnry course
I of the process and products of iuflammation. For whatever
f the view wo may take as to the nature of suppuration in
general, whether we suppose that pus is developed out of an exuded
blastema or that increased proliferationof cells produces pus'Corpuscles,
as an effect of some cutaneous irritant — in either case the fact
remains the same, niimely, that iunnmmatory products nndergn puru-
lent transforms I ion (eilerig umwandfln).

The primary injury to the skin may be produced by the pressure
I of clothing or ligatures of any kinJ, orhy scratching with the finger-
I tails ; the effect is tlie same, mechanical irritation ; and it follows
I ftnm what has be«n already stated, that scratching is one of the
lindircct means of producing pustules.

In fact, a great number of the pustules which accompany prurigi-
I Dous diseases of the skin are called forth by nothing but the patient's
1 Hratehing. This kind of eruption, as well as that produced by

■ pressure in cases of scabies, Iiiive b«en fully discussed in the chapters
Ion that disease and on Prungo. I need only add here thai the
■maladies described by WUhm as Impetigo tftarta, I. tcaiida,
W£ctifHM vulffare and S. Inrulum may be for llie most part referred

■ to pustular eruptions resulting from the scratehing of patient*

■ ■(Tect^d with scnbiej, prurigo or pediculi. .

(4) Beside mechanical irritants, there arc also several substances
tvhicb exert n similar action upon the skin by their chemical pro-
■perties. They tir^t produce only hypcrtemia of the capillaries of the

■ cutis,* bat if the irritation be continued, this will go on to exudation
Kud, by metamorphosis of the exuded fluid, to formation of vesicles,

■ blebs, and pustules.

I may mention bere the numerous smalt pnstules which aome-
times appear very rapidly after iniinctioii of mencuriol ointment and

' Fidt »ol. i, p. 51. • Vol. i, p. 307. ' Vol. i,

UUior't use ot lh« word " idiopatliic," viit oole on lame I»>gc. — [^d.]
' Cr.. Tol. i, p. 53-

For the

'*T

winra^ iiciik^ a^nCfcTrnTg 311& lave mb. eiijid Ti !■■ mercmriale

• "^
S: ic£szL ^izsfQirsw jKCctt ciL ji i aig g euL . xaaxat enetic ointment

Kue i:mct. rmi^ac^ossw ioi£ cc^er unirffnia? vyi^batoooB^ while

I3tf7 :c<s ^r:>£ii!e ^clj ▼^sbdis^ ce 3cc cz&ci^aeDsiT fcdloved by

IS* :-:nt ^ iii* triXa oL ^ns cxiseii dR«es!i& vpcn the intensitj
cc :bf TTiChTTnc Jirsrs toki iiif jascRic^bLi^rr dL uk ddn. so that
ii OK TUftc^ soBfeliEr pxscxjs Batcrcc Uijkl , iaa ioher p sy di ic ia
<r TiilTsicst vC W UK TssoJL 'HEcae wlo ireud the fonn
oif 4 rfGsc;utf ^ oecsci^ cc xs iiwixb vc«ji ttarrfoie IttTe to
clI UK jejssune iiKise jc cme <^ Im&tgii^ V^af , at another

TV $UK ?szi2Ct:s isccr 10 UK ensCKBs eaOed forth br
M7j' w:,xi. >c^:3. as s^UKaxa or im a rfsinuir fcuM, and maj, like
al c<iSfr«v a^ifrrftTOs twcoDf .iiag^^lg. 1^3$ ve nwr often enough
cCi^^mf :i!>f iLixx:)? ivsarjes of saoasisi or Jf^arM tajra*) vith
]^r£^^^.: rvx&ts as ibfsr apDCKs.. aaiduie&ibey cagaxbe Jiitingni^hed
fr;^ oc^ T<astxkr enrcxaxs Vt axT exiaail McmliMiesL So also

,'rvi>->xrJt: .ic :>tf Tryr^sfi. «lj.t: :£ :b* la'-a^ pass izao pustules

\: ::i :^^ .T.^r :iK^ sctr^rsfn:*. u;*: irJrpiiSe ercpdons of pus-
; u ?;> Inu- ' ./» ' ^ '. '^ ' i- ox TSJiT hf i:r?3-c :r: c j , /. tnatm maiica;
y ^ I jf) A^/iwk .*. fv^.'i^Xfi ,- ire • , I. ,-x-V-v*. But, toaroid
7r.^^;r^.y^*:5:*r^v.T^, i r,*j?: *ii ;i:^ft: :i:5 v"vAS!si5caiaon ha» no other
obw^ ^*^itr. to v^^ jj^f*r.:x''C tc :bf <^'>xx:v*I conditions which
x^\h>A' *r. -j.l^^^xusXv rttjrc'jc er^TCi-Nr ir eaci ewe. In their
c\;*"Trju jLvwyirirof ;i>«^ tc«5:V» i:5fi h^l-e, if at ail, from one
Av,.s'::jcT. ^^r. :r.o«\-, frs^i:::: i^c»* wtivi a^xciparT other eutaneous
o, :Jv%it5;.~^. v^r ^>-v>. Jtrsr v.?A^^.'^^^ Vt irown :r uiinown constitu-

: /, I.' « t vus:,;;^ . r .\ r-.\ :v..:jLr.: *.r:.r^::iro is the name I
>;\\-o ^^ '^A^* *':v..->. •Tr'.:v.cr.: } vwu.? :r. :^'f .^■.:T^- or as the effects
v-: V ;■•>■• v-,;^v.\;vv.< />.<^a5j;"^, ru: s^ir.r..^: S? r:-.pkried as dia^ostic
N v* N , : :>.i-:<>c\ S.;.*V. i^r :Vt ;'\Ar..v.e :*r.e ru5:ulc^ seen in Cises of
N, .1 \s, ;>•ur*^^ a:-^. ?v:;r:vjk ^V.crsr tr.ev ati* vV.t ivves^^.^rr, and mav
tv ^ilhv^ut oVji",^:::*: ::vc* c^<:<<*r.:.,;l vV.Ariour o: the primanr

) ^n:^<^b«TT^.^«s v>f 50ib:es ?.:^* a riVN:utri source of pus-

BTIOLOQT. 357

fnlea, tut it is not the pustules bnt the "runs" which are necessary
for the diagnosis of the disease. Again, we may see plenty of cases
of prurigo without a single pustule, though in othera ihey may be
found in greater or less nnmbera, chiefly on the legs ; and the same
applies to eczema.

Beside these, pustules are often noticed to occur as the effect of
idiopathic indammation of the skin (dermatitis] and erysipelas ; in
fact, tlie terniH so long in use of J). pu»titlo»a, E. pKtfulotum, prove
that this obaervatiun is not a new one. Kow since iii flam inati una of
the skin depend on many causes of irritation both external and
internal, the pustules which occur in their course will naturally
have DO other origin and no other aigniflcance than the original der-
^joatitis itself.

It is of course obvious that cases will frequently occur in which

khe concomitant pustules 1 am now discussing will be found mingled

Irith others depending on some of the caosea described under section

1 1, and then our diagnosis must depend upon a more or less arbi-

I'tnry assignment of the several pustulea to the concomitant, idio-

IpBthic or even symptomatic varieties.

If any one will impartially examine the phenomena preaent^d by an

I inflnmmution of the skin, arising from whatever cause, wiien it is

Laccompanied by pustules, be will be convinced that such a condition

IB ()uite as justly named Eryaipelaa r. dermalitia pUMtulota, as Impetigo

TgnpelataiitB. The choice of one or the other expression will

bepend in each case on the predominance of the inflammation or of

'" e pustulea resjwctively ; but it will assuredly never be necessary

keep to both names, aa we And in many works on dermatology.

I do not myself consider aueh subtleties of sufficient importance to

Ifllaim interest from either a scientific or a practical point of view:

■ ID fact I have only menlJoned thein, tirst as of some little historical

k interest, and secondly in order to contribute something to that sim-

pbficatioQ of dermatological nomenclature, which we are now all

striving to accomplish.

We must retrkon among concomitant pustules those collections of
, matter under the cuticle which occur in various febrile and other
J disorders, auil which may be comprised under the general name of
■^metastatic pustules.

A good cxumple is seen in the common affection known as
miosis. Here, circumscribi'i3 spots of inHaramation of various
nzc appear, and by simply developing into abscesses form boils ; or

858 PUSTULAR ERUPTIONS.

eke their surface mortifies, and the slough thus produced gives the
name of carbuncle {anthrax). But meantime pustules also appear,
scattered among the larger swellings, following their evolution and
course, and only differing from them in the process of suppuration
being superficial instead of deep.

Again, in puerperal fever, in severe cases of pneumonia and
pleurisy, and in all diseases in which suppurative inflammation occurs,
it is a recognised fact that metastases from the primary seat of
suppuration may occur in various organs ; among them under the
epidermis, where they appear in the shape of pustules. These
cannot be distinguished by their external appearance, but only
by their sudden and simultaneous occurrence, unpreceded by any
other form of eruption. They have, however, a certain '' slackness''
of shape from the purulent contents not completely filling the
epidermic cavity (matsche Fusteln), and moreover they are not
surrounded by the red circle due to reaction. They rarely form
crusts, because, in most cases, the patient dies from the primary
disease before the pus has time to dry up.

Such metastatic pustules are those which accompany pysemic
affections.

3. The symptomatic or deuteropathic pustules are those which
form a part of a general disorder, in the course of which they occur
as a regular phenomenon, and thus furnish one of its more important
diagnostic characters.

Thus, we never see a case of variola without a pustular eruption ;
for even the so-called vesicles of varicella, which may fairly deserve
the name from their contents drying before they acquire the yellow
colour of pus, contain a considerable number of pus-corpuscles and
run a like course to that of eruptions plainly recognised as pustular
by the naked eye.

As the eruptions of variola and vaccinia have already been
treated of at length in the first volume (chaps, x and xi), as well as
the diseases known as glanders and pustula maligna (pp. 351, 354),
it will here sufiice to refer the readers to those passages.

Treatment. — It follows from the views I have expressed as to the
pathology of pustular eruptions, that the chief object of treatment
is to remove the morbid processes to which they are due.

Apart from their origin, however, we may apply to all pustules
the general principle that in treating an abscess the pus should be
evacuated as soor 5, in order *t its increase as well

TREATMENT.

359

I ts its prejudicial action upon the neigiibonring parts. With this
■ object thelftyerof epiJermiB which covers in the pus must be opened,
I its coutcnts rcuioved, and further funnation of pus prevented.

If it lay in qui power to make a pustule dry up quickly so as to
form a scab, thus hustening the ordinary healing process of tittture,
this would be certainly the sliortest aod the best way l« cure a pus-
tular eruption. But we have no mcaoa of doing this, aa I allowed
speaking of the treatment of variola, anti must therefore be
I content to employ those mexisores whicli are capable of softening,
I destroying and removing the covering of the pustule and its con-
I tents.

For the first object warm or cold fomentation, us the patient
I prefers, may be employed, or wat<'r dressing with lend lotion, weak
I soiution of zinc or corrosive sublimate, and other harmless lotions,
I or fomnitaticm with such vegetable infusions as mallow, lime, vcr-
I bascum, &c. Simple plasters have a similar effect: — £mplas(rum
I taponii, Empl. de melUoto, EmpL iUhar^rifuicuM, Empl. de tperma-
I ceU), &c., and so have uniiritating ointments like Unguentunt altheit,
I Vng. etiwllieni, Vng. linariit, l/ng. titkargyri. Lastly may be
I mentioned local or general batlis, mud baths, anil medicated baths
I tnd waters, e.g. two drachms of corrosivB sublimate to a bath.

We shall never be able to do without such applications in prac-
I tice, for we need them to comfort uur patient and keep him quiet,
I also to protect the affected parts from pressure and friction, and
lastly, in order to soften the covering of the pustules and %o give
early exit to tlieir contents and hasten their healing. Hence,
although a careful consideration of their effects do not allow ud
to ascribe them any specific action on pustules, we may at least
claim for them that they aoswer our objects and further Die hciJtug
process.

Tlie RCtrofic method maj also bo frequently atlopted with good
I effect, especially when the pustules are few and separated. Each
I Bluiuld be opened by u pointed stick of lunar caustic, and this should
I be brought firmly into contact with the floor of the pustule, so as to
I empty its contents and destroy it as a secreting surface. The pbict^
I ahould then be covered with dry charpie or linen mg, and after a
Ifew (lays the operation should be repeated.

In every case of pustular eruption internal treatment is snpcrflnous
I tnd useless. If it is eansed by a local disorder it is enough to tre^
I this, pustules and all, by the local therapeutics just detailed. If on

860 PUSTULAR SHUPTIONS.

the contrazy it is the result of eooie genienl diaetaey the depositioii
of pas in and noder the cnticle foUows this malsdj in its course and
in its dedine; so that when reooTery ensues, the pustules drjrnp into
scabs, which &11 off of themselves or ma j be removed by the ordi-
nary means*

CHAPTEE XXVI.
PEMPUIOUS CHRONICUS,

[Fomjihul^x. Der Blaaemauttchlag^

Thb sppenmnces produced by pemphigus are so atriking that it
B impossible that they should have escaped the Dotice of the ancient
Writers. And ^et one rjtnnot stvy with certainty what name these
writers gave to the di»case. The word pemphigus, derived from the
Greek vlfi^it, was used by them, but not with the meaning now
attached to it : nor did they apply the t«rms vofi^ot and ira^f i^Xoyt c
ill their modem senses.

The expression " Fcbris pcmpbigodes" was employed by Hippo-
crates and Galen to designate a febrile diseuse, attended with pns-
tuleit in Uie mouth ; mid these {which were, by other Greek writers
named fXuKrtSeo ^XtrKtafvuSic. ipkvtnaivm,) may possibly have
belonged to the Herpe* ioMaUt pel fudalia, »o frequently seen on
the lips in fevers.

In one passage in the second book ' On Epidemics,' however,
Hippocrates compares ^XoirrafvtiSfc with the bulls seen in cases of
burua ; and certain writers have argued that the disease referred to
"i this passage was our ])emphigus. But this isentiitly spccuUtivc,
for it is certain that Hippocrates generally keeps to the etymolo-
I gicel meaning of the word, wlmt he ealls " I'ompholiges" being
comraonly nothing more than bubbles of air in Duids, and " Pompboi"
simply wheals and swelUngs, such as are seen in urticaria.

The writings of Oalen show that the word pcmphix was used in
ancient tiuiea in several distinct seuses. In one place he refers uudcr
the name of " FebrU pemphigode^' to the eihalatiou from the skin
of a patient ; in wiothcr, he speaks of it as a catancous affection.

362 PEMPHIGUS CHR0NICU8.

attended with the formation of pustules. In a third passage he
describes under the same name a *' plague*' (Pestfieber) which is
said to have been identical with that recorded by Thucydides ; and
elsewhere he even employs the term pemphix in its original etymo-
logical meaning, for the spirit {irifXifnK, soul) .

It is clear, then, that the word pemphigus was applied not only to
elevations of the cuticle filled with fluid, but also to those containing
air.

In fact, throughout ancient times, watery blebs were rather
termed ^Xvicrafvac, and under this head we must look in the old
writings for information concerning the disease pemphigus. Thus
in Celsus^ we find the following'passage : — '' Puslula livida sunt, aut
pallida, aut nigra, aut aliter naturali colore mutato, subestque illis
humor. Ubi ha rupia sunt, infra quasi exulcerata caro adparet ;
phlyktainai helkodei^ grace nominantur, Fiunt vel ex frigorcy vel
ex igne, vel ex medicamentis,''

Aetius,' again, speaks of an eruption, occurring most frequently
in women in whom menstruation is irregular, and in children, which
eruption consists of ^'papula" resembling those which are produced
by scalds with hot water. Thus far the description would apply to
a pemphigus. But further on we read " ac biduum aliquando, ac
truluum durans,'^ which shows that the disease must have been
entirely different from pemphigus, and was most probably a
herpes.

Ehazes, too, mentions an exanthem, consisting of bullae, similar
to those seen in cases of burns. He says that they are generally
preceded by itching and redness, and terminate in ulcers, wliich
become covered with dark crusts.

Fernelius Ambianus, Gorrseus, Rondelet (sumamed Piso), Sen-
nertus. Plater, and Musitanus, all used the name phlyctenee or hyda-
tides to designate a bullous disease, which they placed under the
heading of erysipelas. In other points they agreed with the ancient
Greek writers. Gorrjeus, however, made especial mention of the
word pompholyx, — *7royu^oXuS, bullay est elevaiio in humore facta
a spintujialuoso.'

Forestus, again, and Schenk recorded cases in which they observed
such phlyctense on the face in children and young persons. And
so also Lepois (1618), who gave to the bullae the name of hydatides.

' * Dc rc medicn/ lib. v, cap. 28.

■ * Tetrabiblos,' scrmo ii, cap. 62. p. 807, Basel, 1542, fol.

n I STORY.

3G3

In t!ie eighteenth century descriptions of tlie disease were given
I by Morton,' who mode mentiou of a sporadic fever, in the course of
I vbich numerous vatery vesicles (vesiculo; aqneee) spread over the
neck and chest of the patient ; by Thierry,* who referred to an
epidemic which raged among the French troops then (1736) occu-
pying Prague; and by Laughuns, who gave an account of a similar
plague, which depopulated Switzerland.

During the same period several isoint*'d coses were recorded,
I irhich probably corresponded to our pemphigus, but which received
I dilFerent names, according to the fancy of the writer who described
I them. Thus, Faustcnau described a ' Fehrii acuta rencuh-ffynpe-
I lacea ;' FrcoscI, a ' FeirU maligna catarrhalit exanthemaiie» pur-
I puracto-piutularit veticulii-uleerota ;' Golicke, a ' fehru vcttcviarii,'

It was Sauvagcs who, in place of the names which had hitherto
been employed, first adopted for the affection under ronsidemtioK (be
designation of pemphigm, which has ever since been retained for it.
But ttiis author's account of the disease is based much Ipss on any ob-
servations of liis own than on the writings of his predecessore, and
on the cases which they had recorded. Hence hin description aud
his division of pemphigus into five species fail to agree with the
results of our experience at the present day. To his species he gave

. the names of P. major, P. ciulrenm, P. Helvctieut, P. laditrut,

f and P. Sroiilientit.

To the species of Sauvages Sagar added a /', apyretioii ; vhilo

I Plenck admitted only four forms, the P. /rrliriiis, P. apyrflM, P. a

I tMtu evluliri iicepiali {Sratilienti*), and P. CTurun.

Some writers, again, have allowed only one species of pemphigus.
Among these are Linnarus, who termed the disease Morla ; Vogel^

I who called it Fetrit tuliota; Mocbridge, who designated it F^rU

\ vencahria.

It is worthy of note that certain celebrated authors of Die seven-
teenth and eighteenth centuries — Among whom ore Mercurialis,

L Lorry, Boethaave, and Van Swicten — give no description of tho
disease, and da not even refer tu its name. Stoll, indeed, quotes
from Van Swieten the account of a case of builous eruption, bnt

L this could not Itavu been a PffmpAigua cirotttCM, for it completed its

[ course by the nineteenth day.

' '0[>eta Mediea,' OBneTa. 1717.

' ' Midecine Expinmonlalp," Pant, 1755.

Sflt PRHPHIQTI8 CBEONICTS.

It ii|ipriini nt l<-.n5t doubtful of what nature were the cases of
"piimphiijUB" R-corded by Kuignon of Montpellicr, Sotutelle of
Bt^amifon, Durgliurd, lUid Btagdeii. The writer last named enm
uuribuH to t)i(? diw.-a8c coiitn^iuua propcrtjeg.

Wichmana, in hia special work,' and also in his 'Ideen ztir
DingDoatik," laid down witli precision the distinctions betweoi the
febri* bulloia (acutt', febrile iicniplligus) and the Pemphiffn* cArvni-
mn, or pemphigus proper. He stated tliat the true pemphigus is
always a chronic alTi-ction, and gave it as his opinion that the njune
should OS far as possible be confined to HUch an afieetion.

Now it appears to mo thst in this, as well as in many other
medical question*, Wiohmann was right. I believe that his views
were more correct than those of any of his contemporaries, and many
of his successors, induding at any rate Frank, Beil, Burserios,
lliomBs, Darwin, I'inel, Swcdiaiir, Boba, Eekhoud, Biiiiel, and
Robert.

Even Willan admitted the existence of an aeuU fempkigvt,
besides the chronic form of tlie disease, which he termed "pampAo-
fy-r." Of fiemphiffut he gave three species : P. vulgaris, P. con-
tagiomi, and P. in/antili*. Hut ho acknowledged that the only one
of these which he had himself observed was the P. infantilu, the
most common of them. Of neithcT of the other two forma had he
ever seen u case. He stnl^d Ins pompAolyx to be identical with the
Pempkigui apyreticHt of I'lenck, and with the Pempkiffus tine
pjfrexid of Sauvages, Of pompknl^x, too, he described three species :
P. benignut, P. diutinui, and P. mjUtarius.

In Bateman's ' Delineations of Cutaneous Diseases, exhibitinf^
the appearances of the principal genera and species in the classifica-
tion of Dr. Willan,'' a fourth species of pompholyx is described and
figured under the name of P. prurisinosus. This is said to be a form
of pompholyx, associated with prurigo formicans. Bateman (like
Wichmann) doubted the existence of a Pemphtgua acutut, equiva-
lent to the "ft^ni ampuUoia seu bullo»a."

The works of the later English dermatologists — from Ptumbc,
Green, and A. T. Thomson, to Erasmus Wilson, Tilbury Fox,*

■ ' B«i(nig lur Lchro des Pemphigus, 1790, Errurt, 4-
' Ed. 3, 1807.

* 4to, Lond,, 1817.

* 'Skin Diseiuca, Ibelr description, pathology, diagnosis aiid tre«tt
8vo, Loudou, 1864, p. 113.

Hillier^ — contain no new views or ohservntions with reference to
pemphigus. These writers bave been content with subdividing and re-
arranging tbe species described by their predecessors. Wilaon, for
instance, places all the species and varieties described by other
authors under three heads, which he lerms respectively P. acvtua,
F. ckronicus, and P. gangrtsnnimn. This classification, however,
accords neither with the views which I hold, nor with the results of
I my observation of the disease.

Before leaving the English authorities on this subject, I must not
I omit to mention an inquiry into its history by Mr. Savary, the
I rcgulte of which inquiry nre given in an appendix to Willan's earlier
I Work.' In this compilation — a work of praiseworthy industry
I vnA great knowledge — Mr. Savary refers to all that had np to
I that time been written upon jiemphtgus.

The physicians who flourished at the commencement of the present
E century in France — including among otiiurs Ahbcrt and Bictt —
■ added but little to the existing knowledge of pemphigus. The
I division of the disease into P. acutut and P. cironicut with various
\ cubspeciea was nniversally adhered to.

Ad epoch in the history of this subject is marked liy the appear-
ance of the work of Stanixlaus Gilibert.' This writer coUftled
together the cases of pemphigus (whether acute or chronic) which
had up to that time been recurd^d in journals and books, and he
also gave an account of other cases which had been under his own
observation. He divided pemphigus into two species : (a) P. acutui,
Lincluding two subspecies — (i) P. a. tiMtUlaneuA, (2) P. a. me-
mettaiws ! and (i) P. ckronicut, made up of (1) /'. c. timpUx,
P«nd (2] P. c. cmnpliealus. This last he described as ap|>earing in
the courac of various other complaints — vaccinia, erysipelas, scabies,
gastritis, peripneumonia, bilious fever (Oallenfieber), "Jihtre adgna'
mique," "f^e alasiquf," "Jihre alaxique adynamiquf" oedema, &c.
This work of Gilibert's may be regarded as the foundation on
which several later writers — some of whom, indeed, even now form
part of tlie staff of the llopital St. Louis in Pans — have based their
views concerning pemphigus. Of these, Reyer, Gibert, and Ducbesnc-
Cuparc have followed Oihbert in dividing the disease simply into

' riandbook of Skin Diicasci for itudenta and prxelitionen,* flro, I^adon,

' \i\e Uaiillirankliriteii,' A«., vide Dole lo p. 15, vul, L
' Uoaograpliie da Pemphifro*,' Ao., P>m, 1813.

366 PEMPHIGUS CHJLOXICUS.

a P. ocvtM*, and a P. eiromicms; whereas others^ led by Cazenave,
have admitted certain new species, especiaU j a P. pr%rigino9U9 acutu^,
and a P. ^pomtamemt fsbrili*. Hie writer last named^ and Chansit have
established another distinct form of the disease^ under the name of
P,/oliaceu^. A third species, termed ' P. mleereux/ has been added
bj Saurel,^ who sajs it occurs in sailors, on the lower limbs. De-
vergie, lastly, has made his contribution in a "P. hAMrrkagique/^
founded on the single case of a girl, in whom the lower extremities
presented bulbe filled with bloody serum, which arose on the red-
dened and swollen patches of an mrtiearia iubenwi, their appearance
being attended with severe pains.

In Grerman literature, besides the comparatively unimportant
works of Braune, Wilmans, Sachse, Berkovsky, Heinrich Martins
and others, I must mention the valuable monographs published in
the beginning of the present century by Wichmann and by Braun,*
and the treatise upon the same subject by Joseph Frank.

In Fuchs' well-known book,^ the complaint under consideration
is divided into two distinct affections. The acute form is called
Pemphigus {die BrennbUuen), and is divided into a P. simplex,
a P^synoekalii, and a P. sj^mptomaticus. It is stated to differ abso-
lutely in character, course and etiology, from the chronic form,
which is termed by this writer PompholyXy and made to embrace
two species, a P. vulgaris and P. epinycfis.

In the work of G. Simon, which treats of cutaneous affections
from an anatomical point of view, this author devotes a few pages
to pemphigus, but merely collects together and condenses the results
which had been arrived at by other observers, and adds no discoveries
of his own.

With the exception of a book by Lafaurie,^ of Hamburg, the re-
cent literature of the disease consists not of independent works or
pamphlets, but of articles in the medical journals, or chapters in
systematic treatises. This is the case with the observations of
Gintrac, Malnistoii, Bamberger, Veiel, Gcist, Lebert, Hertz, Schuller,
Merzmanii, Plirnin«,aT, Schonhcit and others.

' * Annalcs dcs Miiladics dc la pcnu rt dc la syphilis/ No. 7, 1844, F6vrier,
p. 208; ibid., No. 10, Juillet, 1S52, p. 360.

' * Revue th^rapeutique du Midi/ Mai if,, 1H52.
3 * Abhandlung iiber den Pemphigus/ Leipzig, 1823.

* *Die krankhafteu Veriiiiderungcn der Uaut/ &c.

* * Ueber die Unzulanglichkeit dcr bisherigen Pemphigus-Diagnose/ Wiirz-
burg, 1856.

niSTOBT.

307

Lafaurie is Justly dissatisfied willi the accounts of peinphij^UJi
which had hitherto been given. Uc describes the disease as occur-
ring in suveu distinct forms, to which ho gives the following names;
.{i) " aimultited pempkiifu*" (2) "P. fultaeeux," (3) Eczema pem-
Mffodft," (4) " Berpea pemphigttdti" (5) " P. gypkU'tHcng," (6)
" P, pruriglnosua et lu-bercutotu»," (7) P. purai." lie also ar-
' ranges the species of pemphigus on two otiicr different princij)les.
In one of these classifications regard is puid to the durntiun of the
disease. Thus we have a P. acuiui and a P, eArontcus, the latter
being the same as the f. yo/wccw of Cazeoava, while the former
fe occurs in infants and (children at the breast. The other classification
I hua reference to the complications of pemphigus. It is divided into
V^"pure" !ona{P. purva scu ex/oliativut) and a " complieattd,"
Kthe latter being made up of (1) a P. etzemaUidfit sen Ectema pm-
•jdes, (2} a. P. heTpetodf.» seu Htrptt pemphtgodet, (3) a P.
V pruriginosut, and {4) a /'. aypiiliiicug.

But notwithstanding the indnstr; with which Lafauric has rallcctcd

together the casea recorded by otter observers, and compared them

with those which be himself had noted down, one cannot help feeling

that bis work still leaves (to use liis own expression) au " imtde-

guacy in the diagnosis of pcmphigns. There arc in it several

important gaps, which can be filled only by future investigations.

Of the other anthors above referred to, some have contented

I themselves with simply recording the cases which had come ondcr

f their notice ; some have with more or less success infjuired into

the clinical history, microscopical chamclen, and chemistry of

the disease. When I come to spe^k of these subjects in detail, I

shall specially refer to the valuable works in question.

In my 'CUnique' at the General Hospital of "Vienna, I h«vp, in
Ithe course of rather more than twenty years, seen fifty chutes of
I pemphigus. Upon these the following deKription is mainly founded.
I Koles of them are to be found in the 'Zeitschrift der k, k. Gesdl-
|»chori der Aerzte,' either included in my Annual Reports, or pub-
llished, with my permission, by the pliysicians attached to my De-
1 partment in the hospital,

DErmiTioN. — The disease known by the name of pemphigus (ppiu-
l phigus chronicus, pompholyx) is characterised by the tuccnnDt
I development of bulla; or blebs, filled with a colourless or yellowish
I terous liquid. It runs a slow course, partly because the blebs may be
liprescnl in lai^ numbers at the same time, partly because [resli ones

368 PEMPHIGUS CHRONICUS.

are continually breaking oat at different parts. When it sabsides,
it leaves no cicatrices^ but merely stains of pigment.

The subjective symptoms consist sometimes in a painful^ burning
sensation^ sometimes in itching of greater or less intensity. In
some cases the patient complains of scarcely any inconvenience from
the disease.

This definition perhaps includes nearly all the features which cha-
racterise Pemphigus. But in its course it may vary greatly, and
all medical writers have therefore found it necessary to admit certain
varieties of it, each presenting a particular group of symptoms.

Now I am in general by no means fond of splitting up diseases
according to minor diagnostic characters ; nor do I regard it as an
advantage to create a large number of species. But I cannot deny
that pemphigus sometimes assumes very remarkable forms, and
presents characters which deviate widely from those that ordinarily
belong to it.

In this I am thinking not so much of the mere number of the
bullae (' P. solitarius,^ ' EpinyctU/ ' Terminikus/ as contrasted with
P. disseminatu/) ; nor, again, of the figures formed by their juxta-
position {' p. conferlus/ ' P. en gwupeff of Bayer, ' P. circinatus/
* P. gyratu9y ' P. serpiffinosus') ; nor of the presence or absence of
subjective symptoms (' P. vulgaris^ ' P. prurigino8us') ; nor of the
age of the patient ('P. neonatorum')', nor even of complications with
other complaints {' P. hystericus,^ ' P. gravidarum,^ ' P. inftamma-
tariuSf' ' P. gasfricus/ * P. nervosus/ * P. spasmodicus,^ ' P. arthriti-
\ euSy &c. — of which Martius* enumerates no less than ninety-seven

\ forms in his work). I am referring to differences which affect the

1 whole of the appearances and symptoms belonging to the disease,

|> and which stamp the case as peculiar from its commencement to its

I termination.

Now, looking at the matter from this point of view, we find two

forms of pemphigus. In one of these the production of bullae is

I remittent, or even intermittent ; tbov arise now here, nowr tluTc,

I' over the cutaneous surface; they are all ten4e, conlaininir a

! rather considerable quantity of fluid ; when they burst and their

contents escape, or when the fluid dries up, a n^ic hy^r of cvticU
informed. In other words this kind of |)emi)higus ends in rtwrery.
I shall term it Pemphigus vulgaris. It includes the 'P, simuKaneus'
and the ' P. snccessivus' of authors.

' ' Ucber den BlasemusschUg, oder Pemphiguj,* IVrlia, 1SJ9.

DESCRIPTION.

361»

Essenlially dilTereiit from this is Hie ntlter form of tbe disease,
which has been described by Cuzenavc: undrr tbe name of Pemphigut
Jbliaceut. In it the bullce are ninaller and cuntaio less fluid, so th&t
J the; arc ntirnys iluccid, instead of being t^iise. The fluid itadf is
I purulent, and with the roofs of the bulbc dries np into Hat crusts,
I very like those of an eezcma impetiginodes, fur which, in fact, they
I might be niistAkeii. The surface beneath the crusts is red and
I moist, as in au eczema rubrum ; and it remains so even after tbe
I crusts have fallen off, and maciifests no tendency to skin over.
I Tbi;s kind uf jieiiipbigus always begins towards the periphery of the
I body. The appearances to which it gives rise are, either at first or
I in its further course, oft^n like those of n burn uf the first degree. It
\ Bj)reads per conliguum over the skin, the spots first affected by it
1. remaining still unhealed. Thus in the end it covers the whole of
I the cutaneous surface. It invariably terminates in death.

I. PkMPMIOUS VCUJAEIS.

There is no little diflleulty in giving a detailed description of

P. vulgarit, owing to the fact that each case presents peculiarities of

one kind or another, which give to it a certain stamp of originality.

J However many examples of this dL>cwe one may see, one will

I scarcely find two of them alike in all respects.

The peculiarities lie, now in tlie number and size of tbe bnllae,

now in their neat and arrangement. In some cases the dilfcrcDt

outbreaks of the dineaae take plaee at regular intervals, in others at

periods whicli are <]nitc irregiihir. Sometimes there occors a break,

during which no bleba are to be se«i — during which the pemphigus is>

80 to speak, in a stage " aine Mils ;" — sometimes the successive

crops of eruption follow one another very quickly, and tlius fail into a

eingle very prolonged attack {PempAigut diudnui), after the tcrmina-

nion uf which months or even years may pass before the disease retoros.

This mnltiformitj in tlie course taken by pemphigus explains the

large number of spceies of it which were described by the older

§»Titers, and I cnuQot but admit that it is far easier to recugniso

many distinct species than to Avfmc the characters of a single

^H»rmal form. The selection of a prototfipe among the varieties of

^mphigus must always be more or less arbitrary'.

In order, therefore, to have a tttariing-point for my description^

, 870

PKMPniOD8 CURONICUS.

Bi)d to be able to take the different sjinptoins of the dis^nse in dur

^asion, so that any irregularities in its course may receive att«D-

I tiuu, I will first skcti^li in detail n form of ;>ernpbigus which eom-

I moniy ttrminatca in recovery, and which is of shorter dumt.ion than

any other, a form which i may therefore call P. cnigarit ifniffAiu.

I It corresponds wiih the Jf. idiopalMicus dispersus of children,

described by Sehuller ; with the Pddophlj/tia buUota of Fuehs ; witli

the Terminthi neonatorum of Plenck ; and with the P. iitfantllU t.

neonatorum, snd the P. benignui of certain authors.

(a) In the P. tmlffari* bcfilgniia, then, the bullte are lense and fiir
n number; and in a week or two they pasa through the usual
cliaiigcB. The ]iatipnt then remaiiis free for a longer or shorter gieriod ;
or, if no such interval should occur before a frcsb eruption takes place,
this (like the first) consists of but a small number of Uebs,

This form of the disease is observed chiefly in well-nourished,
previously healthy, individuals (whether children or adults), and is
. unattended with any syraptoma which would indicate that the system
I generally is affected. It is accompanied neither by fever, sleopless-
} ness, increased thirst, nor anorexia. If the btillie do not happen to
I he seated where they are exposed to injury by pressure from the
I ctathea or in some other way, the patient is not at all tucon-
venienced by their presence. The duration of this variety of \iem-
j phigus varies with the number of outbreaks of the bultic, ranging
I from six weeks to as many months.

The bulla; may either occur quite irregularly at different parts of

the cutaneous surface, or they may be collected togclbrr in groups,

being perhaps arranged in circles or aemicirclej, or oven (although

but rarely) in patches which spread toward the periphery, while

they heal at the centre, with deposition of pigmcut. A ca?e of this

kind in which the atTection covers an extensive surface may pmaetit

A remarkable appearance, oinl one quite pcciilinr. I have seen one

' fuch example, in which the disense began m the ordinary way with

I isolated buLhe, but gradually spread more and more widtJy, udU'I

I Af. length the whole of the abdomen and chest iiresented one large

[ brown pigment«d surface, at the edges of which there were still well-

f marked, tense bullas, and also red excoriated spot*, the remain) of

lolherblcbs which hrul recently burst. Any niir wlm h;ii5 not bid

I on oppartuuily of watching the dcvelo|)mcnt

\ commencement woold certainly not have h'"'

Ll^ nue terminated in reooveiy.

DESCBIPTION.

371

r A nmiUr example is figured in Wiltion's Atlas.' This form of

mphigua may be Urmeil P. bentgtitu sfrpir/inotus.
t (fi) Pemphigus vtilgarU Titalignut (P. <liutiilii9, of Wilsno ; P. per-
lancutc tt coutintic, of the Frmch; P. cachecticns, of ScliuUcr).
Siis variety of the olTectioii is cliaractcriscd not by any peculiarity
i llie form of the bulltc, bat by their number ami size, by Hja
npiil succession of oulbroaks, and by the patient's health becoming
qniclkly im^mired, all which circumstances indicate from the Grst ttic
probability of an unfavorable issue to the case.

The bullic generally run together as soon aa they are formed, and

lioftcn lose their roofs, which seem {as it were) to be washed away by

rj^ie quantity of lluid accumulated beneath them. In this way there

1 eitensive and painful cucoriations, which sometimes become

viaei with a layer of croupous exutlutiou, and which skin over at

aiu jwinls, leaving deeply pigmented stxins, wliile other spots

"ri without showing any tendency to heal.

This form of pemphigus generally turminates fatally.

I lu some cases, besides the abot'c- described objective characters,

lerc is present a subjectiva symptom, iaiente itching. Aa the bulln

row mori! numerous, this increases imd it sometimea becomes so un-

nrnbtr, that the patient scratches himself day and night incessantly.

t result is that many of the blebs are destroyed, and that blood

nudes from the expose<l surfaces and dries up into black crusts, fay

Irhicb the general appearance of the case is greatly altered.

There is, then, do essential difference between tlie " Pemphigvn
r pntriginoiut," and the ordinary form of the disease. Itching and
T scratching, with their attendant results, are merely superadded to
^tiie usual symptoms of pemphigus. ' It is nut (as Cazenave suppo-ied]
I combination of two distinct offections, prurigo and prmpiigu*. It
I in reality nothing but a {)empliigus, although it may be caltird
¥ Pemphigus pmrtginotutf" on account of the irritation which ac-
companies it.

1. PeMPHious POLiACECS (Caaenavc).

1 This name is given to a form of the disease, of which the course
■ nrf diffcrcDt &om that taken by the variety above described. In
^ta o( DiscMci of llw Skin.' (olio, iS^B-^. [Vfe Imvo btta
d llie ligute rcfentd la. A -cue of Ibia kioil wu recenllj aJmitUd
fiiul.niicleT Uf. tVilki'acarc. Brief notes of it will be fonDil ta
H ud GucliL',* iS«S, vol. i, p. >86.— £dO

PEMPSIOUS CnBONICCS.

it the bulls are generally at first few in Dumber ; they are not lente M
their waiis are thrown into slight folds. They are not colourless, ■»■
in ordinary pemphigus, but are of a more reddish or yeiloTish tint, I
the injected blootl-Tessels of the base being visible through the ifaia
layer of fluid in the interior.

The blebs first (levdoped constitute centres, rouud which fmhl
onea exactly similar are continually forming. These coalesce « " '
those that preceded them ; the small quantity of tluid which tfae/I
contain escapes ; and they dry up into thin yellow crusts.

Before the crusts are formed, this aS'ection presents the aspect of aI
snperScial scald. In the later period of its course it closely r
bles an eczema. Caxcnave compares its appearance, In thi» Utcr|
stage, to that of a flaky pie crust (Eiattertcig, pltisferic feuillet^).

The condition just described is at firi^t limited to a small pari ofl
the cutaneous surface; but it gradually spreads over the whole skin,r
and that without disappearing from the regions which it originally ■
attacked.

Even in this form of pemphigns the general hejtlth of the patient
is not notably impaired, so long as only a moderate extent of Burlaoe .
is afTected. But in proportion as tbe hulise multiply, and as the ■
cutis becomes more and more widely denuded of its rutioolarl
covering, the nutrition of the body begins to fail, and auorexta, I
sleeplessness, and broken rest join in exerting tlieir injurious tnOn-
ence on the system. Accessions of febrile excitement are from tiras I
to time observed, being generally quickly followed by fresh emp- 1
lions of bullee. As a rule, however, such attacks do not lut mora I
than a day or two. They at first occur only at long intervals, but they f
afterwards follow one another more rapidly, and ut last the fever be- I
comes constant, with but very slight (or witliout any) intcrmissioD.i.
Colic and diarrhtca also are frequently seen as concomitant symp.
toms. The brain and the thoracic oi^ans are generally unaffected.

Pemphigus /oluicvut always leratiiiates fataPy, both in diildreo |
and in adults.

In describing pemph^s as a dtsuse wiiicb oocnts in two prin- I
dpal forms, with seven) minor modifications, 1 hsTe no inU-ntion 1
of implying that these ue entirdy d»titict aod rwcntially difTeroit |
from one another, nor of denying that in prolradcd casu transtttiHul
states are somettmea met with.

Vi't find, in fact, that in a case of pcmph^na ibe bulhc are gene-

DE9CBIPTI0N. 373

nUj larger and more tense at first than when the complaint has
continued for spveral vara, nnd has imiiergone repeated relnpses.
In many in'tfineen, the same thing may be observed even of indi-
vidual outbrtraks of the diseaae. At the commenccinent of an attack
the blebs roaemble those of a P. 6rniffnu»; at the end, they hnve
quite the forni belonging to a P./blMceui.

Again, the same may be said of the " P. pruriffinoiiit." I have
in which at first there waa itching, but in which this
byniptom aftervarda subsided, to reappear only when a fresh out-
re^k was impending, and close at hand.

Thus, although the form of the bullie is in part connected with
llie de;;rra of malignity of the disease, the fact that the case has
Mdy been of long duration is in itself sufficient to account for their
icing flaccid. The forces of the patient arc exhausted under such
rcumstanees, and he becomes unsemic ; moreover the cuticle itself
sses into a morbid state.

In the previous paragraphs I have described perophigua as it haa
rally presented itself to me in practice. There atill remains to
B mentioned a form of the disease, of wliicli hut a single example
I come before me, but which on that very account is the more
eserving of a special notice, in order that it may be duly com[>arcd
fith any future cases of the same kiml.

11ie instatue referred to was that of a woman, aged about forty,
who had some six years before been under my care for pemphigus of
the ordinary benign form, and who had subaequently enjoyed excel-
lent health. Without any premonitory symptoms there npjwared on
-this patient's fingers, and afterwards on other parts of licr limbs and
I on her body, blebs of varioas sizes, containing a yellow or
bhitiah fluid. By the bursting of the bulls (which allowed a part
f their contenta to escape) the cutis forming their base waa exposed ;
hid on Uie surface of this waa found a whitish yellow, glandulnr-
Xiking [drtuig) substance, conwx so as to project into the former
Itvity, and so dnnly adherent that it could not be detached. This
tobstance was evidently of a. croupous nature. Subsequently it wna
^rowQ off, and the usual red surface was then exposed, covered with
kew epidermis, whiofa gradually assumed the characters of healthy
jpticle, except tliut it contained pigment.

The disease ran its course in three montbii. Tiie putii-nt recovered
bid has since had no return.

374

FEHPH1008 CHHONlCrS.

To such a case one might pve the name of Pemphigut dipAlAerU
ticui.

In pemphigus bullfe are sometimes formed on the mucons mcni-
bnme of the mouth and throat. Wlien this is the case, the skin also
is general]; airectcd, hut not invariably ; it has happened that bleba
have been aecn on the mucous tract, while the iutegament remained
entirely free from them.'

A young lady came under my own observation, who during many
years had been habit to frequently recurring eruptions of bulhu,
which often deprived the whole lining of the mouth and throat of
its epithelium, so that the patient was prevented taking food or
drink, and even suiTered from dyspncea.

It is hut seldom, however, that the mucous membranes are so
extensively affected as in the instance just referred to. Much more
frequently a solitary bleb appears, or a few scattered blebs, pre-
viously to, or simultaneously with, an outbreak of ordinnrjr pem-
phigus upon tlie skin. Or, again, they arise only at the end of the
attack, remaining after the bullte have disappeared from the cutaueoofl
surface.

It is, indeed, rntber exceptioQal to observe on a ntncoos surface
real bulla!, that is, actual elevations of the epithelium, with collcc*
tions of fluid beneath them. This membrane otters bo little resislADce
that it gives way almost so soon as an accumulation of sernm begins
to form. It then appears as a white membranous covering, which
is very apt to be rolled up by the movements of the tongue, and
finally becomes separated, and is spat out of the mouth. The ex-
coriations which arise iu tliis way heal over tolerably quickly, And
without leaving scars. Unless tlicap im|>erfect buUn; are developed
ixccssivc numbers, and ia very quick succession, they are of bat
I slight importance, and give pain only for a sliort lime. They
[ always, however, inconvenience the patient more than those on the
skin, and there is also a possibility that they may reach Uie ejii-
glottis, render it ccdematous, and produce suffocation.

In pemphigus the general symptoms are few, and arc worthy of

mention only in the later periods of the disease. During many

. years llie patient eats and sleeps as usual, nud reining hia weight

I and his bodily strength. In some esses, however, the system mSen

A ease nf lliii kind is desoriboJ bj Hollet in tlie WiiclieiiiGliTifl der k. k
I Geaelkcbtft iler Aente,' forthejmr 1861 (No. 19].

DESCRIPTION.

375

lo 8 considerable extent from the vciy first. Again, the outbreaks
of bnllic are sometimes preceded by febrile excitement, which
rca|>pe&rs before each relapse, and at last becomes continuous, or but
H«l!ghtly remittent.

If a patient snlTenng from iremphigns loses his appetite for &
inglh of time, it is a very unfavanhle symptom, and points to a
tnpid termination of the case. Another sign of no less evil omen is
the constant diarrhoea which Eometiioes accompanies this complaint.
I have in some of my patients seen intercurrent prieumoiiin, which

I certain cases has even proved fatal ; whereas other patients have
Bcn affected with tubi^rculous disease of the lungs and peritonemn.

Etioloov. — If there is sometimes great difficulty in detcrmininf;
irith any certainty the cuuscs that gi ve rise to diseases which (like Pso-
Bsis) are of fre<iuont occurrence, the difficulty is infinitely increased
<r a disease so rare as that which is the subject of this chapter.
This is the proper place to give some details as to the freciuency
of pemphigus, relatively to other complaints.

i'rom inquiries which I have hiul occasion to make in the General
, Hospital, the Lying-in Hospital, and the ^'ouudling Hospital, of
■^icnna, and from the reports which are yearly issued by the authori-
s of these inslilutiotis, it appears that there is one case of pem-
tohiguB in 10,000 adult patients, and one in 700 infants at the
Jbrenst. Now, the total number of patients in the General Uospital
■is from 20,000 to 36,000; that of the infants in the Foundling;
BHospital is on an average 85,000. The number of coses of pcm-
phigns would therefore be, in the former institution, from 2 to af ,
a the latter 1 2^, every year.

These data arc based on (he printed reports of the hospitals in
question for the ten years from 1854 to 1863, durinsf which period
23^,000 cases in al] were trealwl in the Genera! Hospital, while
^6,66j infants received the bencJits of the Foundling Institution.

But it must not be forgotten (especially in regard to peraphigua
as occurring in adults) that when, in the monthly or annual reports
of a hospital, the numbers of cases of different aiTeetions are recorded,
itbcsc nrenot olwuys necessarily _/>cjfi cases. For instance, pemphigus
rcry often lasts so long a time, that the patient enters upon a second, or
(vcn a third, year of attendance at b hospital. Further, tlie diseme
■nay again and again relapse ; but if the ease is pirhaps readmitted,
ibis is very apt to be overlooked ; and it is entered, not as an old cuse

II which a return of the disease hus taken phiee, but as a new uuc.

PKMPHIQBS CHH0N1CP8. I

Tbas, in reckoning at Grty the number of esses of ppinphigt
wliich I have seen in the Oeneml tlospital daring s period of n
than twenty years (out of a t«tal of 25,000 patients annnally), I do a
mefin lifty distinct indivtdunls. Probably that number dors 1
include more than forty different patients.

If I estimate at about the same number ibe cases of pemphigl
which I have seen in private in Vienna or elsewhere, this will giv<
total of not more than 100 cases, as the basis upon which my knoi
ledge of the disease is founded.

It is true that I have also had opportunities of seeing the ca»
pemphigus which Lave occurred in the Foundling Institution.
it will be easily understood that 1 have not been able to study tlu
so completely as the cases which have been under my own c
the General Hospital. Indeed, the only occasion of my having oi
particular knowledge of them is when one of the physicians t'
institution has been kind enough to inform me of some especial
interesting case. However, the numerical statement of the c
observed there is correct; and the observations published by 1
medical officers (who are pei-sonally known to Die) are suoh tl
can confidently make use of tlK-m.

These figures show that uewly-bom infants and childrenat the b
are much more liable to pemphigus thon adult^i, in the proporti
of 100 to 1 7, In other words, the disease occurs in infants fourfc
times as frequently as in grown-u]) persons.

WHiether in adults or io children, the two sexes seem to !
about equally liable to pemjihigus. Of the cases observed in <
Foundling Hospital during the last ten years, 57 occurred in n
58 in female, children. Of the twenty. five patients admitted w
five years into the General Hospital, twelve were males, thirb

Witti regard to the relative frequency of the alfection nl differs
ages it is to be remarked that there is no special disposition ti
either in early manhood, in the prime of life, or m old age. But, i
has already been shown, it is more common in infants uid ia childM
at the breast, than in grown-up persons. 8omc authors have 1
serted that in childhood pemphigus is more often acute, in adult 1j
more fretjuently chronic. Uut this i» only liecausc in children ■
diseases run through their coutm more quickly, and Icrminnte iibf
shorter pmod than in adults. It is not to be nipposrd UiM t
" acute" pemphigus of early life is a distinct species.

In his 'Monographic du Pemphigm' (|> 167} Qilibcrt has raUed

tain questions with regard to the etiology of the iliseikse, which

■questions lie endeavoiirei! lo answer jiarlly by liis own experience,

partly by the observations of others. These qncstions are as follows :

1. Whether there are any countries in which it is more common
than in others?

2. Whether the season of the year, or any atmospheric condition,
ifluences its occurrence ?

). Whether the application of any substance to the skin is capable
if causing it ?

4. Whether the nature of the food or drink is in any way con-
semedin its proiluctionP

5. Whether its origin i« in any degree dependent on age?

6. Or on sex ?

7. Or on temjwTamcnt ?

8. Or on any emutionat state ?

9. Or on suppression of the menses, lochia, or htemorrhoidal
paxP

10. Or on the "going-in" of any other cutaneous affection f

11. Or on the omission of habitnal vcntesectiotis, or on a rainy
[toold state of weather?

IS. Whether it is epidemic P

13. Or endemic p

14. Or contagious P

1 will now discuss these dilfcrriit points, keeping, as far as pos-
wble, to the order bid down by the writer whom I have c|uoted.
And, firstly, with regard to the geograjihical distribution of pem-
■ })faigus, Qilibcrt says that there is no country in which it is particu-
larly common, and that no climatic conditions are e«i>eciaUy bvorahlc
to its development. The circumstance that more numerous casrs
-lisve been reported in Germany, Finglaiid, and France than in other
)arU of the world is ascribed by him to the more advanced state of
ibe medical profession in these three countries. Instances have, in
~Kt, been recorded of the occurrence of pemphigus in India, in
frazil, and in the United States of America.

Again, the works of Hippocrates, Cclsus, Actius, I'aulus Jilgincta,

iiviceniiB, Bhazes, Fcruelius, Scnnertus, Mnsitanus, Forcstns, and

Etthers, contain passages which show that the disease existed hi

IBcient limes.

Niithrr the season of the ycnr, nor any atmospheric condition,

378 PKMPHIOUS CHROKICCS-

appears to have any influence on the causation nf pempliigtu. fie-a
corded observ&tions are entirely opposed to the idea tliat it is n
frc([neut at one period of the year than at another. It has been I
found to be equally common in spring, summer, aatumn and winter. I

It is true that Gilibert brings forwiird a number of cases iu witich I
tbe disease is stated to have been caused by the action of great Gold,r
or intense heat, on persons uiiaccastomed to be exposed to such in*]
flucDces. He also refers to an account, by Christian Seb'ger, of thel
case of a man fifty years of age, in whom pemphigus was prodoc
by the influence of an unhealthy wind (d'un veut malsain), and ler-l
mlnatcd in the course of a week. Again, Deliuf mentions an m-r
stance in which the same complaint appeared in a man, aged fity*J
two, who "exposed himself to the evening air (der Abeudkuhl«),l
while his body was very hot." Kobert saw pemphigus i
who bad got a " chill." The same cause is said to have produced s
similar efl'ect in a case described by MirogUo, Other examples oTI
tile same kind have been reconledby Consbruch, Hoffmann, Langhutis, J
and others.

But the correctness of these statements is by no means snfBcientljr ■
proved by the facts on which they are based. It ia an arbitiaryl
assumption to suppose that pemphigus was caused by gettmg ehilledfl
or heated, or by an unhealthy wind, merely because the individualfl
had been exposed to one or other of these conditions, before thafl
disease broke out. The hypothesis has uo more valid nn applicntioal
to this than to many other internal and external dticasea of which. A
tlie real origin is unknown to us, and which we are therefore prona I
to attribute to fanciful agencies, such as those under con^iidcrutiou.

The works of De Mcza, Pleack, Hofi'raann, and Langhans contaiol
minute det^ila as to the influence on the production of pemphigusT
exerted by cheese, by impure or decomposing fooil of all kinds, and byf
excessive indulgence in alcoholic liquors, particularly Klecaiupai
wine, (Alanthwcin — vin A'aMH&ci), corn-brandy, or chfrrj--bmiidj'.

Now, as I have more than once pointed out (in the chapters oul
psoriasis, prurigo, acne, &c.),* many persons entertain strong pre
conceived ideas as to the injurious efkcia of certain articles of dietJ
especially salted and smoked meats, cheese, vinegar, &c., aud partioaJ
larly as to their power of giving rise to cutaiutuwi liiseaMS,
ideas are of course not to be overrouie by the simple e
opposite views on the part of individuals, but only l^ tlw ^

ETIOLOGY.

a70

fof exact statistical observations. 1 will, therefore, make but one
j remark upon this subjecl, — that, although there are wide dilferenoes
[ in Ihe nature and composition of the food taken by the people of
I differcut nations and races, tbc same cutaneous diseases nevertheless
occur, and run the same course, in all parts of tlie world.

The paiideinio distribution of pemphigus, — its occurrence at all
seasons, although the diet uswl ut ditrereiit periods of the year is
different, — its atTecting alike mm and women, infants, adults, and
old people, although l.hey live so very differently, — these facts prove
that the occurrence of the disease is not influenced either by the
quality or by the ijnantity of the food.

It is, however, truellintsome jwrsons arc attacked by urticaria after
' indulging in certain articles of did, and it is also true that an
increase in the quantity of tbc serous exudation which constitutes
the wheals in this complaint is all thai is needed to produce blebs,
lo Ibis way, therefore, it is certainly possible for the ingistion of
particular kinds of food lo give rise to bulln in persons liaving a
tendency to be affcclcd in such a way, — which buUro would coo-
stitute a " Pemjihigu» a6 ingetfiii," for those who should regard tlie
presence of buUu; as by itself sufficient to justify the use of Ihis
term. Indeed, Dcvci^ie has described uuder the name of " Pempki-
gut tliulinus iitmirrrkag^icun" a case of urticaria luitrota iu which
bulliB with hwmorrhugic bases appeared at the sommita of tbc
raised wheals.

Momover, I have myself seen casea of urticaria in which bulls
developed themselves upon some of the wheals, while others re-
' inaiiieil in their original coadilion. But in these instances I have
not deemed it necessary to term tbc disease pemphigus, since
I it* course was not thai of a pemphigus, but tbat of an urti-
caria. I have always rcgnrdctl the blebs as merely the results
n extension of tlie pnthuhigical process (the exudation of scrum)
I beyond its usual limits, is quite subordinate to the urticaria, and
I simply aa giviug to it a peculiar character (urticaria baltoia).

Emolional excilrment occupies an important place among Ifae
' causes to which Dickson and Gilibert ascribe pemphigus, being
I indeed a cause to which all diseases arc attributed, although without
L proof. This is iu fact a sort of nltimuiit re/u-jium in the etiology of
I cutaneous disuast^s, being bruuglit in for those cases which cannot
kbe referred to any other origin, not even to a cold. For my
I I attach no value what(;ver to statements of this

880

PEXrHlGCa CBSOXICDB.

Hnii. Betreen 1848 anJ 1860, the inhslKtiaita ol Vieon* pund

tlirot^h a period in vhicli tamj of ifaein were ptued in circamjUocn

that produced plenty of emotiatud exatemati, and also of deprcsaon.

. In this time there was much to rejoice orvt, still more cause foe

I bnienlalion ; (here were gnat vicifsiludes in atfnirs ; hut pempfai-

I gua was not more commoa thau ia previous rears.

According to Giiibert, perrons of IruphAtic temperameot, and
Itiioseof weakly or enfeebled constitution, are particularly liable to
|,ehronic pemyhigns. I behcve, howevn, that in this matter the
lefTect haa been mistaken for the cause. A Pemphigaa of long
■ standing alwa^a lowers the strength, and impairs the nutrition of
ft the patient. '

Among the cnusea to which pemphigus (tike many other diseases)
flias been ascribed, are certain " loci eommuaet,'^ such aa sudden
I suppression of the menses or lochia, or of a tuemorrhoidal flux (no
^explanation being given as to the cause of such suppression). It
B of course to be understood that " suppression " is here synonj-
I mous with " cessation " or " abseiice."

Now, the cessation or absence of the menatiual flow is seldom the

re-snlt of any constilutioual malady, being generally caused by some

disease in the generative organs themselves. Yarioas morbid

changes in the ovaries. Fallopian tubes, or uterus, may prevent the

ence of menstruation, but, -with the exception of prt^nancy,

I we do not know any process by means of which it would possible

r intentionatly to tupjjrets the monthly discharge.

The same may be said of tbe lochia, and also of the )i hemorrhoidal
flnx. There is no proof whatever of the truth of the prevalent
notion timt Llie cessation of such a discharge must be the result of
Lcatcliiug cold. In nil probability, it is by some organic or func-
Itioiiul disease — whether of the sexual apparatus, or of tlie
Irrstem generally — that the flow Is checked, or its occurrence re-
ft tardcd. Now, if in a cuse of dysmcnorrhtEa (for instance) pempld-
Igiis miikes its appearunce, these need not be related to one another
I as cause and effect ; they may both be the elfects of the same general
ftdiseBse. As a pn>of of the correctness of this reasoning, I may
lftp|)cal to the facts that the ccMtition of the Bui is iuflnit«l} mune
■common than is peni|>higna, and that the " Mupprejuion " of a ia*
Mtii&rge, when ossocialed with SRCh an emptioa, by nn means neC4«>
unly precedes it, hut often accompaaics it, or is even of still lat«r
jocurrencfl.

KTIOLOGY.

381

Thus, llieii, 1 do not deny llio existcucc of the " pempUigui Aytti'

ricut" of authors. I simply explain ita real nature. That jx-uj-

pliigiis n[i|]ears and- disappears in combination with the stTita of

" hysterical" symptoms accords with the teaching of experience.

I The fact need excilc no surprise if we t^ike into conaideratioit that

I tiic same cause may f^ive rise to other cutaneous alfectiona (as, for

[ instance, urticaria) which are allied to [leniphigus, and indeed differ

I from it only in degree. Moreover the existence of a real prmpAiffu*

I kyaf^ncu* is proved by the occurrence of this eruption &s a constant

I accompaniment of pregnancy, and by its disapiicarance [in such

[ cnsen] within a short time after delivery.

Certain writers, (for example, HolTmann and Ucbri5art) have

asserted that pemphigus may break out when a person ccasea to be

blcfl at fixed intervals ; and the klter even maintains that it may

follow tliB stoppage of a very severe diarrlitca. In my jadgment,

[ Bucb 8tat«nients no longer fall within tlie scope of scientific discus-

[ lion.

The previous occurrence, and particularly the " tupjire^aitm " (to

\ use the term which once was in vogue) of certain diseases, such as

morhilli, rheumatism, and tinea, were supposed to be capable of

causing pemphigus by Stewart, Gjlibert, and llobert ; but, of

course, without the slightest foundation fur such an opinion.

Other authors attached great importance, in reference to thu

causation of this disease, to a aup^>osed suppression of the urine, and

L t\ta to actual disease of the kidneys. C. ti.C.Braunc,' for instance,

I says: "The kidneys {or organs which excrete the urine), and also

I tbe liver and other viscera and glands, become obstructed or in-

[ farctcd, or their blood-vessels arc contracted by a temporary spasm.

I Now, their function is to remove from the body certain acrid mate-

I rials which are incapable of being used for nutritive purposes. If

these materials are retained by spasm, or by obstructions of any kind,

they arc necessarily thrown upon the skin, in consefjnence of tbe

sympathy wbich exists between it and the kidneys; and they form

on the cutaneous surface a peculiar and " identical " (tdentisch)

_ eruption. Hence, in all probability, pemphigus is essentially due to

I an acrid principle (Scbarfe) retained in tbe kidneys, and thrown ujxin

' tbe skin,"

This writer aUo enumerates stony concretions in tbe kidneys

1 among the causes of pcmphigua ; and he accordingly dividss tiie

■ * Vcriucbc uber den Pempbignt uiid dsi UlucuQeber,' Leipisig, 1795, p. 63.

PEMPBincs cHBoncn..

dtramc Com or it into a ipasBotfie fitietj, or ^. i

imfaretilfv mm, and * P. a eemenmadm — '-iTwii i
Thu Ukqi; of Bnuix vu afttfwsnb dopCed 1^^ |

tin*, ami putieularljr bjr Fuchj. Tbe writa Ivt a^K

his " Pompinffr pemjiiijuM einniemj^' » " ow rf tbe i

pMtur>, occurring with no [cat firqaeiH^ m i

idiopathic uriiuij diwrden." And agaia,

aumriimpa ariiea from Blight and tnositait dtaoider of 'tie t
wcrKtion." He speaka of it a* appearing when t^ c
urine at the end of acute di«ea>cs it interfered witb, ■ftrr i _
in «tiiDulating food, ovcr-irhtating to the anoarj appantai^ bT

In fup])ort of thue OBSKFtions Facha relied on ontaia rht-mif^
data, degHnding on obtcrvatioiis of tlje reactions of the nhne, aaj
of the content* of tlit: bulUe of pemphigus. Thus he* statol that
the duii] taken from the bullse has an add reaction, and that vboi
they hurat the; leave moist patches and sores, which pour fortli ■
•rcrrtion reftmhling urine.

80 far back ni the year 1841" I refnted this theoir, not oolr bj
clinieul obtu-rvations, bat also by citing the results of analvses wbid
I'rof. linj*\iy lind made of the fluid from the buUffi, and of the
liluod and the urine of pittientd ufTected with pemphigus. Soon
ftfliTwurdi, Br. C. ]!. Heinrich,* of IJonn, an'd likewise Simon and
Alitriilge, tuloptod my view, in consequence of investigations which
tlicy hnd mode, niid eases which they had observed ; and from that
time tlie theory of i'uchs was entirely discarded.

Nor can nrtlirjtis, nor syphilis, any more than a metastasis of the
urine, be proved to hn the cause of pemphigus. Quite recently,
indeed, Dr. M'Cull Anderson* has published an account of a »ypii~
lilio [wmpliigus of the palms and soles, occurring, in an adult
patient, in assooiation with undoubtedly syphilitic eruptions on the
liond and face, and with otlier symptoms of this disease. Kicord,'
toot has described and figured a similar case. But, even if the cor-
recluesN of tlio observations be granted, tbey do not prove, and the
M'fiters who placed them on record did not suppose, that the forms

' 0]), oit„ p. 456. ' Op. cit., p. 451 et seq.

* '.Idmliiiiiiioliu Jshcbiioher dea iiat. Staatos,' 184J, p. 334.

* 'Mikroikopitche und cliomi»cho Boitriiga mr pmktigcheu Uedicin,' Bonn,
1844. p. 83.

* " A Sjpliililio Pemphigus in (ho adult, is lUcro such s disease ?" ' Qlusgow
MuliiCHi Jouriml,' Jul;, 1864, p, 138.

* ' Traiti oomplet dei Maladi«i VJn^rieuues,' Paris, 1851, pi. nv.

ETIOLOOT.

883

of pemphigua uow under our consideration are the result of
I i;philis.

Whether in cliildren or in adntts, the bnllw to which syphilis

' gives rise have peculiar ciiarnctcrs, which enable their BVpliilitic origin

to be recognised at once by those who have the nece-Hsary experience,

exactly as is the case wilh the other cutaneous martiTestatiutis of this

disease.

On tliia point I may refer the reader to the differential characters
of the iullout typhilide, a detailed account of which will be found
under the head uf diagnosis.

At the risk of bring tedioas I must in the next place remark that
although biilia may be produceil by the appliciitioii of various irri-
tants to the skin, yet such bullm, however numerous, do not conslt-
j tttte v.pemphiffut. Among the irritants whtch may give rise to this
I ' effect are heat and cold, mechanicai agencies (such aa pressure and
tfrictiou), and chemical, such as the Emp. cantkaridii, sinapisms,
Miereum, &c.

Among other causes to which the disease has been ascribed ere

diiUa ((>)n8bruch), uncleanliness (Hebr^url), railing into stiuking

F Biarali- water (Gilibert), the bite of a seri)eut, even touclnng a dead

I aerpent in Brazil (Sauvagcs), the bite of a dog, treated for a long

time by irritating applications (Muuton), and, hutly, cutting up a

pig which liad died of a guogR'nous comphiint (brnndige Uriiune).

Bnt the cases on which these statements are founded all belong to

the one or the other uf two categories ; either they are inxtances in

irbich, fto( a pemphij/ttt, but a cerUiin numifr of Mia were in fact

roduced by the alleged cause ; or Ihey were really examples of

)enijiliigus, in which, all other recognised causes being absent, the

Biuplion was attributed to anything which liad occurred to the

^tientjust before it broke out.

Medical literature contains numerous records of the prevalence of

1 epidemie pemphiytu, at dilTercnt times, and in various loealides.

z who maintain the existence of an acute pemphigus tbink that

\ is this which occurs epidemically. We tind descriptions of such

I disease written by Schenck in the sixteenth century (i^^^) ; in

^e eighlecuth century by Albreeht (1732), Thierry' (1736),

'Itanghans' (1752), and Hacbridgc, of Ireland {1766}; and, even

■ M^c<;ino eipf rimenlnlc,' 1 751; ; "' PeniphJirui ilo C«inp>."
' IkMhreibuDg del UmatluilM,' 1753. Zilrtcli; 'Aola Helvetics,* ii,
r. jCo ('■ Pemphigus hElvetious").

381

PKMPHIGUa CHRONICUa.

ill the niQeteeiilh century, bj Petict, and by Whitley Stokivf, of
Dublin (1810), ill a paper oa "Pemphigus gangnciiosns."

Of these alleged epidemics two (thai which occurred at Prague 111
1736, and that i)i Switzerland, described by Laiighann) are said to
have been of a particularly malignant character, and even to liave
afforded un mi stake able evidence of contagion.

Having never myself been privileged to observe au epidemic of
pemphigus, I have no choice but to rely on the accounts giron by
the writers above named. I would, bower, eipress my concurrence
with a critical remark, made by Gilibert, namely, that the very pre-
sence of an epidemic disease in all these instances, in addition to the
bullffi, is sufficient to show that these last were not the agents which
commnnicateil the disease, but that the [xjwer of propagating Jtaitlf
belonged to tAr- malady which was snpposed to underlie the eruption,
but of which no writer gave any more precise delinition.

Authorities have long been divided in opinion as to whether or
no pemphigus is contagious, XinnteuB, Cullen, Vogel, Macbridge,
Blagden, and many others have asserted that it is so ; Pison and
Morton Dickson have maintained the contrary. Ousson, Ozauam,
and Martin have without success iuoculated the fluid froui the
buihe, and I have with no better result done the same thing, either
on the same patient, on a healthy subject, or even on myself, in
every case that has come under my observation.

That pemphigus is nowhere endemic has already been stated in
the paragraph in which its pand^nniir distribution is spoken of.

Certain writers, among whom is Lafauric, mention what they csll a
"«/i»«^flWpemphigU!t," by which turmthey evidently designate such
bulls as are produced intentionally by the patient, by mcanaof som«
irritant aj)plied to the skin. Now, I am not my.i«lf of apiiiton that
the name of pemphigus is correctly given to such artijiciat bullons
affections. But 1 may nevertheless point out that there ar«
several things which may give rise to bulln, or, in other vorda, to
g " limulaied pemphiffut."

In the first place, almost every one is aware that by the prrssnrQ
of clothes or bandages, or by the friction of two opposed surfnccs of
akin, a bleb, or even sevwal, may be produced. Such an effect ia
observed, for instano-, on the soles i>f the fret, on th<^ htvis nnil on
the backs of the toc:5, in soldiers, in jouroeymcn, and in tourists, and
cvcti in persons who walk very tnocJi in the slrceta of towns. Snub
" blisters" prevent the individual from going about witli comfort.

■•■nJ may even hinder him from walking at all. When tliej break,
t raw surface is exposed, which gives much pain. And if this be
gtill further irritated by prt-ssure or friction, suppuration may take
place, the akin around may become red, inihiaimation may extend
along the lyiupiiatic vessels of the Umb or prt affected, and the corre-
sponding glands may becomB swollen or even suppurate.

In children and in very fat peraoiu blebs sometimes form on the
■buttocks, where these rub against one another in wulking. Siich an
iDectton is termed an Intertrigo /iuVota (Biaaenwoir). Again, similar
■" blisters" may be produced by the unitkilfnl application of bandagics,
r by wearing hadly.Rtting rtays. and the use of these may in conse-
tqnenec have to be discontinued. Some fonns of bedsores also
Bbcgin as bnllte [Decu/iitut iu/lo*u»).

Tlie fonniition of blebs of tliis kind is especially apt to occur, if
Ibo individual be in a bad statu of health, when exposed to the open-
lion of the above mechanical conditions. A healthy man may tie in
bed for weeks or even mouths {41s is seen, for instance, in the
KcBSG of a fracture of the leg) without bullie making their appearance
■.over bis sacrum or shoulder-blades. On the other hand, in fever-
Ipatientjt, is lying-in women, and generally in all persons who are ill
Isf febrile complaints, blisters very soon begin to form in these
■.Bitaations, constilnting the so-called " DtcvbiluB lullo»u»." In
J healthy children the skin remains sound, even when they are not
B'Carefully washed ; but in those who arc 111 hullie are very apt to
1 appear on the buttocks and inner surfaces of the thighs. Such ap-
liif-anuicfs ought to be. chissed with intertrigo, but they are undoubtedly
■ often mistaken for the disease which Fachs dewribed umier the
Baame of Paidc/iA/yiii madeKfnt, bullota, etciaroiiea, and which
WWillnii called Rupia eiekarotica,

Hcot is well known to be among the causes which may produce
■bailee — an elfect epoken of in the first volume of this work' as Der-
mmatUu eomiiittioni*, el con^eiatimtia, bulhia.

Under the name of vesicant-) or " fpUpmillca" medical men and
■the public generally are wont to apply tg the surface certain snb-
■■tanccs [such as cautlmrides and the cortex mezerei), supposmg
them to be capable of rUriring from the skin all kinds of diseases,
ml or imaginary. Bulln are jiroduccd, and their apjieamtice is
■Icgardcd as a proof that the " dcrivalion" is taking place satisfac-
torily. Opinions differ widely as to the extent to which this plan of
' Vidfti-p. 313,3)5.

PEMPHIGUS CUB0NICC8.

treatment is capable of doing good. Tlierc ure unfortunately very
toanj persons (and among tliem physicians of considerable reputation)
wlio think that the a])pltcation of a large bliat«r (v&icatoirc cam-
phor^ large) is capable of relieving very much, if not of curing, &
patient with an internal inflammation, such as pneumonia, jileoritia
or peritonitis. Others place vithin somewhat narrower limits the
indications for the use of vesicants — employing them in those cases
only in which it is supposed that a morbid state of the nervoas
system may be lessened oi removed by irritating the periplieraJ
cutaneous nerves.

Now, if subjected to unprejudiced inquiry by any one ac<|uaiiiicd
with the natural course of the above-named diseases, this plan of
treatment will certainly not justify the hopes and otpcctations formetl
concerning it. But yet the great bulk of mankind cannot be made
to give up this product of a superficial knowledge. It will probably
remain for s future generation to transfer to tile duimiiii of hislury
such practices of torture, banded down to the present time from tlie
days of Hippocrates.

The course taken by a factitious pemphigus ought in itsiilf to be
sufficient to show bow erroneous ja the supposition tlint intrrad
maladies can be " derived" from the skin by the production of %
cutaneous affliction (whether exan the malic, vesicular, pustular, or
bullous). Nature here provides a number of sources, from which
are constantly oozing streams of fluid, which some choose to call the
" Materia peccans," or the " acrid principle" (Scharfe) of the disease.
The patient perhaps congratulates himself (or allows those nrouud i
to congratulate him) that there arc so many poiota at which all Ids
complaints can discharge themselves outwardly. Itut in the end .
he finds out that in spite of Ills " pempiij/tu" he does' not day by
day gain strength and health, bnt on the contrnry keeps getting
thinner and loses his appetite. In fact be grovs worse and votse
in proportion as more and more discharge is poured out, until at
length, about the time tlmt all the maftria: peccanUi must havn <
escaped, he dies —the result, we must suppose, of Ids having got quite
well!

Tlie obse-TvatioDs of Boock and Daniellsen have recently brought to |
light a new source of ti " PempAi^ut gymplonadcti^' iii the SitjiiaM'
iioM Ofiecorum. This tcrribh; malady is in many caaea preceded bgr
sn erapliou of hullw, concerning which the writcn abore ni

ETIOLOcr. 387

' tnake the following remarks in the text appended to their volume of

plates i'

"In Elephantiadis GrEecorum at the time when the skin hecomcs
sible, niid only at this time, it freqnentlf happens that at
b Boiun points where the sensibilily of the surface in greatly diminished
I or entirely last a pemphigus appears, of the origin of which the ])atient
I ean give no account. The bullie often form during the night, and,

when thiB is the case, they unually Itreak before the patient awakes in

the morning.

" It ia, however, no uncommon occnrrence for a bli^l) to come out

in the daytime, and it has several times hnppened tliEit tlK: autliore

have (so to gpeak) been able to see it apjiear. The size of the buUw

in this disease vitries^ from thnt oCa hazel-nut to that of a hen's egg.
LThey arR tolerably tense, arc filled with a yellowish nwirly transparent
I fluid, and in fact are almost un distinguishable in appearance from
|those seen in burns, but have no iutlamed bonier.

"In the course of five or six hours they become less tranitparent,
Iwid their contents more viscid; and they are surrounded by rose-red
r rings, about t'" broad, lliey gradually increase in size, the red

rings grow broader, and the contents daily rc(|uirc more consistence,
nd at length assume a milky apprnDince. Hy the eml of six or

eight days they have perhaps reached double their original size.
J Finally they break, a sero-purulcnl fluid escapes from their int^'rior,
I uid if the epidermis which forms the roof of the ulcer Cf] he not
LrcmovEd this may heal in a few days. The cicatrix which follows is
Ion a level with the rest of the skin ; it has a slightly reddish colour,

■ but disap|)eani completely after some time.
" If, howevCT, the epidermis (when the bnlla has broken) he from

ftwiy cause detached an ulcerated surface fonus, and this may for a

■ long time continue to pour forth a viscid purulent floid, which
■dries up into moist brown crusts. These sometimes fall ulT and are
■Tenewed. When the nicer heals it leaves a somewhat depressed,
kahining white scar, which never disappears.

" In genera! only one bulla is present ut a time. If, however, it
lliappen that several exist simultaneously at didt-rent points, they
latl run the above-dpscTibed course. When a solitary bleb has
Rip[ienred at a particular spot it is almost always followed by othen
I at the same upot. In fact in most cases st^veral ap[)enr in succesitii^n,
' Recneil d'OlwemlioDS sor lea htaluliM de la Pcau,' par MM. Bocck et
GD. lit. iii, Tuliu, Chriitiuiia, t86i, p. 3.

888 FSXPHIGUB CHROmCUB.

one after anoiher. Thus the aSSDetioii may laat tat yeua, during
which, except for tcij short intervala, the patient is nefer firee
ftom it.

''It ia moat freqnoitty in the earheat atagea of Elephantiaaia
Gnsecmim that this pemphigus is originatty. defdoped. But it
doea not entiicfy disi^pear in the kter peEioda, although the in-
tenrala that elapae between the different buUfe are then longer.

"It would aeem that the affisction in qneation has a special
predilection for certain parts of the sikin, especially thoac^ anch aa
the elbows, kneea, handa, and het, which are aabjeet to pressure,
firiction, or direct mechmiical injury. Exampkst, however, are not
wanting of its attacking other parts, — ^in one or anothar caae of ita
attacking almost ereiy part Thna it ia certain that the anesthetic
ddn readily becomea afEected with pemphigua at thoae pointa which
are exposed to alight external irritation; and alao that the affection
is not infrequently seen at other points, where no aoeh cause for it
can be discorered.^'

All that I can add to theae remarka of my eateemed friends, the
Norwegian writera above quoted, is that Prof. W. Boeek showed
me at Christisnia patients affected with Elephantiaaia Gnsoorum, on
whose skins sup^dal white scars were risible, which (as I was
informed) were the marks of the prerious ponphigus.

Akatokt. — ^If the development of the bullse of pemphigus be
watched from their first commencement certain varieties will be
observed in them. Sometimes a circumscribed light-red spot ap-
pears, perhaps of the size of a lentil or fourpenny piece; this is
paler in the centre, and may even present a tinge of white, indicating
the point at which the bleb is about to form, and from which it will
spread outwards over the surrounding red surfiBce. In other cases
the spot, besides being red, is raised above the level of the surround-
ing skin, and in fact is at first a wheal, passing afterwards into a
bleb. In yet other cases the bleb is not preceded either by a red
spot or by a wheal, but begins originally as a small collection of
clear fluid beneath the cuticle. Thus hypersemia of the skin may
exist before exudation is poured out^ or the latter may be formed
before any congestion of the papillary layer is discoverable. In this
respect the bullse of pemphigus arc precisely like those which are
produced artificially by vesicants, and therefore by watching the
formation of a blister one can sufficiently study the process by
which blebs in general are developed.

ETTOLOQY. 889

rag to the observations of Qustaf Simon,' there
I ajipear in tlio first place small vesicleii, which gradually inrrease in
[ iinc, coal<««', and ullimatcly form the large bleb or blister. If
I the vesicant be applied to a )iftrt where the Iiair-t>acs are tliinijf
[ Bcalten^d, tbe cuticle remains in contact with the cutis at tboM
I points which are ihe seat of hnirs, longer than at those apota at
which no hairs exist. ITii; surface of the newly formed bleb is then
I marked by depressions corresponding to the sites of the hair-sacs,
I white the intervening surfaces are raised : this being the result of
V the adhesions between the epidermis and the hair-sacs, But as the
I quantity of Huid in the blister increases it breaks down the ndliesioM,
I ud ibe cuticle then becomes uniformly raised.

If the cuticle forming the roof of the blister be removed and its
[ under surface examined, it will be seen to present a number of
[ email processes, which arc in fact the linings of the ducts of the
haii^sacs.

lu pemphigus the buUie are formed in precisely the same way.

vVccording to Wedl' microscopic examination of the contents of
tJic bullffi yields the following results : — The fluid, which is at first
k colourU'ss, or of a yellowish tint, contains originally no formed
I elements, or only such as an: in the act of developim-nt. On llie
I apphcation of heat it becomes turbid from the production of a ftne
I Succulent precipilale uf albumen in n molecular form. Sometime*
I one may even obtain a pcUicuhir deposit. A sort of stnicl urcless
Ijuembrane is produced, which falls into fold!<, like a curtain that is
I drawn aside, and may be spread out to cover n considerable surface.
I On the addition of acetic acid this snbatancc undergoes no change.
I "l^' hether it is, or is not, of a colloid nature remains to be determined
I by future inveslignlions. When the fluid contained in a bleb
I becomes opaque it contains pus-corpusch-s in largo numbers. A
■ little blood, too, is not infrequently poured out by the inilamcd
|cutis; and this reddens the fluid.

Onstav Simon says that the contents of the bullae of pemphigus

■consist of a yellowish -white turbid liquid, corresponding in compo-

ffeition with blood serum. In tliis liquid float a nnnibiT of ordinary

is-ccUs, which form a light deposit if it be allowed to stand for a

'D'tt tinutknnklieitcn, darch aiiat<»iii«elie Ver&nileruogcn eriKnlert,' ii
^Auil , Berlin. 1851, p. 195.

' Qmnils&ge der pallioIogiuibeD Hislolo^e.' Wlen. 1654. )> 344.

890 PSMPHIOU8 0HB0NICU8.

Saw days. In the oases examined by Simon it always Iiad a feeUe
alksline reaction.

According to my own observations^ wiem a 6ie6 isJtrHJbmedt
the action^ on test-paper, of the fluid contsined in it is perfectly
nentral. Bat in the case of boIloB which have existed a longer time
I have always found the reaction alkaline, at first feebly, but after-
wards more powerfdUy.

Chemical analyses of the contents of the buUn of pemphigus have
been made by different observers. Frans Simon^ obtained the
following results, from a specimen of sp. gr. 1018 :

lanooiiiti.

ftt, imJading dwJflstcrips 2*600

SsinK^ive matters solable in alooliol, lactate of soda, dUoridsa

of aodiiim and potasaiam 6*500

Prindple aoliiUe in water, resemUing ptydin (Spaidiebtofl) i^gioo

Aibnnkon, with plios{dialea 48*000

Water 5MO*

Acetic acid and piu-oella oadetmiiiied.

No urea could be detected in spite of the most caieful search
for it.

Five years later. Dr. C. Berth. Heinridi, under Simon's direction,
examined fluid from bullse upon the same patient. According to
Heinrich, it bad on this occasion a powerfully acid reaction, from
the presence of free acetic acid. The following are the results of
his analysis:

Ib 1000 puts.

Water 959*8

Solid matters 40*2

Albomen and muoons oorpuBcles .... 28*1

Fat 3*

Extractive matters 3*

Fixed salts 4*5

In a case of this disease which was under my care Prof. Baysky
analysed both the contents of the bullae and also the blood and the
urine. The first-named fluid was feebly alkaline (not scii), and of
sp. gr. 1021. It contained 21 parts of solid matters, including
albumen, fat, and lactate of soda ; but neither uric acid nor urea.
In the blood, again, there was no urea ; the soda-salts in it were
diminished. The urine was strongly acid, of sp. gr. 1020. It

' 'Beitrage zur phjsiologischen und pathoiogischen Chemie und
skopie,' 1844, Band i, p. 284.

ETIOLOGY. 891

I yielded an excess of lactic acid, and also of urea and uric acid, bnl
[ nut of uinmoiiiacal salts.

More numerous analyses Imve, in fact, been made of the urine in
[ pemphigus than of fluid from ihc buUtc. Thus IlcUer^ examined

tlie urine of a patii^nt who ultirii:itely died of the diaeaae. The sp.

gr. was ini7'5. It was made up of ihc following constituents:

Water ■-%,-, So

Sdiil mottcn .... -tA'iO

Urra . . . 14-63

nrio aciJ . . _ . o-^S

Extr«cLi<cs "'79

Yhcd aalu 7'jo

Of the fixed salts the enrthy phosphnto were present in the
Donual proportion ; the sulphates were in great excess ; tb« chlo-
rides comparatively diminished. The quanlity of urea was oonsider-
abty leaa than the average.

The results of the nnidyaes above referred to, of the contents of
[ Ibo bulla; in )wmphigus, differ a good deal from those of an exami-
nation by Girardin of the fluid from some bulla which were deveU>{>od
I on the abdomeu, and which Wilson is inclined to regard oa of on
herpetic ubaructer. Tliis tluid contained :

WbIm M'J'Soo

Solid maltrra 6o.;oo

AHjutncn 49*100

Cbolril urine ^'■ilS

Alooliolic Gilnctivu ■07,'!

Pbosplmtea of (oda and lime and chloride of lodiuin 3'TSO

IlilliiT asked Dr. Gee to examine on four separate occasions at
' short intervals the urine of a boy, seven years old, atfectcd with
' pemjihigUB. The results were in some respects not very concor-
[ dant, but when combined are as follows :

Brine 456 cub. etmlr.. or 16 dudcc*.

Una - i7'4J4gniu. or 368-S gnios.

TJrioacid 0514 ., or jgj „

Cbloride of todium .... 3893 „ or 60' „

Lastly, in a case of pcmpbiguB which came under Prof. Uamber-
I ger's observation, and which he believed to be of syphilitic origin, one

'Heller's 'Arclii* fur pbyiiolt^iMhe and p»tliok>gi»clic Chemic und
I Hikroakopii!.*

■,- - • *

V-:--

.-. ■ 1 ; ;■/ .■ - * ...

tt».:-..!t.i , a-. ;i ^'.;. ■• '. .r:.o- f.l '/-.,/.:.. \:. .rT c.:.

. "... a" .1 .il".-*.!

.5 v^. ,.'.':: are

ETIOT-OGT. 393

mown to us, amyloid drgenerations may present themselves."

He 's of opinion, loo, that other cutaneous affections of longstanding

require to be placer] in ihe samn cnlegory. He qant^s an observo-

[ tioD of Professor Lindwunn, who found amyloid degeneration of

Ktbe cutaneous papills Iq a case of chronic skiu diseaso, which

Iterminated fatally after twelve yi-jtiV duration, and in which the

l.ip|H>anuices were so heteir^ncous, that it was uncertain whether the

I «lTection ought to be called pityrissia rubra, psoriasis, lichen rubn*,

ir ichthyosis.

I can from my own experience add notbing to these statement*,

■iinTiDg made no investigations in that direction in the cast-s which

l^liave come before me.

DiAGNOSia.' — In the reoc^ition of pemphigns, when in its stage
lof full development,, there is no difTumlly whiitever. No other
e ia attended with the formation of bulla) over a large surface
\tnd in successive outbreaks.

But the cose is very difTerent when the complaint is beginning, or

when it is already of long standiiig. Tlic mere presence of n few

(uuall blebs on particular regions of the body does not conatitnte

I pempbigufi, for in herpes and even in ee^ema and scabies the

I Vesicles, when crowded together, often coalesce into buUro. I

^ would particularly draw attention to the fact that 1 hare nenn in

adult patients three ciwes of scabies, in which there were formed,

beneath the burrows of the itcb-mite, blebs as large as beans or even

I hazet-nnts, tilted with a transpareiit tluid, and similar to thow of an

fc ordinary pemphigus. The disr4ise would certaiidy hove been mistaken

I for a pemphigus if one had not recin^nised the cnniculi which ran in

Ithe roofs of the blebs, and winch of course showed that these were

■Ibe results of irritation caused by the acarus scabiei. In children

lecabics is even more commonly attended with such apjieaninces.

To avoid falling into errors, therefon', one must, in examining a
■'bullous eruption, keep before one's mind all the different causes by
i*hich it may Iw produced, and even reserve to some extrnt one'i
Tjodgment, until by the Dccurrmce of a i^cond outbreak of blebs all
|donbt as to the nature of the case bas been removed.

There is, however, another class of cases in which it is still more

leasy to make a mistake, — those in which a pempbigns has existed

Bfor a lone time in a severe form and over a large extent of surface ;

1 that in fact the cuticle of the whole integument, or at least of

nide continuous tracts, has been undermined by fluid, and has been

894

PEMPniOrS CHKONICUS.

in part washed away, iii part included in the crasts which have been
fonned. In auch cases no stratum of healthy epidermia exists which
could form blebs. The ajipearances just described are observed!
principally in that variety of tlie disease which is termed P.Jbliaceut;
they ore very similar to those presented by an Eczema rubrum {B.pem-
phggodeio^ I^faurie), for which, indeed^ the disease might aatiiralljr
be mistaken by any one who had not seen the case at au earlier period,
before it assumed this peculiar form. There are, however, charactas
which enable its real nature to be recognised, even in its later stages.
These are the diffusion of the eruption over the whole cutaneoiu
surface; the weakness, depression, and emaciation of the patieut,
the deeply pigmented appearance of the skin ; the entire absence
infiltration; and there being less itching and less discharge thai
in cases of eczema.

On the other hand, it is easy to diatiiiguiah a non- syphilitic
pemphigus from a bullous eruption of syphilitic origin. In the
latter the contents of the bleb always dry into thick crusts; in the
former no such crusts are ever seen, the nearest approach to them
being the formation of thin yellowish "crustoe lameliosaj" (Schup-
pengrinde). Again, the crusts of the "Syphilitic pemphigus "alwaya
have beneath them ulcers of more or less depth ; in the non-syphilitic
disease these are wanting. It is only when the bullffi first break
out that the two aJTections might possibly be oonfouudod : for theai
neither crusts nor ulcers exist. 1

I have only further to remind the reader of a remark which B
made when speaking of the so-called P. acutus,' — that (as an excep-
tional occurrence, or by the coalescence of vesicles originally distinct)
bnl1[B may be formed in several other diseases besides pemphigua.
This may he observed, for example, in variola and in varicella, and^
also in herpes iris, urticaria, erysipelas, S:c.

Prognosis. — At the commencement of a case of pemphigus it itfj
not possible to say with certainty what will be its termination,
general the following are to be regarded as favorable signs ; that
the bulla:, unless very numerous, are tense ; that fever is absent
that the patient is not very advanced in years, nor very debilitatei
On the other hand, a very bad progiiosia should be given when th(
blebs are flaccid and but little raised, when they are present in larj_
numbers, when they occur in an old subject, when febrile symptomij

es.

' Vide vol. i

P- 395'

^^^^

PROGNOSIS. 895

low tfaemselTcs, when there is loss of Bppdit^, unci
vers fail.

, a pemphigus is less dangeroua in its early
S? wheQ the patient has already gone through aevciul
attacks.

'ITjus, we may give a roore favorable opinion in those forma of the
I disea!>c which benr the names of P. /ifniffHM and P. ki/nierieut
I than in P./oliaceut. But in general one should be prepared to
npect that pemphigus will in tho end terminate fatally; and there-
fore the prognosis should always be guartled.

Tekatmknt. — Medical writers have differed so widely in regard

to the causes to which they have attributed penijiliigus, that they

f have naturally been no less divided in tho remedits which they have

■ proposed and made trial of for its cure; and yet no nietlidne has

■ hitherto been discovered which has shown itself capable of checking
I the progress of the disease.

This unsatisfactory conclusion is the one to which observers have
l>t all periods tended.

Thus in the work of Joseph frank' we find the following note-
I worthy passage : — " Against purapliigus 1 have miule trial of various
KTemedics, diuretics, purgatives, onli^corbuttcs, the viols tricolor,
' issura, the inoculation of scabies, inunction with oil, nervine tonics,
mineral ncids (particularly nitric acid), baths of »Ii kinds, sulphur,
mercury, borax, lime-wat4;r, potash, soda, milk, animal and vegetable
.' diets, and many other things besides, — but all in vain. Some extol
kiron, others venKset-tion, and yet others cold. The fifii Irealmmt of
upie diaeoK if to leave it olonc. In a simple case of pemphigus
) medical skill and care are efleetivc, not so much by the administra-
tion of medicint^, aa by regulating with judgment the conditions
in which the patient is placed, and by protecting him from whatever
may be bjnnoua. Without doubt it is fruitless to seek for htpreiji':

I One must act according to the general indications, and at mo»t
Icndeavour to alleviate the accidental complications which may arise."

By tlie side of this quotation, from a writer of a former generation,

II may pla»! the following remarks, from the work of Dr. Hertz, on
Pemphi^a chronieve : — "The more powerfully a disease re^i»ts nil

Inedical treatment, the more numerous are the remedies which arc
|lccommendeil for its euro .... According to the most trustworthy
Fobscrvations no real si>ecifir exists, and therefore treatment can
' Op. cit., 3 Thcil, p. 101.

»• • tw

- .»-*

-. • ■.

I •

-:* " .wT L-r- '.^ •: li -;. Hl-TL-^ ' SriL'rls.'.;^

TREATMENT. 397

ive found osd'ul m pemphigus, Llic first to be meutinned ia eolti
III some cases I have employed baths and douches, in oliiera
X)inpTC3Se3 coiitiuuiilly applied for a coDsidentblti length of time;
md in otiier instnuces, bi^jiides the compresses, I have used the
regular hydropathic method, including " packings " in wet sheets
and mild shower- ba ths ; and after & cnurae of seveml monthi' dura-
tion, 1 hav« soinetiintis succceduti in elTuctiiig a cure.

In Bome cases, again, I have mailn trial of t«^id baths, bat these
have not always been well borne by^ the [jaticnts ; and sonie patients
lie even refuiwd to continue tbem, in consetjuence of the bullru
Komirig more numerous while such bnths were being used. In
c instances I have added to the bath bran, caustic potash (half a
ruin to the [lint of water), or corrosive sublimate (one third of a gmio
•■ pint) ; and with these I hove often obtaim-d good results,
lomctimes, lastly, I have prescribed lar, batha ; that is, 1 Irnvc had
tile patient rubbed all over with the ordinary ot. eadinum or ol./itp,
IDd have then plnced Iiim in a bath, in which he remained from txn
D fourteen hours, or even for a whole day and night, The first few
bmcs that the tar is ajjplicd it gives rise to a certain amount of pain,
■bich sometimes even lasts as long as &n hour, but ia of no great
intensity. But if this plan of treatment be continued, it causes les*
md lesi pain, and those spots which were denuded of their cuticle
idually heal over under its um.-. In no case have I se^n " Ur
Mths" produce any unpleasant effects, although I have repeatedly
(dercd them, not only for "pemphigus, but also for psoriasis and
icr chronic cutaneous alTectiona.
Another mode of tjrcatmcnt which I have several time^ employed
Irith advaiilage is that of the tm/ile cvnlintnnt* balk. One of ray
patients bcgnii by reiiiaining for a hundred dnys and nights unin-
terruptedly in tlic bath, with the exception of the times at which the
bowels were relieved. Nine months afterwards a relapse occurred ;
lad be then returned to the bath, and Iny in it continuously through
k hundred and nine days and nights. Uc was cured of bis pem-
diigus.

I have since used the continuous bath in three other cases of
«in)]lLigu8. One patient niinained iu it screnty-six days, another
rty-soen days, the tliird twenty-six days. By the cud of these
iriods re5)>ectivcly a cure took place.

In my early trials of this plan I considered it to be necessary to
tnploy a special apparatus, of which I have already given a full

r ■ -•

- ' • ' ., "

-■■ . «.

• '^t-

T •

> •

1 .

•r •- . .

■ ■ I • »■ ■/ ■/■'

. .;';

■ ^

- -i

CHAPTER XXVII.

SchmutzJiechU.

My intention in treatiiiff in a st-paratc chaptor the condition
loted b; " Ilupiit," ih not at all to sanction the usual view tliat
icre is a non-sypliilitio disease of tlie skin wliicli retpiirps tliis title,
the contrary, it b my opinion that no i>ucb non-speciHc malady
its, and that all the suppoaed instances of it ought to be other-

named.

HiSTHttV. — In looking through the works of our prwlecessors, we do
It lind among thoao of antiquity or of the middle ages any mention
ir the word " Uupia" as denoting a ddinitc discMC, or even describing
eculiar condition of the skin. According to Rayer, the ti^rm
ira.1 Qrst applied by Lorry ; but, on referring to the passage, it is
evident that the latter author says nothing about rupia, but only
nses the Latin word rupe$ in its ordinary sense.' Nor does the word
oecur m the well-known works of Plenck and Wiliim. It is in
Bateuinn's account of his sixth order of cutaneous diseases that we
first fmd a midady described under the name of rupia. It is placed
with varicelhi, vaccinia, hcr}KS, miliaria, eczema and aphtha, and is
led as follows :

An eruption of broad and tiattish veaicles in different parts of
le body, which do not become continent ; they arc slightly inflamed
at the base, slow in their progress, and succeeded by an ill-con-
ditioned discharge, which concretes into thin and superficial scabs,
that are easily rubbed off and presently regenerated."

Batemau proceeds to divide mpia into three varieties — B.
iplex, K. prominent, and Ji. rafiaroCiea .^ the first, he says,

' More corrccllj wtillcn RJijpii, from fiv*os. torAe*. dirt,

* Id speaking of ulcnn. he snyt, " linrrrt Mepe cali* cruktii Buperpautli ei
nipiiim nil insUv »eH oiutun cieipirnlihiu." — ' I)c Morbis CaUmiis,' p Si.

* See iiii reprcMutationB in plates S3 aiiJ 54.

400

consists of " little vesications," the fluid contained in which '

la tliickeu, and becomea nt length opatjue aud somevhst pun-

fonn."

This description is, in my opinion, self-contradictory, for vendj
cannot have puriform contents. Indeed, the otdy characteti
peculiarity which is assigned to rupia (or rather to the vnriely j
j)r(mineiu) is the conical scab or crust " not unlike the shell c *
small limpet." _

The subdivisions of the disease made by Bateman do not appear
suIKoicnlly distinct from one another; and, on the whole, I camiot
see tluit Ihis writer was successful in justifying the admissioit of
uon-syphilitiu rupia into the list of recoguised diseases of tiie s]cia,J

But, allliough Pliimbe, Alibert, Biett, and other contempora
of Buli:[naii protested ngidnst the systematic introduction i
special ciitaiieous disease under the name of rupia, insisting that it
is impossible to establish a distinction between it and ecthyma, yet
later writers, some of tlicni still living, English, French aud German,
have reproduced witit scarcely any variation both the de&oitioD]!
and the ilassiHcation given by Bateraan.

In the works of Jonathan Green, Todd Thomson, Fox i
HiUicr, down to the latest in 1865, we lind the existence of rupia
assrrttxl us beyond all doubt, and these writers only dilfer as to
whether it should be jilaced among iuU/t, vetieula, 01 ptulul^, and
whether three or only two species of it should be accepted. Etw_J
Krasiiius Wilson, in the first edition of hli work (London,
p. 143), placed rupia along witli pemphigus, and described it i
bullous non-syphilitic disease. Since then, however, he has obaen
that ocdy syphilis can produce that peculiar form of cutaneoi
disorder wliich is distinguislied from all others by its conict
•cabs ; and, moreover, that beneath these crusts there may alwajl
bo found ulceration of the skin. Accordingly, Mr. Wilson 1
himself corrected the error in his original account of lupia, as mi^'
be seen by a reference to the later editions of his work.

Among the French authors, Cazenave and Schedel, Gibert, Chausit,
Dcvergie, Itayer, wo find an almost uniform definition of rupia.
D^ollesul^■Dupllrc, however, only mentions it incidentally in speak-
ing of ecthyma, and hence does not regard it as an independent
disease. Uupia is usually defined in French dermatology as charac-
terised by " separate flattened blebs of various size, ^ed with ft,^
eerouB, or purulent, or sometunes dark-coloured Quid, and dryi

t^rilS

uorS

appear
:aimiot
ioit of

•oratijS
I of ^

that it

A, yet

rman,

QitioDjfl

witbfc^H
dryiadH

I ec tt

ntsTORr. 401

(l into thick crusts, bciicatb wliich more or less deep ulceration is

find iu Bayer the most ^icalous defender of rnpia as n distinct
. lie maintains that it occurs more frequentlv than pem-
phigus, and that if it is not generatlj- recognised as such, thi> dependii
iifioD the fact that in rupin the blebs are never >o numerous aa in
the latter aflection, and that they soon become co>ercd with sc^bs,
that surgeons have described theui as atonic ulcere. Huycr also
!rts that tlie tlattened blebs of rupia, contoiuing a semi-opaque
cannot be confounded with those of pempliigus, wliicb an
', jiromiuent, and tilled with perfectly transparent serum. Morc-
', he procceils, it is equally easy to distinguish the thick, imbri-
crusta of rupia, oflca very prominent and like oyster-sheila in
Appearance, from Lhi^ It^uf-like kininie of pemphigus when arrived lit
the same stage. lastly, rupia may be recogniwul ns distinct from
ecthyma by its primary form being vesicular and not pustular, so
it (according lo Unyer) tlie only difficulty th»l could arise would
Then eruptions of both rnpia aad ecthyma appear at the same
ic and upon the same individual.

Of Uermun dermatj^logiata, lliecke givej no observationa of his
own, but only repeats those of the iVendi and Bnglisb writers,
inclining rather to the views of Alibcrt than lo those of Itnyer.
itav Simon also says but little of rupia from his own experience,
nfiocs himself to a recapitulation o( the opinions of others,
adds: "We first observe that rupia may occur as the result of
ndary syphilis; mnuy physicians have believed that it is ulways
syphilitic origin, but this is denied by others, wlio maintain that
have met with it in persons not affected with that disease."
ion does not coincide with the opinion of certain writers that
is a modiGed form of pemphigus, nor yet with that of Fuclia
it rnpia is always the consequence of scrofula. This lost author
;C3 " rhypia" in hia fifteenth family of cutaneous diseases, wliich
names " Serophuloses," and in the third genu.i — Schmntzgrind,
imutzmfe ; but he only admita Batemau's si)ccics of H. timplex and
prominent, regarding R. eieharolka as identical with PrmpAigwi
' nfilit n. neonahrum maliffiiMs, and placing it in his twelfth family,
Ihymoplanin," under the title P/vriophlgti* etcAamliea.
Prom this hiiflorical nccount, it is clear thai, sinci; llnti^man intro-
L-d n new disease with the name rnpia, although very many physi-
e ngrrcd with hia views, others have held opposite opinions.

CIIAPTEU XXVUI.

Utttnorrhagiit Cutanea}

I ISiB frwiiient occumnce of liKmorrhage into the tissues of the
tin is the tiHtursl rtsult of it^ great vascularity, the dt-licocj of ita
ppilkry veasela, and the auperticia.! poaitton of llus fine network,
ifcich exposirs it<a everv eit(.Tnal iiitluence.

I llic process of cxtnivasftlioii of blood is denoted by such well-
larked signs that the disenses of llie skin which are produced by it
Km a very natural group.

\ Cutaneous hseuiorrbnge is, however, sometimes combined with

r pathological prucessn, especinlly inflammation. On the other

ind, an eruption of purppra may be produced by severe cases of small-

ix; !<iinilar cxtrnvnsaliuns of bluod accompany malignant scarlatina or

Hastes ) and tliey form an e»«cutial and constaitt part of the symp-

inis of other exudntive diseases, such as Ert/lheaia confuii/orme,

tacK, it becomes diflk-nlt to distinguish this class accurately from

iBt which biu been last dt^scribed, and some diseases already meu-

incd must again be referred to.

I Historical Notices. — Asearly as the timcof Hippocrates we fiud

»:htiB mentioned na exan/icnmla eii qua mlimm mortibm trriri

THi timiUima. Wc also find a pasiiage in the Hippocratic

(itings which speaks of a dangerous concurrence of epistaxis with

Vk fn'cal evacuations \ this evidently points to a morbu* Aamor'

iaffievs, bat there is no mention of any concomitant afTection of the

A third passage, which runs as follows, has also been referred

i purpura: — Oriuutur auf^m Ifuae e mariaie leiAatilim mordit, velut

rP iitorl/ut fi/txt>iefH» dieitsT. Wi-dl, writing in 1 ;02, interprets this

' TLii r.linptcrwuvriltru by I'mfcssor Albert KciJer, of Virnua, and reiiicd
H ProfcBftur lletirs.

■ «.•.

I . , ,

V- ,*^

J *

:• i ''

' / .•

-:ij*k-:

—It "i.j;

every

T Ike n

} ebsei

niSTORY AND pATnoi.onT. 405

eorpusdes cnnnot pnsa through thn poreo of the wb1I» of rewels,
every escjtpc of blood from its norm^ poaitioa must be preceded by
Ike rujiture of a blood- vessel.

~'irectobserv»lioii conftnns this oondiwion. For nltliougti it is
poMibIc to discover the injury to the wall of a captlUijin
already inflUrat«d with bloodj yet occasions oft«n arise of
Tving huw the ii.Ymorrhagc occurs by tlie iiid of the microacope.
Ill the experiments which have biien made on the transjiarciit mem-
brnncs of living nnimaU in order to observe the process of in-
flammation, it is no uncommon Accident fur nmM extra variation! of
blood to occur. It is then disitiiictly Kcn bow the blood, issuing
from a particular point of a vessel, compresses the aurrounding
tiisuea or insinaatos itself among their interstices; whciras inflim-
mat^ry cxuilattoii of u^rtaiii of its constituents take* place uniformly
throughout an entire capdlary region .

llie aolution of continuity which of necessity precedes the exit of
blood from a vessel may be prmhicpfl by citermd mechanical force,
as by wounding or croshinp. it may, however, simply tesuit from the
pressure of the stream of blood exceeding the rcsisUlice offered by
the wnll» of the vi«*el. Hence, it follows that whatever increiwe» the
pressure of the blood-current, or weakens the resisting power of the

Iwd-vessels, may caoao their walls to give way, and ha;morrbage to
Our present investigation is limited to the capillaries, since it is only
tiiia part of the cireulation that cutaneous hemorrhage occurs.
^*hen we consider the great capacity of the cnpiliury iirstem air a
tole, we can easily Iwlicve that tlic incrt^ased rapidity of circula-
m produced fay excessive action of the heart will have acarcely any
appreciable effect upon the lateral pressure eiert«d on the walls tif the
cnjiillnry vessels — so long at least as then? is nowhere any obstacle to
: free passage of the blood beyond. And practically wo never
i pyrexia to be the direct cause of hicmorrhage. Bven when ex-
nsalions have already occurred, incrc&sed action of the heart from

lupervi'mng does not at all alTect them.
The obstructions to the circulation which most freijiieiitly lead to
iDorrhage arc those which produce a sudden stoppage over a wide
, such as violent coughing, straining, and epileptic attacks.
a- which are gradually develo[ied, by valvular disease of the
tart, by IocaI intlnmmalioD, or by ob!tt4>ration of singlu vmons
uiks, may produce great dilatation of the capillaries (cyanonii),^

t '

. ■'' . '. '/«■.■■.-•. -. .." ■'

,'■ -', IT-'-';* a-

• - rw- •-

■- ■ J — '

^^■rr.l

tTS PATHOl-OOY.

407

trpliah tint and make Ihu subsequent scab ilnrk-brown. The same
coiiditiou ma; be observed in smallpox, altliougb tti tbis disease pur-
puric spots ma; aliio be produced by other causes and so appear before
the sli^e of iullnmmntioii and indep<«»kiitly of it. Of nil iuflamma-
tor,v diseases of the skin, Erythema ru>Jo»um produces the most re-
markable hemorrhage, each of the wheat-like elevations eharactcr-
e of this disorder liaviTi<; in its centre a holluw Dllfd with blood.
Icru is n common belief that the blood itself mn; undergo
« which allow it to ooze through the uninjured wall of a vessel.
Teaii oirtainly be shown that the numerous extravasations of blood
wliicli tnke place in scurvy, puq>uni mid other diseases, depend on
certain physical or chemical abnormalities of this fluid. Oustav
Simon tells us that Gaspard, Magendie and Virehow have even pro-
duced artificial hiemnrrhage in the intestines and other parts of dogs
by injecting various putrid matters into the veins.

But sinee ever^ denation of the blood from health is uecessanl;
followed by a change in the cohesion of nil the elements of the
tissues, these hirmorrhages arc more easily explained as the result of
softening of the vessels and parts adjacent from disordered nutrilioni
than by supposing that hlood-corpiiscles have been exuded through
the walls nf the capillHrieK. Simon maintains that in these cxperi-
menls hieraorrhage follows the injections too (luickly to admit of the
hyjKithesia of disturbed nutrition. But if we hear in mind how
rapidly changes in the blood produce such effects on the soft parts
puscular weakness and change of countenance (which roust be
t of altered nutrition] there does not appear much force in
E«bjectioo.
t the same time, it is no doubt possible and even probable that
1 an eSeet of tiie composition of the blood on the con.tJB-
r of the tissues may be produced through the medium of the
Axmann has caused extravasation of blood by int<mnipling
ervous supply of parts (Simon). He destroyed xeveral ganglia
e great sympathetic nerve in the frog, and the result wn* not
f hscmorrhage, but softening of the tissues in the parts thus
1 of nervous influence.
e tini-atiun remains, whether n pnrlial destruction of the blood-
iiscles may not tuke place within llie vessels from swine chemical
'. and then the liberated hmmatinexude through the uninjured
A spot so produced would not be distinguishable from
ue heemOTThage by any external character, for in the latter

408

CUTANKOU8 ILCMORRHAGK.

the blood-discs soon disappear. But tlie researches of
othcra have demonstrated the presence of blood-discs in extravan-
tions wliieb have foUowed changi;s in the composition of the bloixi
(purpura bemorThagicB), as well as in hiemorrhage upon t\ie
surface of mucous membranes occurring under the same eoiiditioiB.
So that this point may be considered as decided in the negative.

Fprtuer changes after extravasation of blood. — ITie bli
after leaving the vessels, immediately passes through certain chan^
which are denoted ia superficial hEemorrhage by an alteration
colour. These dejiend chiefly on transformations of hieniatiii.
cording to Virchow, the colouring matter may either leave the cor-
puscles or remain within them. In the former case the blood-discs
become pale, and gradually diminish in size, until they entirely dis-
appear. Meanwhile the basmatin combines with the surronndiog
fluid, and ia then most easily seen in the clots formed from the
extravasated fibrin, or in the solid parts of the tissues into which
the blood has flowed. Afterwards the dilTused mass of iiifHtrated
hrematin collects into .distinct granules and larger masses. If, on
the other hand, tJie htematin remain in the blood-corpu.iclea, thi
become smaller, denser, darker, and more resistent to the action
any fluid that may be added to Ihcm. They may continue sepai
from one another, but more frequently form rouuded or an^li
mREses, which consist on an average of from five to fifteen corposct
rolled together. These masses quickly assume a darker colour, titf'
separate blood-discs disintegrate and unite, and thus the whole coi
at last to form a single, close and firm dejwsit of pigment; or
may result several such deposits, which often present the form
trefoil leaves, mulberries, &c.

The shape of the hiematio deposits thus formed from entravasated
blood is rarely completely spherical ; they are mostly angular or
otherwise irregular, the lai^jer ones often presenting the strangest
shapes, the smaller appearing in the form of fine dust. When
ODCurring in the skin they have commonly an orange or reddish-
brown colour.^

A further change which htematin undergoes is transformation ii
hiematoidin, a minutely crystalline substance. This
occurs in such quantity as to be recognisable by the naked eye.
The crystals themselves, according to Virchow, appear in the form
of oblitjue rhombic prisms of a fine ycltowish-red colour, which in the
' Gostav Simon, ' Die Hautkranklieiten,' Berliu,

loHtM
n liH

int<»^|
mea^l
Bye. ^B

CHANGES AFTER EXTRAVASAT]

I* luger crystals acquires a briUiaut mbj tint. Sometimes mnill
plat«s may occur along vith tliese, which ofteti resemble llic cnstals
I of uric acid.

^^■In most cases the crystals are very amtiil, and hence not nsAj
^^Hognised even b^ the microscope. Ihey appear as fine streaks of
^^Honring matter, or as niinutt; amorphous mnsxra ; but wlim cnrr-
^^Hl; i lives Minted, llw formiT ivi^olvc themselves into a collection of
^^Htmhic prisms, and the latter into a mass of cr^'stals.
^^H^cse blood •crystals may be reganled ns thi! regular and typicnt
^^nn into which cxtravosated blood finnlly passes in oil purls of the
^^^fe where it is present in large quantity. Each individual hteaior-
^^Hgc may leave behind its contingent of bccmatoidin crystals, and
^^Hac when once formed, remain fur an iudeftnite time lying in the
^^^pnes as compact and permanent structures.
^^BWhen the transformation of bffimatin into this stable form takes
^^Bee near the surface of the skin, thv spot where heKinorrha^e took
^^Hte remains for a lon|{ time, or rvev during the whole of life, dis-
^^Hguished by a yellowish-brown discoloration. Hut not unfn^quently
^^^B blood -corpuscles and htematiii disappear so complcleir that not
^^Beligbtest trace remains behind. Some of the eorpiiMlm appear
^^Hthivc cases to become quickly and entirely diftulrji^atiHl, while
^^^Bers fall to pieces so as to form nmall granules before they are
^^Htaplctcly ol)surbe{I. Upon what conditions depends one course
^^B the other in each individual cas« is not known. The size of
^^^B original extravasation has probably the grenleat effect. When
^^^B considerable, the hmm.ilin has time to crystallise Ijefore absorp-
^^^B can take place; hence in these cases a mark usually remains
^^Hond, while amnll ha.-morrhages commonly dtsapjtear without
^^HHi^ any trace of their presence. Again, a permnm-nt deposit of
^^^fement is usually observed in those places where hicmorrhage has
^^^BOrred repeatedly. N^uniemus other conditions, such as tlie state
^^Hthe tissues and the quality of the ex travasated blood, have probably
^^^fenence on the permanence of thi^ Ineinorrhigic spot, but their precise
^^^Eou has not yet been invent igttted.

^^^pCAt ANii Poll MS OP H.KyuititltAGK. — ^Tlic mont Common Sent (if
^^^■sion of blood in the skin is the superficial and vasculnr layer of the
^^Binm. In its deeper ports, and in the snbcutancous fascia, hicmor-
^^^■ge is less common, but more extensive when it dues occur. In
^^^H former case, the blood-eorpuKcIrs are scattered among the elr-
^^Bits of the cutis in small masses, onil the dcciicr and softer layers of

THE FORMS IT ASsrMES. 411

of the skin, papuh* ; but in this cane it is not certain that a slight
nmount of exiidatitm may not have aided in their fnrmatinn.

(.5.} Lastly, it may happen that cxtravasat4.-d blood will raise llie
cuticle into a bladder (M/a). The small blebe produced bj direct
violence alone contain pure blood, and thia coai^ulates ver;
quickly, so that the sobd elcvnlions llius formed can no longer bo
called anything but wheals or lubcrclw. Uecmorrlmgcs which di-pmd
ou some internal primary cause spread more readily to the sulicuta-
nrotis tissue timu under the cuticle. When a biilln dues occur in
these cases, it ia usually the effect of exudation, the blood-corjiusclea
being held susjjended in the sccrefed scrum.

It is dinicuU to say what detennines one or another of Ihexe

forms of culancoiis lirmorrhage, exwpt when they arc tniumntic in

origin. The more diffuse extravasalion of blood is probably always

the result of a severe form of whatever intenial malady may hnve

occnsioned it; accordingly we find thnt wheu the htcmorrhagc

de[HTi(!s on some disorder of the blood, the size of the cxlravasatinu

appenrf to sUnd iu direct relation to the degree uf the primary

affection. We have, nt present, no data on which to founil nn

explanation of the various sbapM assumed by ench spot of biemor-

rhage. Tt cannot admit of doubt that the distribution of the

^^_$Utaneou3 blood-vessels has influence on tliese forms as well as on

^^HpUMc of cntaaeous exudations ; but extravasations of blood are not

^^^bsud BO constantly around the highly vascular hnir,folltcle5 as are

^^^Ke products of intlammation. External conditions often determine

^^^■rpnrticuLir grouping of the hicniorrhagic spots, as seco in Purpura

^^^^ In very rare cases blood has appeared on the anrfacc of the
skin without previous injury to the epidermis. In these ex-
ceptional cases it is probably poured into the sweat-glands and
foUicles, and passes tlience through their dncts ; at least, the
rmenhility of the cuticle to fluids leads to this as tlie only
lible conclusion. At the same time petechia: are usually seen in
1 itself, "When this is not the case, the blood is probuhly
around the convolutions of the sudariparnus canals or in the
^iit part of the hair- full ides, and so is not apparent to the eye,

1 supcriicinl lucmorrhnge is sometimes conAniKl to a smidi
, and scanty in ijujintity; soun-timcs it spreads over a large
or acquires importance from the amount of cxlnivn.°itted blood.
IS been observed in the most different regions, the exfremi'

412 CUTANEOUS HiSMORRHAGE.

ties^ the trunks and the scalp. It may even occur in the same indi-
vidual in diverse places, either at the same time or at intervals.

Cases of this kind have been observed in persons of the haemor-
rhagic diathesis.^ But we meet with the same condition in others,
and especially in chlorotic and hysterical women. Here, according
to Fuchs^ the hsemorrhage returns at definite intervals^ usually
at the menstrual periods. Tlie case mentioned in the first volume
of this work (p. 94) of a otherwise healthy man, in whom, every
night, blood exuded from the leg and back of the hand, is one which
I myself saw. In some cases a true coagulable blood appears to
have been effused, but in many others only serum stained with
haematin ; so that these haemorrhages have been often regarded as
blood-sweats (hsemidrosis).

All changes in the skin produced by extravasation of blood
exhibit the following characters, which, in fact, depend on the
nature of the process itself.

(i.) They are never transitory, but last until the exuded blood
has become disintegrated and absorbed. Hence the length of their
continuance generally depends on the amount of effusion, ». e, on
the extent and the depth of the haemorrhage.

(2.) They have no tendency to increase or spread, but preserve,
as a rule, their original extent. If a spot of haemorrhage does
grow larger, it is in consequence of a fresh extravasation, and takes
place suddenly. At the same time, a second discoloration appears
near or around the former.

(3.) They appear in the most different parts of the body, but
most often where the pressure of the blood upon the walls of the
vessels is increased by natural or morbid causes.

(4.) They always end in absorption, which takes place after they
have passed through shades of colour corresponding with the changes
of the extravasated hsematin — purple, green and yellow. Their
disappearance is not accom])anicd by desquamation, and only when
the haemorrhage is extensive docs a pigment-mark remain during
the whole of life or even for a loni^ time.

The only instance in which extravasation of blood chanj]jcs into
another form of disease is occasionally seen when scorbutic petechiae
upon the lower extremities turn to ulcers.

* J'ide ' Allcgcnicine Storungen der Erniihrung und dcs Bluts u. s. w.,' by
I'roffssors Virchow and Vogcl and Ilofrath Stiebel — the first of the series of
wurks of which the present treatise formed the third. P. 267.

1 1

ITS CONSTANT CUARACTKRS.

413

(5.} The; may be cli^&rljr recognisnl afu-r ilcatli ; nidiM^ the puHur
' the rest of the surface makes them theu moro dutiiict thaa
before.
I have already explained nt length that cutaniious Iiremorrhoge
1 produced iu two diB'erent and, in a certain sense, opposite
taiys, either by meeliaiiica) au<i external injury, or by pressure of the
nliimn uf blood upon iLe walls uf the vessels which contain it.

Since the latter case involves, aa I have pointed out, softening of
Ibe tissued geiierally, and great liability of the vemcUwalU to
" iplurc, while in the former they mny bt- jK-rfrclly healthy, it
pBults that from these two causes arise two kinds of culuicoiu
lemorrhnge, essentially distinct.

Jn the one case, the patch of purpura is a local affection of the

dcJD, and may be called idiopathic' hfEmorrliage : in the otbcr, it

Li^peiids on a ^ueral tlisorder uf which it is only a single result, and

I deserves the name of symptomatic hnsmorrliuge. The former

iriety is generally single (unless the cause was maniTold] , and when

e extmvasoled blood is absorbed the whole jiroccas a at an end,

bd dues not return of its own accord. Symptomatic huworrhuge

jUDally occurs at various points over a large surface of the skin;

vhen these petechiie ore absorbed, health is not re-cstublifbed, bnt,

L the contrary, frt-sh effusions nmy occur as long ns the general

lady continues.

These distinctions are snlRcicntly marked to justify ua in dividing
MtuneouB iitcniorrhages into two c^lasses, and treating of llie idlo-
Mthic and the symptomatic separately.
'J'hose extravasations of blood which aru caused by local disturb-
c of the circulation stand midway between tlK^se two varieties.
; since they are not precede<l by any primary disease of the
Wpillaries or of the tissues, and rarely occur without some external
nciting cau!«, howevej slight, they wdl be best considered under the
UopatUic class.

Idif'palhic Cutiueotis Hitmorrhiige*.
The causes which produce eitraviisation of blood while it is normal
B composition and tlic vessels are »Lso t>crfed', are removal or dimi'
Wdoii of aliHotpkenc prcMture, confutiom and Koundi. The two
^mer onuses are not essentially distinct. Diminished pressure from
■pping or other causes ruptures the capiUaries in the same way na
' I.e., iivvOMtit. Cr. vol. i, p. .113, Dolc-

"* - — i»— -=- TT — «..

.- 'lit:-

9 ■

r _

#1 / / I I'- ' /I ■*,.,' « • I f J

/ i. '.:

» . ■

.1. . iTiIf.-Lvira

COM'DSIUNS.

415

'tuiiformly iniillrnkd itiruugli the tissues ; this is tlie slightest form
of coritusion. More extensive fissumg may prgdace a larger hoUo*'
in wlitch as much blood collects as Ihe extcnKibility of its walb will
allow. This second and more sevi're degree of contusion gives rise
to bicbs with blood or blood/ serarn (Blutbculr), while the former
aim ply rauses ewhyinosis.

When thi- blood has been poured out at minute points, it goes
ftirough the changes before di'scnbcd which produce the wclUknown
liades of colour characteristic of a bruiae; and after lasting for
Weeks or months, according to tiie extent of the cxtraviksation, it is
completely absorbed.

But if it has collected in a single large cavity, the course of events
B diffeR'iit. When the quantity is moderate, it gradually soaks into
Hie meshes of the true skin ; the bleb is thus emptied and sinks down
e to present the appearance of a simple ecchymosis, and with this
I further progress corresponds. When, however, tlie original
■emorrhage and the bulla funned by it are very extenmve, although
same process begins, inflammalioii supervenes in the tissues
round before nil the blood has soaked out, and hence the bulla
kth the blood it still contains is shut off by a thick wall from the
^rls around.

When reaction is strong, an abscess may thus be formed, and
pis is the most common result ; but if suppuration does not occur,
e cavity may remain for a long time as a cyst containing coagulated
' fluid blood. In some rare castas the blood may disappear, and
y a clear colourless fluid remain which seems to be secreted by the
lemhranous cyst-wall that has gradually been produced. Such a
:x>us cyst, when once formed, may last an indefinite time.
The external appearances whicfi accompany these pathological
langes are as follows. The freshly -formed bulla is a smooth,
hemispherical and genexally very hard elevation, purple nt its summit,
»nd not unfrequently showing a slight lucenitiou corresponding in
form with the instrument which inflicted the bruise. Small blood-
cysts of this kind often sink into sunple ccchymoses in the course
~afew hours. Larger ones soften at the sumniil by the second
f, while the circumference becomes harder, and an ordinary
eemorrhagic circle forms around them. When this occurs in skin
r bone, as in the scalp, the bard and abrupt edge rill feel like
t of a depmsed fracture of the skull. If the rounded shape and
e of severe general nymptoms do not decide the diagnosis, the

41(1

CUTANEOUS HaiMORRBAOK.

linger shoatd be iiriuly pressed opon the tumour amil it becama
slightljf iudenlfd, liko an tcileraatous surface.

^Vben the cavity has acquired a distinct wilII, the whole of tlie
strelliiig is soft, and, if the hUxxl has coagulated, a kind of crcpitaiioa
may be felt, like the impression produced bj' nibbing i'tarch bclwwn
the fingers. When the last transformation deecribed, thai iolo i
B<^rous cj'st, has taken jJacc, there arc no meaiu of distinguishing it
from a " )iygro[na" produced in any other way.

A peculiar form of purpura is produced bjr a small part of Ux
skin being squeezed between two hard blunt surfaces, as a pair of
pincers. If the most superficial layers of coniim are alone crashed,
the extravasatcd blood collects immediately beneath the epidennD,
and raises it into a brownish-red, and aft<?rwards purple or black
bleb, tense and painful. This becomes flaccid in a rew daja, as the
serum of the blood is absorbed ; and after retnaiutng iu this slate
for about a week, the cuticle which forms the bladder drops off,
and under it is then seen a flat brown scab, formed of the solid
remains of the blood ; this is easily rubbed off, when it is found that
3 fresh layer of epidermis has already formed beneath.

When a bruise is very severe or extensive, the htemorrhage in. J
comparatively small, especially in the centre of the crushed t
because the muscular wails of the vessels are paralysed orer tbc]
whole surface. Tlio inflammation which follows reaction is in themtg
cases very violent j and as a second obstruction to the circulation il
thus caused, mortiflcation of the parts, either partial or genera^ ^
results, as soon as the inflammation lias reached its culminatii^ J
point. Lastly, when the contusion is of the greatest degree of.]
severity, all vascular and nervous life completely ce;
aifected part at the moment of injury; the crushed textures neTOt
recover themselves, but remain cold and insensible, and are at li
cast olf as a slough by the reactionary indammalion which arises v
the surrounding healthy parts.

DUignonia. — There is seldom any doubt whether an extravaa
of blood has been produced by a bruise or not ; the acuteuew fl
the pain at the moment when the injury was inflicted docs not allow
the patient to forget it. And in the rare cases in which the con-
tusiou was so slight that it passed unnoticed, the ha:morrhage itsell
becomes alone of importance, for it must depend on some inte
predisposing cause, [)rubab!y a morbid condition of the blood.

The case, hoirever, is different when the patient wishes to coat

CONTUSIONS.

417

I the cause of a apot of cITiucd blood. It is thcu. no doubt, nocessary

[ to distingnish by its ^yniptoma wheDicr or not it ilepttnd upon a

[ bruisr. The inquiry iMlongs to forensic medicine, nini only its

[ ileatures of patbological interest can here he referred to. If the

I tkiu be itself in a healthy state, extravasations will only appifar

where the instrument which caused the contusion was applied.

I Uecbanicnl mhocks to the whols body produce hicmorrluge upon

tile mucx>us membranes alone, as the conjunctiva. Smce bruises

we always produced by the direct action of a hard substance, the

' following cliaracteristic8 will help us in detcruiiiiing the traumatic

origin of a cutaneous ecchymoiis.

(t.) The bruises generally occupy the most exposed regions,
[ Bud are moat sevtre on the eonvexittes of the body, and the most
prominent parts of these.

(3.) They correspond more or Iom entirely with the shape of
e instrument that CAUsed them.

(3.) Either thfie is a single spot of htcmorrhngc, or, if there
e several, they are larger than those which occur spontaneously,
t so uitiform among themselves, and distributed on the most ex-
ipOBcd instead of the most dependeut parts.

(4.) Iiastly, our diagnosis will be helped by the accomi>anyiug
laymptouis — the generut condition of the patient, hia appearance,
: amount of pain he sufTers, and the degrcr of reaction oft in-
ainmation.

I'roguom. — II m exceedingly difEcult to make » prognosis in the
ise of severe contusiim^, and especially to decide whether gangrene
I likely to result. The appearance of the injured part is not
ncisive, even for an experienced surgeon ; uor di>es the degree of
isibility or the amount of cxlnivnsiilrd blood otTord more help.
t is the more difficult to form a right judgment because the result
\ the injury will very much depend upon the state of the patient's
enilh at the time, the mrntal ."hock experience*), the general con-
ssioQ of the body, and opon many individual habits, such as
Baking. In thc«e eases the safest guide for prognosis is the cause
the injury. Bruises from explosions or machinery, and hite«
Bictcd by animals wiLli blunt tcrtb, as horses and csuids, call

a un&vorahlc prognosis.
, Trva/mrni. — Wligbt bruiws do not need any treatment. The
Dcs«ifely acute ftiiiu felt at the muuirnt of inflictiou disappears very
jUuorptioa of the cxtravAsated blood can only take place
27

418 CUTANEOUS HEMORRHAGE

when it has passed through the changes detailed above^ and we have
no means of hastening this process.

If the blood has been poured into a cavity of some size, it is
possible, at any rate immediately after the injury, to squeeze it into
the interstices of the surrounding tissues by moderate and suitable
pressure. This treatment is a popular one, and undoubtedly tends
to hasten recovery by increasing the absorbing surface. But if the
contusion occurred some hours ago, and the blood is already co-
agulated, or if any reaction has begun in the neighbourhood, com-
pression would only do mischief. The attention of the physician
must then be directed to preventing or diminishing inflammatory
reaction, and the best means for this end are appUcations of cold
water or of ice. Arnica, which is everywhere recommended by oral
tradition, and everywhere popular, is never of the slightest use. If
the tissues are but little crushed, it may do no harm ; but in severe
contusions, which lead to dangerous inflammation by reaction, its
effect is always injurious. Only in the first hour or two after the
infliction of a violent bruise, while the injured part is insensible,
and passive congestion appears arouTid the extravasation, may the
appUcation of an aromatic irritant for a short time be of advantage.
But as soon as reaction has set in this treatment must be stopped
and cold used instead.

The treatment of the swellings which may remain after contusions,
and of the gangrene which sometimes follows, belongs to surgery
proper, and will therefore not be entered upon here.

Extravasations from wounds. — The only kind of wounds
which cause subcutaneous haimorrbage in a healthy skin are punc-
tures so small that the openings they make in the cuticle are quickly
closed again. These are chiefly caused by the bite or sting of
animals, especially of those which suck after making an incision.
Thus, a petechial ring is commonly observed round leech-bites, par-
ticularly when they have been api)lied to loose textures like the
scrotum, or to a morbid surface, as that of an inflaininatory swelling ;
but the most numerous examples of these ecchymoses are furnished
bv flea-bites, so that some authors have described the efl"ects of these
insects' operations by a special name, Purpura pulicom. It might
seem unnecessary to pay further attention to these commonest^
though insignilicant, injuries of the human skin, if cases did not
occur in which they have led to errors in diagnosis.

A flea-bite, then, produces a spot of haemorrhage as big as a pii*^

FaOM WOUNDS. ilv

n the most supetfictal laycn of the true skin, ami this he-
s (juickly surrounded by an injected circle of about double its
;, trtiicli again is souietinies eilgcd by a Itgbt, almoBt white border.
! the bite la (|uile fresh, it is scarcely possible to diatinguisb
the extravasation from the hypereemia around it, since both are
equally bright coloured. But very soou the circle of active conges-
tion becomes paler, and the spot of ecchymosis darker, so as to
make tliem clearly distinguishable. In a few hours the hypenemia
completely disappears, and the central extravasation which remains
I riio longer prrsmts any difference in appearance from an ordinary
Mpot of ]iurpura.

If then several of these spota are seen together, they might, on

'a superticial view, be taken for /'. simplex or for scurvy; and all

the more so bocanse tbcy generaUy occur in such numbers on

prrsouB who have lately come out of prison, or lodging-houses, or

^barracks, places which cause a caclipctic appearance, and make rie-

relojnnent of scurvy not iinprobahlc.

The most important point for diagnosis ia the distribution of the

c spots. Fleas love lo nestle in the folds of the underclothing,

ind hence the skin is moat covered with their bites where the clothes

c in thick folds, as on the neck, the wrists, the middle of tlic body

irhcre a waist-hand or belt is worn, and the legs above the ankles.

I beside this there will always be found some spots with the

lenemic circle still around them, and the presence of the fleas

K'tthemselves will of course direct att«ntion to their bitcs,

EXTIUVASATIOJJH FROK URCItAMCAL I)[SOIL0Klt.S OF TUB ClltCrt^-

TION.^-On [larts of the skin which aro subjccled lo conataiit
disturbances of circulation, such as are caused by varicose veins or
t'haiiical obstructions, ecchymoses may appt^ir as the result
' very slight braises, or even from exceasivc muscular action.
y may also accompany such exudative affections as eczema, which
^ftini o(«urs under the same conditions, and in this case they will
IpScr some peeidiaritics in tbeir course.

Since the pressure wliicli the blood exerts on the wall of a vessel
I, under these circumstancx-?, greater than that pro[>erly belonging
D the part, not only will the Iwmorrhage be exfenaive, but several
^tnvaaations may easily occur in the same spot. Ucnce the
J uf the hlocid ponred out becomes so consiilerahle that it
a DO loDger b« camplebebr mibsurbetl, hut, after passing through

'i20 CUTANKOUS IIJBMORRHAGE.

Ihft chan^iii flr.-.McriVjed in a former part of this chapter, reuiAias
wlif^c it was exuded, and the place continues marked br a brovn
pif(mfrrit-H|)ot for a long time, or even for the whole of life.

Wilhin di!HcrHi«^« a form of purpura which, he asserts, occurs only
in old |KTHonH, ('.s]K;cially on the lower extremities, and is cli<tixiirui«h€ii
hy loii^ p(;rKi.Htenee of the separate spots and bj repeated recurrence
of tli(r liif;morrli''i^e. This 7^ A^ni/is of Willaii has been explained
by tno«<l |]ite wriu^rs an a nimplc purpura occurring in aged people,
lint liiiteman desoribc-H the case of a woman in whom purpuric
H|iotN huce^'HMively appeared for several years without cci*sation, and
nni.'irkH thnt it is an error to confound ordinary purpura occurring
in ohi per)|de with true /\ neuUU.

Aei^onhn^ly, 1 think I Khali not be wrong in treating of this
vfiricty of purpnni herr, altliougli neither Willan nor Bateman makes
any mention of ob^truetions to tlie circulation. It is, no doubt, true
th;it thi^Mi- fxtravasationH c^ecur most frequently in elderly persons, if
not in the very a^cd. Varicose veins are less frequent in the youngs
and when they do ocxtur are of less importance, because the tissues
have ^n;at<T power of nrsistance. The seat of this affection is alwajs
the, lower extremitieH. After the effusion of blood has occurred a^ain
nnd fif^ain, tiie skin beeomes remarkably chrmired in colour. If the
ret hvnirisr* Jin* vriisiii iiiid seattcred thf limb will be covon.-d with
niirinToiiM brown ^[)(»ts f>f j)iLMMent, wlnVli are readily distinct from
the i'nrroundin^' t-kin, and irivc it a s])()tt('d or marbled api)earance;
if tliry an- lar^n-r and eonlluent, it will show great blotches of a
uriiforni dark brown tint.

When till rr is obvious disease of the blood-vessels, this form of
]Mirpura is easily nco^niscd. iJut even when none can be discovered,
we, may presume, tiiat it exists, if we find extravasations repeatedly
occurring in otiiervvise healthy persons from slight exciting causes
and eoniiiied to a (lefliiite reinon of tin* bodv.

■

Tlie^e. extravasation "5 need no treatment in themselves, and offer no
rational incljeation lor aiiv. Hut siiu-e tln'V ot'ti-n reeur, and sir.ei.- it
is obvion^ th:it in a spot wliere the jire^sure of the eireidalion is
abnonnalK L'reat there uiil ;«lso Ije constant I v inereasinir iliialatioii
of the vein-<, Mild >o at lii>t a 1 jeinorrhaire f)f nion* inij»or(.mer, it
follows that stejjs nin^t i.e taken lo j)revuil the pro^'^ei^s of liic evil.
The surest plan is to apply pressure from wiiliout, either i)y bandag-
ing the leg or by wearing an elastic stocking. In the case of the

PCftPCKA SENILIS. . 421

I thb tmit»Mit is not easily carried ont ; and it is uniieceoaai^ ,
I for spirituoas or otbei cold lotions are quite snfficieut for lll«
I porpotw.

SpnpUmatir. JT^iimrrinyet.

Tlie mode of pruduciion of bwmorrUage generally has been fully
treated of by Professor Virehow in tbcwork nlready referred to (f. p.
413, itole), ne also discusses hirniopliilia (liiumorrhagic diatbcns)
and scurhutua, conditions wliicii lead to eiitxavasation of blood. Tbe
formrr is not so much clianicteriHed by the »i«mtaneous occurrence of
lisraorrhagc as by tbu readiness wttb vliicli it is produced by roc-
cbatiical uauses, and tbe frequently Inrge quantity of blood that is tost.
But exudation of blood into the texture of the otitis is one of the
essential characters of scorbutus. Spots of eccliytnoeie appear, vary-
ing in size from a lentil to a crown-piece and upwarda. They occur
I first, sod in greatest number, on IUk lower extremities, but sometimes
I ipread over tbo whole body. Occasionally the cuticle covcrinjj; a
I Korbittic pnteh is raiivd into ahlcb by a discoloured exudation; and
I when it Lns fulleu off, shows beneath an nicer, sometimes only 8U|K'r-
I ficial, sometimes deep, with fungous granubtions, which very readily
I bleed. More frequently exlensive hseraorrhage into the deejH-r
lltyrn of the corium and into the s ubeulnncuiia tissue produces flitl
liand rather hard swellings, painful, and livid or bluish in colour.

All cutaneous hemorrhage, whether idiopathic or symptomatic, ia

I gencmlly classed hy authors under the generic name'piirpiim ; but

I they do not agree ns to the pathological processes which arc iucluded

is title, nor arc any of their views on tlie subject remarkable

^r clearness.

■ Wiilan dcstiiigui.'ibcs five kinds of purpura: — P. liotpUx, nenili*.
tehic^ca, MrlieaiUffebrilU ; to these may bo added the affection
lllrtl by him Lithen liriii«t, which he separated from the other
jBmorrhngic disorders nnd placed among his Papula-. I have
'ready discussed the true character of P. teHtlu, aud ranked it among
pe hemorrhages pmluced by mechanical means ; but the mnaimni;
* adopted by Willnn cnnnot be regnrded as independent diseasea,
' they oidy imply either gome uniniportnnl complication, as
urfieaiu, or the presence of some additional m«Udy, oa P.
teiectiea.

PURPCRA anEUMATICA.

423

1 them follows a new eruption of petechia, so that the whole
Iness may be prolonged for week.';.'
This form of puri>ura la usually met witli in the strong and
ocnlthy. Ac^ordinp to the observations of Fuchs, however, those
who liave long suffered from chroaie rheumatism are oecasionally
aLt;icke(i. It is moat fretjucnt l)etween llu.^ ugi» of twenty and thirty,
e never been seen in children or aged persons, and is more common
a than women.

j The diiignMm of the mnlady, when fully devetoiied, is without

Bty dilTicutty. Tbc preliminary rlienmatic pain.*, the spots not dts-

[learing under the finger, their distribution, and the absence of

mptoms of scurvy, distingnish it from all other affections. It is,

Iftwcver, no easy task to recognise Prliom rhrumatka in its early

r, bccauBe the pains, which arc then it* only symptom, occur

loch more frequently lu the result of some other disease tlLan as

e forerunners of purimro.

L ^hcpro^Mu is, for ihu most part, fsvorable. The pains vanish

l&b the appearance of the eruption, «nd though relapses often occur,

e duration of the wliole malady is even then very limited, bo that

e sudden outbrenk of ecchymosid which so alarms tbc patient is

kst to bo regarded by the physician as an unfavorable symptom.

t the same time there are, it must be confessed, casps of tliiN rheu-

Mtic form of purjiuni which lenninnte fntolly, even when thero is

9 concomitant disease, as tuberculosis or morbus Brigbtii, (a which

B can ascribe the result.

I Tile Irealmeni of Pelioiii rieuaaU<'a is purely expectant. There
I no danger to avoid, and we have no means either of shortening
I course or of preventing the possibility of its ending in death.
E^st in the horizontal ])osilion may, however, be enjoined u enncn-
tial to a rajiid recovery. And sincet the pnina experienced demand
nme trrjitment even before a diagnosis can be made, there in no
mbt that in every case something will be prescribed by the
grsieian, aiid as little tliat the subsidence of the patns whidi fol-

t will be regarded ns llie effect of the prescription.
' Fuclia ipcaltB of Ibo danger tlial umj befiU iLe palieot if time apots uf
fajniMis sliould ludilunlj iliuppear. But it i* mcaDceinble ttut blood onc«
rnvualtil shdulii be rvibanrbed before it boi ^ae tlirongh its regular
pnentire obungca. Ileucc suddea dianppcarancc of petfcUitr is iiripouiblo ;
. (uppnac lliut Fachs, wlio mms well iciiuainled wilh tbe nature at
e ipotn, iiitdH llje aaturtion just quttt«<i ralhnr trum an erroiKous llicory
n from anj notuol observatiua.

424

CUTANZODS SAHOKBllAGIC.

PoiiPURA siMPLBX, BiutJUKieakranii^. — Th^ esBentinl clm-
roctcr of purpura is the apoataueoas development of pet«diiK,
ecattcred over a large part of the surlttce of the hody.

It ocxnirs without any marked train of symptoms. No doubt
when it first appears patiuuls sotaetiines complain of feeling unwtiU ;
tliey have no appetite, and say they are li^leae and pooriy; but
these symptoms are, of course, not peculiar to purpura, and mav be
entirely absent. In the latter case, the eruption of hivmorrbagie
spots is the only, as it is always the most imporlant, sign of tlie
disease.

These ecchymoses vary in size from a tiea-bite to a lentil, mn
purplish in colour, and afterwards dark brown ; they do not nM
above the level of the ^n, and do not disappear under the 6Dger.
Moreover, they are always discrete, sharply defined, and round or
irregular in shape. They are either confined to the lower exUenit-
ties or are distributed over the whole body, bat mure thickly od the
legs ; the part least often affected is the face. Their dietrihutioD is
quit« irregular, though th^ occur in great numbers. Sayer haa
noticed that in some places they form definite groups. Accordtas
to the same autiior, the epidermis is occasionally raised by the
extravasated blood at scattered points over the surface.

Long livid lines, single or branching, may sometimes be ob-
served between the spots of ecchymoais, or a considerable apace ini^
be converted into a uniform livid patch. Tliese extensive eilrsvA-
salions are chietly met with on the back of the hand, on the inst«p,
and on the inner surface of the arms and thighs. They do not
appear all at once, but as the result of repeated subcutaneous
hicmorrhage. And since the pstieuL's attention is nut drown Ui
these large patches by any subjective symptoms, it is commoQ for
the physician to come upon them iu various stages of involution.

In some rare cases purpura begins with tlie formBlioa of flat, red,
irregular elevations, varying iu size from a lentil to a bean (Pmf'
\ j>»ra uriicam of WiUan), a condition which is only distinguishable
I from urticaria by the darker colour of the wheals and the complete
I absence of itching. These elevations hist only a few hours. At
1 first they look like the result of infiammatory exudation, and tlwir
Iredness rampletely disappears under the Angrr; but they rnptdijr ,
I become more livid, are liws atrccti'd by prcssurr, siufc to the level of
lUio surrounding skin, and in the course of from ten to twenty houm
their first appearance have compli-tcl; changed into flat,

PURPURA SIMPLiX.

■K5

1 spots of eccliT 1110319, which cniutot be distiDguislud from
those of ordinary purpura cillier by their appearance or their furtbcr
course.

Since tlie slight inflammatory symptoms aie only produced hf the
tame imt«tit which is the can»e of the liKmorrlagc, it duei not
nppwir desirable to regard thia deviation from the ordinary course of
purpura ae constituting a dititinct disease. Indeed, it is poeaiblc
that the same cause may, in a sensitive skin, produce a wiieal,
wd, when reaction is ^ghter, a petechial spot uuprocudcd by
ijpencmin.
Occaaionally small papules develup themselves between the ecchy-
!s; these have a livid colour And resemble them in all ulher
npects, botli as regards appearance and course. For this condition
[ propose the nami; Purpura papiil-ota.

Willan reg;nnlcd it as a peculiar diseacc, and dcserilird it as Liek^n

^^vidui, but slates liimself that it kas the greatest likeness to pur-

Kpnra, and naturally belongs to it. In fuel, the fommtian of papuh-s

'\ not of more im|)ortance in hmmorTbagic than in intlammatory

f dutAsea of the skin, and wc know that mAny of the latter proiiuce

netimes papules, sometimes only macula;, without any ditrfrenee

Kic their characteristic symptoms. The formation of papules pro-

* bably depends on a lai^e amount of hemorrhage occurring in a

limited space, and ficcordingly we find extravnsiitions which prodnce

them most often surrounding the h air-foil iclra, because tluno arc

I supplied by a c^uUary network which comes directly from tlie

r tissues.

AVhelher or not an attack of puqnira begins with papules, the
qipearance of spots of cccbymosis, and the subsequent changes they
> undergo, are the only (diameters which are essential for
iagnosia. The changes of tint from livid to brown, to green, and
it last to a dirty yeliow, have been already described. As the colour
) the petechial become less defined, iodistiDct, and at last di»-
ar entirely without any dcsqoamatiofl.
The change of hue begins almost always at the edge of each
r else over its entire surface at once. Bnt TUyer asserts that
Hoqition oommeiicea in the middle, so that yeJlowisb rings may
main behind for some time. In those rare cases in which blood
I exiravasatcd under tlie epidermis it dries up into a small bLickish
rust.
As soon as abso^tiuu i* oomplcts, every morbid symptom ditf

426 CUTANEOUS HEMORRHAGE.

appears ; but the disease must not be regarded as cured until several
days have passed without any relapse.

The etiology of purpura is in almost every instance very obscure.
Since it occurs in healthy and well-conditioned persons as well as in
the feeble and scorbutic^ we cannot ascribe it to plethora or anaemia,
to excess or deficiency of nourishment.

Its sporadic appearance argues its independence of telluric infla-
ences^ And since the mucous membranes and other tissues are
exempt^ we must suppose that the causes of simple purpura a£Fect
the skin alone, much more at least than any other part of the body.
Hence it is safe to assume that temperature and clothing have great
influence in causing it.

The diagnosis of- P. simplex is estabhshed when petechias are
present, without, on the one hand, any mechanical cause to account
for them, or, on the other, such primary diseases as typhus fever,
or haemorrhage from the mucous membranes.

The only traumatic ecchymoses that could occasion difficulty
would be those produced by a multitude of flea-bites. But these
may, as I have already remarked, be distinguished by their peculiar
mode of arrangement and by the presence of fresh hyperaemic spots,
so that witli a little care mistake may be avoided. It is possible,
however, that an attempt to deceive may be made by producing
factitious purpura, by blows with a hard brush, for example. But
such traumatic ecchymoses are always accompanied by signs of in-
flammation, at least at first, and are either confined to some part
of the body which the patient can easily reach, or, at any rate, are
distinctly more numerous in those regions.

The prognosis is entirely favorable. The whole affection, if confined
to a single eruption, lasts only from eight to ten days, though it may
be prolonged by repeated relapses for weeks or even months. Since
these relapses cannot be foreseen by any antecedent symptoms, and
since they often take place when the previous eruption has almost
disappeared, it is impossible to say in any given case what the
duration of the malady will be.

There is but slight indication for a special iroatment of purpura,
and we have no means of hastening the absorption of the extrava-
sated blood.

The only prophylactic measures possible are removing anything
in the habits or mode of life of the patient which may seem to havt
favoured the attack. At the same time, we may stimulate i

rURPCRA StMPLKX.

427

lOTinal iictivity of the skin, nnd i^specinlly its involuntary maKuIar
fibres, by exercise in the open air, by cold baths, and by do«che».
It will depend on the extent and distribution of the eruption
f vhetlier rest or movement is d^irablc. If the.rc an; l&i^e v ibices
>ver the lower extremities, the former must be prescribed ; in other
Hsca we may advise raodtTatc exercise,
PniPURA H4(M0Ra>iA0icA, Morbus mafulomn (Werihoff), Blat'
eckenkrankhfit, Land-acurv^. — Under this name most authors
lescribe a disease which begins with extravasation of blood into the
ikin and stands midway betwi-en eim)itu purpura and scorbutus.
It is distinguished from the former by the size of the ecchymuscs,
^ their extension to Uie mucous membranes, and by the occurrence
r hieniorrhage into the mucous cavities. These, as 1 have before
Kmarkcd, are oidy diiTcreuces of degn'v, nnd until we obtain a more
tact knowledge of the real nature of these diseases it is diflicull
I make any deliiiite sepanitiun between them, especially since we
iGvt with every gradation, from a few petechiii: on the skin to large
fittravasations combined with fatal iuternal biemorrliage.

On the other hand, many observers would identify P. kamor-
lat/ua with scurvy, regarding it as only a slight degree of that
But even those who believe that both olTectious depend on
■<tbc same rratU must admit that they differ in their essential pheno-
mena, and that, at all events, they do not stand in the relation of
differences of degree ; for we often sec very slight cases of scurvy,
while, on the other hand, purpura may be accompanied with the moat
piolent symptoms uid end iu de»tli.

CkaracferiHk synip(om». — Without any known cause, there comes
D a feeling of exhaustion and fatigue and disinclination to work,
rant of appetite, and sometimes tieadacbo and oppression of the
. At the same time the patient looks ill, the (.■ountenanee is
I and the skin Qaecid, while pyrexia is cither very shght or
Utirely absent. These premonitory symptoms may last from two to
n days before the actual outbreak of the disease. But, {>erliap» still
lore frequently, the disease will suddeuly sliow itself iu an eruj>tion
t jjeteehia;, or even in violent htcraorrhagc.

\ The macule appear at fln>t on the lower extremities, where they
f esnly cKaiw notice, then on the tmuk and arms, but,as arale,
' face ruanina intact. Many of these patches are as large as a
w*>^ IvKCTi wbilc belwrcn tbeni are'sentlered nuineroaa
> ■ hemji-seed iu size.

428 CUTASE0C8 aiBMoaBDAGE.

At the same time, or soon after, (he like ecehjiaoscs uppesr^l
the mncDHs membrane of the Ups, the cheeks, Ihc hard and t
palate, and the gums. These spots aie at &nt of a hrightctr i
than on the skin, but aFterwanis become daikfr mid nlmust b
Meantime there is no improvement in the general e^rnipton
the contrary, if these have been abscut at lirst, Ihey ai;|Knr with ti
first eruption of petechifp.

The form and distribution of the raacnlas is qnite irregular, b«l
they are largest, and most numerous on the lower estremitie
thej Grst appear. While the primary cniption is passing throiij^
the ordinary changes of colour, fresh ones follow in other paiis (
the skin, so that in a few days one may see cechymose* in
stage of involution.

At the same time the skin i» so vulnerable that ver^ al^hi
pteHBure is enough to produce a spot of h«morrhagc, Uetica t^
easily happens that, from natural or aecideulal cireuinstancta^ thi
ecchyinoses will be much more numerous and more extensive in a
parts of the body tlian in others. Thus, below the knee they i
often unite so as to form great patches as big as the hand, n
was from this circumstaiiec that the English surgeons gave the n
of "Black-leg" to the P. /tarruirrhaf/ica which was so cocumon i
the Caffre war.

In addition to these symptoms must be mentioned the o
of heemorrfaage on the eorfacc of mucous membranes. The mot
Irequent kind is epistaxis, then hleedltig from the gams, the bowi
and the urinary passages. Uicmoptysis and uterine ha^mo^rila^ m
much more rare. From wha^vcr source effusion of blood lalcct
place, it is often very considerable and freipiently recurs. TJic n
rxhausting condition is when (different tracts of mucous mcmbmm
are affected at once. Such hfemorrliagc is accompanied by pyre
the temperature of the skin is increased, and the pulne riats to la
or more. At the same time tUere is remarkable muscular wrakncsa J
headache, and loss of apjiplite, with a dry condition of the longw.l
When the hnnehial inncou* menihrane is attacked tiiwo is freigucmkl
cough and expectoration of hhtck blood, while auscultjition discover
moist rattles in one or both lungs. Tf hen therts is hnmorrka
from the stomach or intestines the patient feds vague pains in tLiJ
abdomen, and great (]uantiliea of bUck blood are vouiilinl or posed fa
stnol. I/a»tly, wh'm tbe hladiW is the part affectrd the srinikl
hecomes of a dark r«t oolour and d«posits a scdiioo&t of blood-^iA. \

PURPCKA U^aiORRHAtilCA.

'J29

The first appearance of htcinorrLngc is sometimfs accompanied
I by a feeling of relief to the patient j and when this occurs it may
I be taken as a favorable eymptom, for then the irhole couditioa often
[ takes a turn for the belter. But if the bleeding continues, the
\ iiicreasing weakness of the patient, oppression of the chest,
( muicit vtililanfea, faintness, and actual syncope, bear witness to the
degree of aiuuntin. When Ihe course of the malady is prolonged,
there may supervene adcma of the feet, and in rare cases even effu-
sion into the seroua cavities of the body.

Morl/id anatomy. — When tlie bodies of tbos« who have died of this
J form of purpurs are examined, there are found extravasations of blood
I in tlie tikin and subcutaneous fascia beneath the spots of ecchymosis.
1 This blood is easily removed by » stream of water, and there are
I never any signs of inflammation in the netghbonrbood. Similar
' etTutdons may be observed in the mncoua membranes, and less com-
\ monly in the pleura, tbe [tericardium, and tlw membrane lining the
\ heart. The bronchial mucous membrane ts, ns a rule, unaiTected
I (GaJatIi).

As to tlie cfaarartcr of the blood itself, anthorities differ greatly.
It is gfineraily dark and but little disposed to coagulate. Tlie prc-
I seiice of blood-discs has been established by the rescarehea of Legrand.'
' After conlinund and re|)e»led hiemorrhiiges it becomes lighter, bright
I red, and at last like wal«T in wbieb raw meat has been soaked : in this
I «tute Legrnnd, Eayr and Diett found it \a contain almost iiornMl
I corpuscles', but to be incajmble of coagulation. Albers, however,
I Mserts that he has seen the blood in cases of P. i^morrhagica coagu-
I late as completely as any drawn in inflammatory diseases.

According to an analysis by Becquerel,' the blood taken from the
I vein of a patient suffering from tliia malady had the following cha-
ncters. It retained a dark colonr for four and twenty hours, and
remained reniurkably Unid, without any separaliun into ctot and
I aerum. After stirring it for an eijaul time not a trace of tibriu
i could be discovered. The corpuscles remained united with the
jm, and could not be Beparat«<l by the action of cold or by snl-
1 pbnte of sodii. In looo parts of blood Ibere were *to;V44 of water
I to I9<^'5^ of Hobd matter, but Ikicqucrel did not saoct^d in a»eer-
[ taioing the relative amounts of the solid constituents.

Courie and retui/t. — Ilsmorrhagic purpura is the most acute in

Tlnion Mciiirjdc,' iSgi.
' tliioted bj Gustav Simon, 0|i, cit.

430 CUTANEOUS HEMORRHAGE.

it0 character of all the allied processes which hare been discuased in
this chapter. lu bad cases it may proTC £atal in a few dnjs nfkcr its
first appearance, or within the same space of time recov e r? mar
ensue. Each of these events is, however, rare. In most instances
the patients recover, bat it is several weeks before thev n^ain pet-
feet health.

In favorable cases no fresh petechis appear^ and those alieadj
formed chauge coloar, become pale, and at last disappear entiielv,
without any desquamation. When the disease lasts a long time^ and
especially when exhausting hemorrhage has taken place, oedema of
the feet or even ascites may not improbably supervene, and thus
convalescence be greatly retarded.

When death occurs, it is usually as the result of repeated and
severe losses of blood, leading to extreme ansmia and collapse.
OccasioDally it takes place under typhoid symptoms, which come on
during the last days of the illness. It is highly probable that this
is the consequence of some decomposition of the effused blood, and
the subsequent reabsorption of its products into the circulation.

Etiology, — The really efficient causes of hemorrhagic purpura are
entirely unknown. It has, no doubt, been asserted that it occurs
chiefly among the lowest class of people, who are ill-fed and who
live in damp, close, and cold dwellings (Fuchs) ; that it attacks
children and women more often than men ; that it sometimes
appears in numerous cases at once in marshy districts or in those
bordering on the sea ; and, lastly, that it often accompanies conva-
lescraice from seven; diseases — conditions all of which favour the
occurrence of scurvy. But there are a sufficient number of observa-
tions on record to i)rovc that P. ho'morrhagica may be developed,
not only without one of these 8Uj)posed predisposing causes, but even
under exactly oj)posite conditions; for it may attack strong and
Mcll-fed persons, who live in the greatest comfort. Hence it is
most probable that the circumstances enumerated above have but
litth* influence in producing j)urj)ura, and that they have been
brought forward only berausc they are well-known causes of so
nearly related a disease as scurvy.

For tli(^ most part, this severe form of purpura appears spora-
diejillv, but occasionally so many cases occur at once that we must
assume; them to be (le|>endent on some telluric influence.

bhujmmh, — The character which distinguishes 1\ hamorrhagica
from similar and allied disorders is the simultaneous aj)pearance of

PURPURA H^MOBBnAOICA. 431

ihvmoscs on the akin and of lileeOiiig from tlie surfacp of tlie
macoU9 membranes, lu simple ))iirj>uni petccliiie uccnr withoat any
frxternal hEcmorrhage ; in casies of bi^morrhagic diathesis {haino-
Iihilia) there are either no [Hilechin; nt all, or, if present, they owe
their origin ta some slight traumatic csusc. lu scurvy, it is IniCi
both symptoms are combined, bat this diflease may be distinguished
_£^m bEemorrluigic purpura by the following chnriict«rs.

(i .) Scurvy is developed under the influence of depressing causes,
whether purely menial or acting directly on the body, sueh as defi-
F'Cient or uusuituble food, air loaded with moisture or with oi^.iuic
products, and the foggy cold of iiortliem countries, with other
telluric agencies. Purpura, on the other hand, generally occun
without these conditions, and it is even doubtful whether they favour
a appearance. Hence, it follows of necessity that scurvy, as n rule,
ifl'ccts many inhabitnnts of n district at once, because they arc all
apoited to the same injurious induenees ; while tliis is very rarely
the case with purpura.

(a,) Tlie premonitory symptoms of scurvy — melancholy, sense of
fotigue and weakness, pain on movement, cachectic appearance. He. —
e either quite absent in purj>ora or only appear in a vrry slight
[degree.

(3.) In an attack of scurvy the pulse is small and the sounds
' the heart weak from the first. 'I'he gums swell, lose their
fpithelium in places, and exude a serous secretion stained with
|)lood, wliilu the teeth become loose. Beside the petechia; on the
lliin, extensive citravasations of blood take place into the sub-
nitttneous fascia, and form hard and painful swellings of a purple
iolour. The ecchymoses themselves readily ulcerate on the lower
Bxtiemities, and some of the bones, cartilages or joints become
painfnl and swollen from elTusion of blood beneath the periosteum or
perichondrium. None of these symptoms mark the course of
"jmrpura.

[4.) Lastly, death from hsemorrhnge seldom occurs in scurvy ;
e often it resulls from saiiguin««-serous effusion into the cavities
«f the pleura or pericardium, or from pytcmia and blood-poisoning.

These differences not only serve to establish the diagnosis between

fthe two diseases in practice, but aUo prove that they are essentially

taistinct, although we cannot yet define them as more than oolloctions

f certain external symptoms.

Proffnotif. — lu comparison with the allied affections treated of m

CUTANBOQS RjEMO^KaAOK.

this ctaplcr, /*, hfrnnrriagica is > dungerous disease, for tfaen
the pattcut is often imperilled. It is exceedingir diffionlt to 4
mine the ilegree of Ti»k and the probitble resuJt of tlie malidjini
given case, since nn attack which seems at first of slight impoiUact
Bu^ suddenly assume a dangerous character. Tlie number mi
size of tliP petechia bear no rclatdoa to the internal hs^noRht^
vhich may be great in amount when the maculse are few and smilL
Ilcuce the kind of eruption offers us no help in judgiog of the p»-
buble ifpgree of severity of the attack.

It is scarcely necessary to mention that the prc^oofis is moR
favorable in thecase ofyoungirobust, and previously healthy pontn^
than in the aged, decrei>it, and sickiy ; and when the food, lodging,
and other external circumstances arc good, than under o^qnab
conditions.

Slight btemotrhages which are followed by a feeling of reUef td
the patient have no untoward signiScance. The more estensive and
prafusR the bleeding, and the greater tlte weakness and lassitode &
occasions, the more probable is a fatal result. The tract of mocoua
membrane from vhich hemorrhage is the most frequent and the leait
irapoftant is that of the nasal passages ; the worst sign is when blood
is effused from several regions at once, as the lungs, the bladder, and
the intestines.

Again, the appearance of typhoid symptoms augurs ill for the
patient's life, for, deptmding upon the absorption of decomjtosed
blood, they are almost certain signs of approachii^ death.

Treatment- — In consequence of the fact that plethoric perwHU
often fall sick of F. AMnorriaffica, and that slight loss of blood at
the onset of an attack is accompanied with a feeling of relief, it has
been proposed to begin the cure of purpura with •veneneetion. This
mode of treatment found its most zealous partisans in Italy and in
England, countries of precisely opposite climates.

On theoretical grounds, bloodletting may no doubt be jostified,
for there can be no question that it relieves the wall of a congested
vessel from the pressure of the circulation, and tliat it is expodieut
for the blood to run oiT by the veins rather than break through the
cspillaries of the lungs or the intestines. But in practice very few
physicians adopt this mode of treatment, for in sbght cases there is
DO necessity for it, and in severe ones no one cares to increase by
artificial means the great loss of blood already suffered.

The treatment by calomel, jalap, and other drastic purgatives,

PURPnaA U^MORBHADICA.

433

f^.

lute

H^L cold

P^Vtbit

' tion

liich has been also recommenileJ, liaa noUiing in its favour, tlieorc-
ica! or empiricaL AYc may therefore dismiss it at once.

As early as the tiaje of Werlhotf iu the seventeenth century, acidf
and eiiKAona liark held an important place in the treatment of
Mi/rittn macutnms ; the former were uauaUj prescribed at lirat, and
decoction of cinchona during convalescence. This plan of treatiHeiit
has kept its ground to the present day, though bark is now replaced
by sulphate of quinine. Both drugs are, no doubt, of great service

■the acids, especially phospho-sulphuric acid and Acidum HalUri,^

astringents, quinine as s tonic.

During the last few years perchloride of iron has been much
•raised as a specific against hicinorrhagic puri)ura by Mignot,*
Argaing,' LoufEct,* and others. It has been administered, both
internally as an aqueous solution in the proportion of i to 370, and
also as a lotiou in somewhat more couceutrated strength. The
great efficacy of this compound as a styptic is enough to explain
the good results which have been obtained under its use. Hence
its exhibition is unquestionably indicated in all cases of purpura
which arc accompanied by dangerous hemorrhage. In the same
way other hicmostatic remedies, such aa alum, tannin, and rhatany,
may be found useful.

But it ia of at least equal importance to keep the patient obso-
lutely at ti'tt, and to employ vild freely and efRcietitly, whether
by cold lotions, or by giving small pieces of ice to suck, or by
cold clystcia, or simply by preserving a cool state of the whole

face.

Diet and other points of general treatment depend entirely npon
state of the patient as to nutrition and strength; hence no

livcrsal rules can be given on the subject.

I'onrijRi IN ASSOCIATION WITH PYUEsiA. — Wcrlhoff was aware
that purpura often appears in combination with severe febrile affec-
tions, e8[)ccial!y with variola. InWi!!an's oft-quoted system wc find
a disorder described under the title Purpura febrilia, which ia
ushered in by severe pyrexia, shortly followed by an eruption of

tcchiic over the whole body ; it is avcompaulcd, he tells us, by

' CE. vol. i, p. 343, BOia.

' ■Gaj.desHdp.," i860.

■ 'Gat. de SlraialKiurg,' 18

'Gu. desEvp./ 1S61.

4ai

GUTANEODS HiCMOKaUAr. K.

functional disturbance uf ihe entire organism, and somctiinea by
lii^murrbage from ihe mucous cavities, and, as a rule, soon cuds m |
deatii.

If wo compare the representations of later uutliors, it is aoarcelj
jioasible to form a clear notion of Ibis condition. Wilwn de>cnba I
^. ffl/rilia as an nlinoat iniiocmit disorder ; few of the Franub |
writers make any mention of it at all; and iu Geminay Fucb*
alone haa accepted Willan's account, but without tclliJig us du-
tinctly wbetlier lie ever saw the coiiditiun in tjueation himself.

According, then, to our present knowledge, we are not juslLfind

in assuming timt there is a peculiar diseaso corresponding with

"Willan's description. Many of liie cases which led him to derise

this species of purpura may have belonged to /'. Aauu/rrAaffica with

I pyrexiiil symptoms, and others may have been moroly parts of soioo

I other severe malady, most frequently, perhaps, of variola.

Variola niora, F. hismurrhxgica, Schwarze Sliiilimi,~~la
\ the first stage of smallpox it soaietimes happens that such sevcra
I Lasmorrhages occur in the skin and from the mucous membranes |
I that death ensues before any other symptoms can be developed.
' This form of tlie disease generally begins suddenly. A [)cnoD who
has received contagion is attacked by a fccUng of eickiiesi. This
is followed by intense headache, unusually severe depression, tuiuca
or actual vomiting. He ia obliged to take to his be<l, the tempera-
ture of the body is greatly increased, and the pulse rises as higb u
140 in a minute.

Occasionally there is also a diffused erythematous redness of the
whole trunk, but especially marked on the chest and abdomen, like
that wliich often occurs iu the ordinary course of variola. lluB
rush, which, in conjunction with the symiitoms of pyrexia, may le«d ,
to a diagnosis of scarlet fever, di»ap|)cars in a few hours.

It is generally on the second day that purpuric spota apiwar, with
aggravation of the previous symptoms. The patient now losea
oonadousne^, grows excessively restleAS, the pulse becomes tiaall
and can scarcely be counted, respiration ia harried and stcrtoronsj
the scanty urine is stained dark red with blood, and blood mingles
with the involuutnry stools.

The petechia;, wliich at first apjieared about the navel, now «prc«d
mpidly, so us in a few hours to eovi-r the entire body. lt<^spirattoa
is impi-ded by ha-morriiage into the lungs, and the ryiuionia thiu
d dccjicus the dark purple or ulmoiil black colour already pru-

VARIOLA IldSMORaHAGICA. 43j

• duceil by liieiiiorrliage. The sputa are reddened, while dark blood
oozing from the inoutli and nose dries aji into bhick crnsU upoa
tlie lijis^ and these, unless they are removed, help still furtluT to
embarrass Uie breathing. Similar drj black crusts cover also Ibo
teeth and the midille uf the tongue.

By this tirao the temperature of the body has sunk below the
Dormul stanilari], the pulae is thread-hkc and scarco perceptible, the
patient ia completely unconscious and no longer responds to ;iiiy
stiii'iulus. The petechia; have all clmnf^ed to small purple [lupuk-s,
which lire lliiekest on the face, ani!, in fact, represent the tlrst stage
of the eruption of variola. They seldom arrive at further develop*
EfifiHt, since death coramoidy ensues on the second or tliird day after
the appearance of the symptoms. In the very rare casca in which
life ia prolonged so that tlicy develop coinpletrly, tliey are no longer
filled with blood, but with pus, and their yellow colour then con-
trusts alrongly with the surroundiog livid skin.

In severe cases of simple variola, pustules are sometimes found

filled with coagulated blood, especially on the palms aud soiei<, but

' these have not been preceded by extravasation. Hero the hamor-

Irbage is not due to a general aiTectlon of the capilhiries, but simply

V to the violence of the local inllanunatory process.

Even when the course uf f'arioia nigra allows time for true pus-
tules to form, the result is atUl fatul ; at least there ia no caao of
recovery on record.

Wliea the buily of a jiatieut who has died of this (lipase ia

Lfxamiucd, blood is found cxtrovasaled In nearly all the tissues and

Argans. The mucoua tnemhranea are covered with ecchymoscs like the

■skin, here imd there very ciclcnsivc, and soaking through Llie whole

fsubmucous tissue. In the lungs, the liver, the spleen, masses of blood

Bimay bo found as big as a tist; and hfemorrbago occurs uliio in

tlie braiu aud its membranes, the muscles, the lieart itself, and even

1 the bone nnd periosteum.

We arc (^uitc ignorant of the changes the blood sutTers in this

:, and in what respects its chemical comj)osition tUtTcra from

[Qiat of health, As soon as {iiistules or even papules are developed

tlieir position decides the dingnosis. But that even those cases

::h petechial appear without any elevation of tlie surface

I really the elfect of the cotitagiou of variola, is proveil by

their occurrence during the course of severe epidemics of that

"lisease.

486 CCT1.NS0B8 RXKORRHAGB.

Tbo onlj other msladj in which tiie appearance of peteehii
seriooA or tatal moment is scailatina. Thej are not nnct
doling an attack of measles, bat do not then denote naj
danger. Nor doea their ocourrence in t^i^iiia or cholera afi
prt^osta to my important extent.

PIUHTBD BI J. B. iHhiXD, BIBXHOLOIUW C

LANE MEDICAL LIBRARY

To avoid fine, this book should be returned on
or before the date last stamped below.

FEB U W
DEC 28 1973

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