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*<• 



PATHOLOGY AND TREATMENT 



DISEASES OF THE SKIN. 



J. L. MILTON, 

■. JOHN'S HOSPITAL FOK HLSEASES O 




LONDON ; 
ROBERT HARDWICKE, 192. PICCADILLY. 



/af/. <yyz. . -?/?, 



LONDON : 

WYMAN AND SONS, PRINTERS, GREAT QUEEN STREET, 

LINCOLN*S-INN FIELDS, W.C. 



PREFACE. 



»o« 



THE foil wing work being devoted almost solely to Treatment, 
but little has been attempted in the way of systematic 
arrangement. The observations in it are principally clinical. 

As far as opportunities admitted of doing so, the views of those 
most capable of forming an opinion on the subject of Treatment have 
been carefully, and I hope I may say truthfully, given. Any short- 
comings in this respect are due to the impossibility of reproducing 
everything that has been written on so wide a subject 

There is a good deal in these pages which would be sought for in 
vain in any other work. For instance, I believe that up to the 
present time scarcely any mention has been made of Mr. Startin's 
excellent Lectures published in the Medical Times, while but very 
scanty justice has as yet been done to the various Papers by Dr. Hilton 
Eagge, one of the best and most truthful observers of the present 
day. The reader will see that I have, however imperfectly, tried to 
remedy these omissions. 

No attempt has been made to set up a new classification ; but as 
some arrangement was necessary, that of Willan — a system which 
bids fair to live as long as any of the thirty classifications brought 
forward during the last few years — has been followed. Here and 
there I have departed a little from it, and perhaps in some few cases 



iv Preface. 

might have departed more, and with advantage. Thus it might be 
better to class Pityriasis rubra with Eczema, and Pityriasis versi- 
color with Tinea. But, after all, such an arrangement might only 
be temporary, and I have therefore left both diseases where I found 
them. 

Brief definitions have been added for the purpose of enabling the 
reader to identify the diseases for which treatment is recommended. 
I hope, however, it will be distinctly understood that these are not 
intended as descriptions. 

The reader will observe that no mention is made of many diseases, 
such as Vitiligo, Pellagra, &c. The reason is that the observations 
being, as I have already said, chiefly clinical, it seemed better to 
confine them to diseases I had seen and treated. Syphilitic diseases 
of the skin are omitted altogether. To my thinking they are 
altogether unsuited to such a work. 

The number of cases of Skin Diseases from which these notes 
have been taken is variously put down, sometimes at five, sometimes 
at ten, or again, at sixteen thousand. This is owing to the fact that 
the diseases were examined and reported on in sections, and con- 
sequently at one time from a larger, at another from a narrower, 
field of observation. 

An attempt has been made to break up the host of remedies 
advised for these diseases into groups. This seemed to me the 
only way of grappling with an evil which gathers strength almost 
daily. 

Very free use has been made of the pages of the Journal of 
Cutaneous Medicifw. Indeed, this paper was started in the belief 
that it might be made a storehouse of original communications 
which, without it, would be difficult of access. As some very 
erroneous statements have been made about the origin of the 
journal, I will take the liberty of giving the true version of the case. 



Preface. v 

Towards the close of 1867 I proposed to Dr. Fox to bring out a 
periodical of this kind. After some discussion, we both agreed that, 
considering Mr. Wilson's position, it would only be courteous to 
propose that he should edit it. This task Mr. Wilson undertook. 
It was stated in the Medico- Chirurgical Review that he was assisted 
in it by Dr. Fox, but I always distinctly understood from Mr. Wilson 
that, beyond the contribution of an occasional paper with his name 
to it, he received no aid from that gentleman. 

I am sorry there should be so many errors of omission. Their 
number is due to the fact that some of the sheets were printed 
while I was almost entirely unfitted, by repeated attacks of pain 
and illness, from attending to work of any kind. 

St. John's Hospital, 

October^ 1872. 



LIST OF CONTENTS. 



Chapter I. — PAPULiE. A. Strophulus, i ; B. Lichen, 4 ; C. 
Prurigo, II. 

Chapter II. — Squaivle. A. Lepra and Psoriasis, 24; B. Pity- 
riasis, 35 ; C. Ichthyosis, 42. 

Chapter III. — ^TiNEiE. Tinea, 52. 

Chapter IV. — Eczemata. A. Eczema (B. Ulcer, included in 
same group), 75. 

Chapter V. — Erythemata. A. Erythema, 171 ; B. Erysipelas, 
175; C. Urticaria, 178; D. Purpura, 187; E. Pernio, 189. 

Chapter VL — Exanthemata. A. Scarlatina, 191 ; B. Rubeola, 
197; C. Roseola, 197; D. Variola, 198. 

Chapter VII. — VESicuLiE. A. Herpes, 202; B. Pemphigus, 211 ; 
C. Rupia, 213; D. Miliaria, 214. 

Chapter VIII. — Pustul^e. A. Impetigo, 215 ; B. Ecthyma, 223 ; 
C. Acne, 225 ; D. Sycosis, 240. 

Chapter IX. — Furunculi. A. Boil, 244 ; B. Carbuncle, 244 ; 
C. Charbon, 247 ; D. Aleppo Boil, 248 ; E. Delhi Boil, 248. 

Chapter X. — Tubercuue. A. Lupus, 251 ; B. Scrofuloderma, 
280 ; C. Leprosy (Elephantiasis Graecorum), 284 ; D. Chelis, 
313; E. Epithelioma, 315; F. Rodent Ulcer, 318. 

Chapter XL — PARASiTiCiE. A. Scabies, 319; B. Phthiriasis, 324. 

Chapter XII. — RELiQuiiE. A. Warts, 328-; B. Corns, 330; C. 
Molluscum, 330; D. Scleroderma, 332; E. Rank ' Perspira- 
tory 335 > F. Leucopathia, 336 ; G. Ephelis and Lentigo, 339 ; 
H. Chloasma, 339 ; 1. Bronzing of the Skin, 340 ; J. Silver- 
staining, 346 ; K. Naevus, 347 ; L. Mucous Tubercle, 348. 



LIST OF CORRECTIONS. 

Page 93, line Z^,for " to show " read " I have shown/' 
Page 136, line z^^for "pustules" read "papules." 



CHAPTER I.— PAPULA. 



A, Strophulus. B, Lichen, C, Prurigo, 

A. Strophulus («j, /, masc), possibly from ar^iii^c^ pain in the 

bowels, or (rTpo<i>a(o, to turn. 

Definition. — An eruption of small, prominent, generally hard 
papulae, varying in colour from a vivid red to white, attended with 
some itching, and ending, after a few weeks, in branny desquamation, 
generally seated on the face, but may appear on the neck, arms, 
shoulders, back of hands, breast, and loins. Peculiarly a disorder 
of early infantile life. 

Divisions. — i. S. intertinctus or red gum, red gown of the older 
writers, in which the papulae are red ; 2. S. confertus, or rank red 
gum, or tooth-rash, in which the papulae are paler, but more nume- 
rous; 3. S. volaticus, wildfire-rash, in which the papulae are red, 
and grouped in small clusters of from three to ten or twelve ; 4. S. 
albidus, white gum, in which the papulae are hard, small, and whitish, 
with a red halo ; and 5. S., candidus, pallid gum-rash, in which they 
are white, without a halo.-^ 

Treatment. — Strophulus rarely requires active treatment. Some- 
times the bowels are a good deal disturbed, there being griping, 
irregular purging, and symptoms of acidity. In such cases mild 
doses of antacids and aperients, — for instance, a combination of 
soda and magnesia with a little mercury and chalk, will do good. 
To this some carminative, like dill-water or cinnamon-water, may be 

B 



^ 



2 Treatment of Strophulus, 

added. Strophulus is by no means necessarily connected with 
dentition, but if there be any irritation set up from this cause, it 
cannot too soon be removed by lancing the gums. 

A lotion, containing half a drachm of borate of soda and two 
drachms of glycerine, in three ounces of elder-flower water, may be 
employed almost ad libitum during the day, and at night cold cream 
or an ointment containing five minims of chloroform, half a drachm 
of glycerine, a scruple of calomel, and three drachms of lard, may be 
smeared on the part. If, however, these remedies are to do good, it 
is absolutely necessary that the materials employed should be pure, 
and this is only too often not the case. The stufl" constantly sold as 
cold cream, prepared with bladder lard adulterated with lime and 
salt, is a very different thing from cold cream made by a first-class 
chemist. I have known two or three applications of what passed 
for zinc ointment remove the epidermis from the scrotum of a 
patient, suffering under a tender state of that part, almost as 
effectually as a blister would have done, and yet the irritation of the 
surface thus denuded has been relieved by the use of the same oint- 
ment properly made. Mr. Wilson relates, that having been con- 
sulted by a surgeon, he ordered him zinc ointment, which the 
surgeon procured from his own hospital. Mr. Wilson, anxious to 
know what a hospital's idea of zinc ointment might be, asked to see 
a specimen, and was favoured with a view of some stuff much more 
fitted for greasing cart-wheels than for applying to the human 
skin. 

This neglect is all the more unpardonable because very simple 
measures will ensure efficiency. Thoroughly purified lard should 
be used, and this can only be had by paying a higher price than 
usual, or by taking the trouble to melt down the flare, after soaking 
it in cold water, and strain it through flannel : the addition of ten 
grains of gum-benjamin to each ounce will prevent aCny rancidity. 
The pure gum or tears should be picked out, broken, and digested 
in warm lard for forty-eight hours. This mixture is afterwards 
strained, and then the active ingredient is added. For zinc oint- 
ment the oxide is used,* and as anything to be used for the hands, 
head, or face cannot be too free from colour, and, as the white 

* Bell's formula for preparing the benzoated oxide of zinc ointment is as 
follows : — R. Adipis prseparatae 5yj» Gum. Benzoin pulv. 5j ; liquefac cum leni 
calore per horas xxiv. in vaso clauso ; dein cola per linteum, et adde oxyd. zinc, 
purif. 5j ; raisce bene et per linteum exprime. 



Ointments. 3 

oxide, made by combustion, can now be had very pure, I decidedly 
prefer it to the bufF-coloured oxide. 

Some writers say ointments are barbarous * and apt to become 
rancid. But a remedy which promotes the patient's comfort and the 
cure of the disease most certainly ought not to be called by such a 
name, and when it is rancid either there has been a great neglect or 
bad materials have been used. 

The reader has only to use ointments properly in order to satisfy 
himself that in eczema, and many other allied affections, they not 
only exert a most decided action over the disease, but that they form 
the best defence yet discovered against the irritation which the con- 
tact of air with the diseased surface is apt to set up, a point of vast 
importance in very raw or cold dry weather, preventing all the 
injurious s)anptoms which so often follow the admission of air to a 
denuded and irritated surface. 

Most ointments, if properly prepared, will keep good for months. 
In general, however, patients are quite in the dark as to what is 
requisite for securing the benefits which these valuable applications 
yield. They think, when an ointment is ordered, that anything will 
do, and that it can be got equally good anywhere; whereas, compara- 
tively speaking, few chemists really pay such special attention to the 
subject as is requisite to ensure excellence. Again, ointments are 
left uncovered, often in warm rooms, while too much care cannot be 
taken to preserve them fresh and sweet, and this is in general only to 
be effected by keeping them closely covered up and in a cool place. 
The pot used for holding an ointment should have a tight-fitting lid, 
and a piece of wet bladder or lead-paper should be inserted under 
the cover, which is always to be replaced so soon as the ointment is 
no longer required. Finally, when an ointment is to be applied to 
an irritable skin, it should either be melted by placing it in a saucer 
over boiling water, or thinned down with almond-oil and smeared 
gently over the part, no more being prepared at a time in either way 
than is requisite for the occasion. 

' For strophulus confertus Mr. Startin prescribes the internal use of 
biniodide and bichloride of mercury, and directs the irritated surface 
to be bathed in yolk of egg mixed with tepid water. When the sur- 
face is dry or chapped, Mr. Wilson recommends the use of an oint- 
ment containing half a drachm of liquor plumbi to the ounce (the 

* "Creasy applications under any circumstances are barbarous, and often 
injurious in the treatment of cutaneous disease." — Burgess. 



4 Definition of Lichen, 

spermaceti cerate or ointment of the London Pharmacopoeia being 
both very good vehicles), or an ounce of oxide of zinc ointment, 
rubbed down with a drachm of spirit of camphor. 

B. Li'cHEN {en, mis or enos, masc), from Xeixny, oc,*a scab, lichen ; 
tree-moss. Gonaeus derives it from Xetx(^f to bum, to creep. 

Definition. — An eruption of small, hard, red, conical papules, not 
followed by ulceration, pustules, vesicles, or discharge, though one or 
more of these may complicate it in very severe cases, accompanied 
by heat, tingling, and often violent itching ; each papula becoming 
covered by a thin, small scale, or having the summit torn off by 
scratching. 

Divisions, — i. L. simplex, where the eruption is moderately red 
and scattered over the surface of the body. In more severe cases, 
and when it has lasted a long time, the pimples are seen in clusters, 
and the cuticle grows harsh, thick, and chapped (L. agrius). 2. L. ur- 
ticatus (nettle lichen), in which the pimples are large, often bear 
a suspicious resemblance to flea- or bug-bites ; and, on scratching, 
look like spots of nettle-rash : seen almost exclusively in children 
and delicate women. 3. L. tropicus (prickly heat), very small, hard, 
rough , papules, generally in clusters, attended with the most violent 
itching, and mostly seen either in the tropics or in persons who have 
resided there. 4. L. planus (Wilson), in which the papulae are dull, 
red, flattened, and glazed at the summit; always associated with 
constitutional disorders. 5. L. scrofulosorum (Hebra), in which the 
papulae are the size of a millet-seed, pale, yellowish, and red, scattered 
in smallish clusters, covered with little scales, and not excoriated. 
6. L. lividus, the same as L. simplex ; but the papules are of a 
purplish colour. 7. L. pilaris, in which the papules surround the 
hairs at their base. Both these divisions might, I think, very well 
be abolished, but Mr. Wilson and Mr. Startin retain them. 

Treatment. — In simple lichen, especially when acute, it is not 
necessary to do more than keep the patient quiet and give a 
febrifuge and brisk aperient. Citrate of potass or soda taken 
effervescing every hour or two acts very well in these cases, and now 
and then it may be requisite to give a mild sedative at bedtime, 
such as fiwt grains of extract of poppy or lettuce, with a little opium ; 
or tincture of hyoscyamus, to be taken in camphor mixture, may be 
prescribed. So soon as convalescence is established, a grain or two 



Treatment of Lichen. 5 

of quinine dissolved in a little dilute sulphuric acid can be given two 
or three times daily. 

My business, however, lies principally with the chronic forms of 
lichen, and of these, lichen agrius and lichen urticatus are selected 
as t)^ical divisions, the tropical form being very rarely seen in this 
country, and the forms mentioned by Hebra and Wilson having 
been very seldom seen, even by them. The remedies, then, for 
these varieties of lichen may be arranged in the following order ; 
and, provided the leading indications they afford be carefully looked 
to, the form in which they are given may be left to the taste and 
judgment of the surgeon. 

These remedies are : — 

1. First a tonic such as nitric acid given in some bitter infusion 
for two or three weeks. About fifteen minims in an ounce of 
infusion of quassia, or a wine-glassful of water with a drachm of 
some tonic tincture, like calumbo or cinchona, may be taken three 
times a day about half an hour before meals, or quinine may be 
ordered.* When the patient is low and anaemic steel may be given 
in the form of citrate or tincture instead of nitric acid.t Which- 
ever be given, an aperient should always be ordered at the same 
time. 

It is advisable, in some cases, to examine the urine, and should 
oxalate of lime be found, nitro-muriatic in the same doses may be 
substituted for nitric acid. 

2. Any particular disorder of the health, such as rheumatism, 
gout, or wasting, for instance, or of a function affecting the health, 
such as indigestion or inactivity of the liver, should be met by 

* The following formula will, I think, be found very useful : — 

R. Quinee disulphatis, gr. xij. 
Acidi sulph. dil. 5iss. 
Tinct. cardam. c. 5ss. 
Aqu^ cinnam. ad ^vj. in.* 
Coch. amp. i. ter quotidie sum. 
t The reader can try the subjoined formida : — 

R. Ferri et quinee cit. 5j. 
Ammon. sesqukarb. 5ij. 
Spir. myristicee Jss. 
Syrup, simpl. 5ij. 
Aq. ad Jvj. xt\_. 
A table-spoonful, in a wine-glassful of water, to be mixed with half an ounce of 
lemon-juice and drunk effervescing three times a day. 



6 Mode of giving Arsenic. 

appropriate remedies, as, for instance, iodide of potassium and 
colchicum, cod-liver oil, mild doses of mercury, &c. ; and / would 
most strongly recommend any such disturbance being thoroughly set right 
before the real curative trecUment is begun with; by curative treatment 
I mean that alluded to and the use of arsenic. 

3. Lastly, in all refractory cases, a course of arsenic should be 
ordered, and as so very much depends upon the way in which it is 
given, I shall once for all venture to bring forward what I believe 
to be the conditions essential to success ; for if arsenic is to. do good 
it must be used properly. By this I mean, that whether the plan of 
prescribing it in small doses at first and gradually increasing them, 
or of beginning with large doses and decreasing them, be adopted, 
the plan, once decided upon, should be regularly and consistently 
carried out ; and if any interruptions to it be thought requisite they 
should only be made on really valid grounds, and be as systematic 
as the rules for taking the medicine. The surgeon may often suspend 
the use of arsenic with advantage ; the suspension of it by the 
patient without orders can scarcely fail, sooner or later, to retard 
the cure. If the patient will give up arsenic whenever he is going 
out to see his friends, or when he has friends coming to see him ; 
when he is away on business or on pleasure, both being, of course, 
potent reasons for neglecting treatment ; when he is tired of medi- 
cine, or fancies it may not agree with him, in short, if he will take it 
in any way but the right way, he had better not take it at all. 
Properly employed, arsenic is quite as safe a medicine as mercury or 
antimony — if, indeed, it be not much safer; though some practi- 
tioners who give these freely enough, seem to regard ^senic with a 
special horror ; but it is only safe, just as it is only useful, when 
given in this way. 

I cannot say that I think the plan so strongly pressed upon notice 
by Mr. Hunt, of giving full doses at first, and gradually reducing 
them to such an amount as will maintain a decided action on the 
system, and of always giving the dose upon a full stomach, is the 
best, and, I believe, he himself does not stand out so very strongly 
for it as he did. Mr. Hunt deserves the highest praise for the reso- 
lution with which he has sought to force upon the profession a 
recognition of the value of arsenic. But, at the same time, I think 
it cannot be denied that the opposite system, if carefully worked out, 
is equally useful. It is therefore, perhaps, of little moment which 
system is adopted; but it is of great moment that it should be 



Treatment of Lichen. 7 

steadily adhered to, and that a proper preparation of arsenic should 
be given. 

For lichen, De Valangin's solution is one of the best formulae; but 
the surgeon must remember that there are now two preparations of 
this name : the original, twelve minims of which are equal to five of 
Fowler's solution, and that recommended in the British Pharmaco- 
poeia, which is of the same strength as Fowler's solution. Ten or 
twelve minims of the former, or four or five of the latter, may be 
given three times a day, either with the food or directly after, but on 
no account on an empty stomach.* If taken with the food, it may 
be mixed with anything the patient is drinking, as tea, beer, wine, 
&c. ; if taken after food, with a wine-glassful of water. 

I have no faith in arsenic in the shape of pills, or indeed in any 
solid form whatever. Besides, many persons cannot take pills, 
especially in great numbers, and they are not at all suited for 
children. The only remaining preparations of arsenic, of which I 
have any great experience, are Fowler's solution and Donovan's. 
Till I tried the solution of the chloride of arsenic, I thought Fowler's 
the best of all, and even now I would not undertake to prove that 
De Valangin's is better though I believe it to be so. In most skin 
diseases, except lepra, I think that, as a rule, it will be found to 
agree better with the digestion. Should the reader prefer Fowler's 
solution, he will find it, despite the changes in opinion called into 
life by fashion, a most valuable remedy. But I would strongly 
recommend the omission of the compound spirit of lavender, the 
objection to which I pointed out years ago. The faint mawkish 
taste it gives to the medicine is far more repulsive to many patients 
than anything either bitter or sour. I am glad to find that both 
Wilson and Hardy sanction the expulsion of such a nauseous and 
useless ingredient Donovan's solution proved useless in my hands. 
I never saw any harm arise from using it, but it would seem that 
others have. Mr. Hunt says, " If there be one medicine more 
dangerous than another, it is the villanous compound of arsenic, 
iodine, and mercury, known by the name of Donovan's solution." 
I share in this view so far as to believe that it is generally unde- 

* Liq. arsen. hyd. 5ij. — Ph. Brit 
Aquae 3xxij. n\,. 
Coch. min. i. ter quotidie sumend. 
More should not be ordered at a time, as it spoils. When a larger quantity is 
required, a small pottion of some strong spirit or tincture should be added. 



8 Mode of giving A rsenic, 

sirable to give either iodine or mercury in combination with arsenic ; 
an occasional dose of either can do no harm, but we retain a much 
better control over them by giving them separately. 

In an able paper * on the action of arsenic, Mr, Hunt, who now 
admits that this drug may be given in rising doses, makes the very 
important statement, that after one preparation of arsenic has 
been taken for some time, another may often be given with the 
best effects. The absorbents seem to take up a mineral poison 
very well for a while and then to refuse it, just as the stomach 
sickens after a while at a monotonous diet. At this juncture, if a 
different preparation be given it will be taken up greedily. I 
have repeatedly tested this observation of Mr. Hunt's with two 
arsenical preparations, — the solution of the chloride and the liquor 
arsenicalis, and have frequently remarked that when the action of 
the former began to flag, there was a rapid and manifest change on 
resorting to the alkaline solution. Whatever preparation of arsenic 
be employed, it is essential that it should be freshly made, espe- 
cially in warm weather. 

The dose and the mode of taking the arsenic having been decided 
upon, the next consideration is the length of time it requires to 
be taken; and respecting this I believe there is but one opinion 
among those who have most carefully studied the subject, which is, 
that it must be continued till the disease is thoroughly subdued if 
not altogether cured. Mr. Hunt looks upon a pricking sensation in 
the conjunctiva as a sign that the curative action of the arsenic has 
been set up, and he considers that, if just enough of the mineral be 
given to keep up the action, we shall get all the good we can from 
the remedy with the least amount of disturbance. In some persons 
arsenic brings on a dirty brown staining of the skin, with desquama- 
tion, where it is hidden from light, and Mr. Hunt finds that a dose 
large enough to keep up this discoloration, and yet not large 
enough to make the conjunctiva tender, will ensure the curative 
action of the medicine just as effectually as the largest amount. I 
believe myself that one of the best guides we can have is the action 
of the bowels. When the arsenic is making the stools a little more 
fluid and frequent than usual, it is doing all it can do, and it is 
rarely necessary to make any change in the mode of administering it. 
I have repeatedly found that after a short course of three full doses 

* Journal of Cutaneous Medicine^ vol. iL p. 350. 



Treatment of Lichen. 9 

daily, the daily use of five minims of Fowler's solution would cure 
the relics of an obstinate skin disease and at the same time keep 
the bowels in perfect order \ for arsenic, properly given, instead of 
exasperating soothes an irritated state of the bowels. 

With some persons, arsenic in very small does will bring on 
nausea, irritability of the stomach, sickness, purging, and a general 
feeling of being very much out of sorts. Perhaps the best method 
of meeting these disagreeable symptoms is the following : — ^The 
arsenic is interrupted for one day, a mild pill is given the night 
previous, and a dose of magnesia in the morning ; the patient may 
lie in bed, if practicable, during the early part of the day, and take 
only very light food ; the arsenic is then resumed the day after, and 
taken the last thing before going to bed. If it still produce sickness 
and irritation, the dose must be reduced again, for there is always a 
point at which arsenic will do good, without inducing disorder of the 
health ; in fact, the dose which just stops short of this is precisely 
the dose that effects the greatest amount of benefit. Some surgeons, 
in case of great sickness and irritation, add opium, hydrocyanic 
acid, &c, in order to diminish these ; but my opinion is quite op- 
posed to the practice. I have always found that arsenic answers 
best when its action is not masked. 

I may here remark, that in many thousand cases of disease of the 
skin, I have never seen an instance of such remarkable intolerance 
of arsenic as Mr. Hunt speaks of. The smallest quantity I have 
known to disagree with a grown-up person was about two minims of 
Fowler's solution daily. I had under my care a woman suffering 
from erythema, who complained so much of disturbance in her head, 
and excitement, from the use of De Valangin's solution in very small 
doses, that the quantity was gradually lowered to two minims a day, 
but in this instance, I had every reason to believe that the patient 
was not very anxious to be cured. 

Patients often get tired of the mere repetition of medicine, how- 
ever well it may be agreeing with them, and then they or their 
friends propose giving it up for a little while, and trying change of 
air, &c. I believe this to be, in almost every instance, a mistake to 
which the surgeon should not yield : once a hold gained over the 
disease, it ought never to be relaxed ; patients suffering under com- 
plaints for which arsenic is required generally derive much less 
benefit from change of air than they expect, certainly far less than 
compensates for interrupting a course of arsenic and having to go 

c 



I o Treatmen t of L ichen. 

through the whole process again ; and travelling, unless it can be. 
continued for a very long time indeed and under very favourable 
circumstances, will not cure a bad case of skin disease. 

Mr. Wilson recommends* for the constitutional treatment of lichen, 
the mildest aperients, followed by bitters and mineral acids, by 
chalybeates and quinine, or by quinine and iron. In chronic cases 
he has much faith in arsenic. For lichen planus he gives the ferro- 
arsenical mixture. His local treatment consists of juniper tar soap, 
tepid bathing, emulsion of bitter almonds, with hydrocyanic acid, 
bichloride of mercury and spirit of wine, and lotions of carbolic 
acid. His great remedy for the itching, and one which he considers 
a most valuable agent in lichen urticatus, is a lotion of pyroligneous 
oil of juniper and spirit of wine, an ounce of each in six ounces of 
water. In obstinate lichen circumscriptus he recommends gentle 
friction with ointment of ammonio-chloride or nitric oxide of 
mercury, or the ung. picis liquidae. For lichen planus, lotion of the 
bichloride of mercury or the solution of the pentasulphide of 
calcium.t Mr. Wilson thinks daily bathing of great value. 

Mr. Startin bleeds for this affection. For the lichen sparsus of 
authors, he uses a lotion of bichloride of mercury and creosote 
water to allay the itching. In cases of lichen pilaris, accompanied 
by asthenic look and languid circulation, he prescribes the per- 
sulphate of iron in infusion of quassia, and ointment of white pre- 
cipitate of mercury and levigated sulphur. For the feverishness of 
lichen agrius he gives purgatives and diaphoretic diluents, with a 
very strictly regulated diet ; after these a quarter of a grain of iodine, 
with twenty minims of liquor potassae and ten of colchicum wine, 
three times a day, with creosote ointment and a very free use of 
baths. He then gives calomel and opium at bedtime, to which 
succeed bichloride of mercury, in doses of one-sixth of a grain, and 
lotions of bisulphuret and bichloride of mercury applied warm. 

* Diseases of the Skin^ sixth edition, p. 202. 
t The following formulae may be employed : — 

R. Hydrarg. perchlor. gr. viij. 
Mist amygd. 5 viij. r\. 
Lotio ft. Or elder-flower water may be added in the same proportions. 

R. Calcis vivi Jj* 
Sulph. sublim. 30* 
Aquae Jlv. 
Boil, stirring with a wooden spatula till the fluid assumes a greenish hue ; 
then strain. 



Definition of Prurigo ; Treatment, 1 1 

Finally come aperient chalybeates and lotions of borate of soda and 
glycerine. For the livid form (lichen lividus), Mr. Startin uses 
acid chalybeates, hot-air baths, and sulphur fumigations. Lichen 
tropicus, which he considers to be the same complaint as pellagra, 
is not marked out by him as requiring any particular line of 
treatment. 

C. Pruri'go (^, /;//>, fem.), irom. prurire, to itch. 

Definition, — ^An eruption of small, pale papules, with a dry, greyish, 
or yellowish state of the skin, accompanied by intense itching, sting- 
ing, and burning ; wasting of the body ; skin often marked by long 
abraded lines. 

Divisions, — i. P. mitis, in which the papules are soft, smooth, 
solitary, and dispersed ; generally scattered on front part of fore- 
arms, belly, and thighs ; often nearly of same colour as the skin ; seen 
mostly in middle-aged persons, or the young. 2. P. senilis or formi- 
cans, emmet prurigo, where the papules are fewer and larger, and 
accompanied with the most violent itching sensation of being 
stabbed with a needle, crawling and tingling ; generally preceded 
or accompanied by considerable disturbance of the health, and a 
dirty-looking state of the skin, which is almost always marked by 
scratching. 

Treatment— \m all forms of this justly-dreaded affection, the 
remedies which seem to have succeeded best resolve themselves 
pretty well into six classes. 

I. An alkali. — Soda, for instance, seems to have always been a 
favourite ingredient in the prescriptions of the most successful prac- 
titioners. I do not attribute much importance to the form in which 
it is given ; perhaps the carbonate, or a mixture of carbonate and 
sulphite, answers best. If there be much indigestion or acidity, ten 
grains may be given two or three times a day just after meals, either 
in an ounce of bitter infusion with which a little compound tincture 
of cinnamon or spirit of nutmeg is combined, or it may be adminis- 
tered in conjunction with aromatic confection and dilute hydrocyanic 
acid.* These remedies should be continued till all indigestion is 
removed ; should no indigestion be present they may be given up at 
the end of ten days or a fortnight. 

* R. sodge carb. 3ij ; Acid, sulph. dil. 5j ; Conf. aromat. 5iiss ; Acidi hydro- 
cyan, dil. Ph. Lond. m. xx ; Ac^. menth. pip. ad S^iij. Coch. amp. duo bis terve 
quotidie sumend. 



1 2 Treatment of Prurigo. 

2. A remedy is required which will act on the skin. Sulphur in 
some form or other is perhaps the mildest and most certain. Anti- 
mony, however, in such a preparation or dose as will not nauseate or 
depress, may also be prescribed with benefit, and I see no objection 
to combining these remedies with a little nitrate of potass. When 
the skin is very dry and harsh, as it almost always is, a powder con- 
taining these ingredients may be given on going to bed in a little 
gruel or warm whey.* Like the previously mentioned remedies, 
these need not be continued more than about a fortnight. 

3. The use of either these two sets of remedies should be 
accompanied by a course of medicine which will act gently on the 
liver and bowels, as, for instance, the occasional use of small doses 
of iodide of potassium, with rhubarb, either in the form of infusion 
or pill. A little mercury may be given in the shape of blue pill, com- 
bined with soap henbane, and jalap or colocynth ; or as grey powder, 
with nitrate of potass. + Mr. Startin places mercury under interdict, 
though I have never seen it do the least harm. 

♦ Or try— 

R. Antimon. sulphur, gr. xij. 

Pulv. resin, guaiac. gr. xxiv. 

Olei ricini q. s. 

f. pil. xii. ij omni nocte sumend. 

R. Liq. ammoniae acet. Jiij* 

Vini antimon. 

Spir. aether, nit. aa 5iij. 

Mist, camph. ad ^yj. in.* 

Coch. amp. duo hord somni sumend. 

Whichever of those two may be selected, it should be followed by a glass of 

hot whey taken after getting into bed. The antimonial wine should be prepared 

by first dissohung the tartar emetic in ten times its weight of boiling water and 

then adding the wine. When it can be procured, essence of camphor, two or 

three drachms to six ounces of water, is much superior to camphor mixture, 

which is almost, if not quite, inert for adults. 

f For instance — 

R. Potassii iodid. 5j. 

Syrupi aurant. 3iij. 

Mist, camph. ad ^ij^ 

Coch. min. i. bis quotidie ex aquae cyatho vin. sumend. 

R. Pil. rhei c. 9ij. 

Divide in pil. viij. i. omni noct. sumend. 

R. Pii. coloc. comp. 5SS. 

— hydrarg. 9ss. 

Ext. hyoscy. 9j. m.. 

et divide in piL xii. i vel ij pro re nata sum. 



Treatment of Prurigo. 1 3 

4. But the great internal remedy in prurigo is arsenic, and in all 
very severe or long-standing cases, and in those which do not 
seem to be benefited by the preceding treatment, I would advise 
that it should be immediately begun with, and the other remedies 
used only as auxiliaries, or in the place of the arsenic when it is 
necessary to withhold it. It may be prescribed in full doses, and 
when this is done, I am disposed to share Mr. Hunt's opinion that 
prurigo is not such an intractable disease if properly treated, although 
I am aware that the statement may be looked upon as a modern 
heresy. Under the old plan of treatment it seems to have resisted 
every attempt to subdue its malignity, and, perhaps, there were more 
suicides from prurigo than from all other diseases of the skin put 
together. Mr. Hunt says — " Of the entire recovery of a patient 
thus aflfected, or even of considerable alleviation of suffering, not 
one single gleam of hope can be gathered from any author who has 
written on the subject And yet there is no truth in the whole circle 
of medical science more vividly impressed on my own mind, than 
that, under proper management, arsenic is an effectual remedy for 
this disease." Mr. Hunt bleeds to faintness in refractory cases be- 
fore giving the arsenic : in one case he took about seventy ounces of 
blood from the arm, and probably fifteen additional ounces by 
leeches ; and certainly, according to his statement, the success seems 
to have quite justified the means. Lisfranc used also to bleed in 
cases where the itching was connected with difficult menstruation, 
and the practice is said to have been very beneficial. 

5. Certain remedies which seem to stimulate nutrition in some as 
yet unknown way. Of these two are well worth a trial — strychnia 
and cod-liver oil. The strychnia may be given in doses of a 
sixtieth or a sixty-fourth part of a grain every three or four hours 
till a decided effect is produced upon the disease, or till nervous 
symptoms show themselves, when it may be left off. It sometimes 
acts Uke a specific upon the pruritus, and when this s)miptom is 
once thoroughly quelled we shall seldom, if ever, have much 
difficulty in dealing with the remaining symptoms. Nux vomica 
was a favourite remedy with Neligan, but I believe we are indebted 
to Dr. Burgess for this mode of exhibiting its active principle. It 
should not be taken along with any other remedy, whereas the cod- 
liver oil may be given almost as an article of diet for a long time 
and in moderate doses, quite inespective of any other medicine 
the patient may be taking. I confess my entire ignorance as to 



1 4 Treatment of Prurigo. 

how cod-liver oil and strychnia may act, and it may perhaps save 
some trouble if I say, once for all, that I am not prepared to oflfer 
any explanation of the action of medicines, for the simple reason 
that in respect to most of them nothing whatever is known for 
certain, and as to cloudy conjectures and cabalistic forms of speech, 
I leave them to those who like them. I am content to admire at a 
distance the person capable of solving such questions as causes and 
modes of action,* as I quite despair of my own ability to do so. 

6. A free use of hot baths, especially the vapour bath and the 
turkish bath. I prefer the latter when it can be used ; next to that, 
I decidedly give the preference to the vapour bath. But when the 
patient is very nervous, suffering, or supposed to suffer, froia disease 
of the heart, or subject to fainting ; where he resides at a long 
distance from any establishment or baths of either kind, or where 
expense is an object, the hot bath is our only alternative and 
fortunately it is a very good substitute. The water should be at 
quite ninety-eight or a hundred degrees of Fahrenheit. The 
patient, so soon as he enters the bath, should scrub himself all over 
with the flesh-brush, lather the affected parts with either the soft 
soap of the London Pharmacopoeia or Pears's transparent soap, 
and then let himself down into the hot water, in which he ought not 
to remain more than three or four minutes. Having dried himself 
thoroughly, he should apply any ointment he may be using and 
dress directly. 

But the turkish bath is the thing ; it scarcely ever fails to do good, 
and is, perhaps, more peculiarly suited for prurigo than for any 
other disease of the skin. There are many persons in the habit of 
sponging all over daily and who, therefore, have quite made up 
their minds that they require no other kind of purification. They 
cannot too soon be undeceived as to the efficacy of water used in 
this way ; it will no more free the skin from soot, dust, dead scarf- 
skin and secretion, than rubbing a horse gently down with a soft 
towel will make his coat glossy. To rid the surface thoroughly of 
these impurities two things are necessary : free perspiration must be 
induced and the skin must be well rubbed and kneaded. Trainers 
are well aware of this, and when preparing a man for a fight make 
him perspire freely and then rub him down with a hard towel. The 
vigorous system of cleansing adopted in a turkish bath is more 

* Felix qui potuit renim cognoscere causas. 



The Turkish Bath. 1 5 

like that used in training than any other, and will soon open the 
eyes of those who put their faith in cold sponging only, by bringing 
away an unexpected quantity of dirty skin. As there is no danger 
to be apprehended from the use of the bath so long as the simple 
precaution is adopted of not staying in too long at first and always 
taking the bath on an empty stomach, it can scarcely be overdone. 
I have known one taken three or four days together without any 
harm arising from it, and should not anticipate any. 

Some most extraordinary objections have been made to it. Mr. 
Hunt, for instance, expatiates with grim sarcasm on the portentous 
aspect of things on entering a turkish bath — the air so hot as to 
make one fancy that it cannot be breathed without setting the lungs 
on fire, the kneading and trampling on the patient and the drowning 
with a deluge of cold water ; but he admits that it cures fanciful 
people of their whims in superlative style. Then one of the whims 
it will cure them of is fancying there can any harm come from 
using the bath. 

Whichever form of bath be adopted, I would strongly insist upon 
the necessity for taking it regularly and often enough and not 
yielding to any nonsense about baths being lowering, weakening, 
&c. I dwell upon the subject because the advantage of hot bath" 
ing in prurigo generally so soon becomes manifest If nothing 
else be gained, free perspiration is promoted, and though this is no 
panacea yet it is attended with relief. Prurigo often breaks out in 
persons who have nothing to reproach themselves with in regard to 
cleanliness. Mr. Startin, indeed, says,* *•' that the neuralgic itching 
which some writers consider as a form or variety of prurigo is, 
perhaps, more frequently met with in the respectable walks of life 
than any other cutaneous affection." Such persons often seem sur- 
prised at being told to make free use of hot baths, but they 
forget that they do not take sufficient exercise to keep the skin 
in a healthy state, and that means which would do very well with 
men riding twenty miles a day or working hard at training, are 
quite inefficient when exercise is reduced to a gentle stroll. Elderly 
persons in good circumstances, and people who have retired from 
business, often seem to think it is hardly respectable to go beyond 
a steady walk, but prurigo will not yield to such gentle means, and 
till regular active exercise has become a settled habit, the action 

* Medical Times ^ vol. xiv. p. 193. 



1 6 Treatmeut of Prurigo, 

of the skin must be encouraged. In all cases I think no woollen 
ought to be worn next the skin. 

Mr. Wilson gives generous diet and tonics in this disease and 
considers arsenic, properly given and watched, as a specific. Fric- 
tions, baths, carbolic acid soap and juniper-tar soap are his chief 
local remedies, but he looks upon the prognosis as doubtful on 
account of the exhaustion and suffering which accompany the 
complaint. 

Mr. Startin's treatment of prurigo is that of lichen ; he relies 
chiefly on mineral acids, chalybeates, opium and ammonia, and 
has never found benefit from mercury or arsenic ; on the contrary 
they rather do harm. In a very severe case of prurigo formicans, 
recorded by this gentleman, twenty drops of dilute sulphuric acid 
and ten of Batley's sedative three times a day, followed by tincture 
of muriate of iron in infusion of quassia and an opiate at bedtime, 
proved perfectly successful. These means were, however, seconded 
by the use of an ointment of white precipitate of mercury and 
creosote, ten grains of the salt and a few drops of the fluid to an 
ounce, and after this a weak solution of bichloride of mercury in 
creosote water, used warm ; later on, the ointment was entirely dis- 
continued and bisulphuret of merciuy was added to the lotion. 
A strict diet, consisting of milk, bread, and boiled meat was ob- 
served. Mr. Startin finds hot-air baths and cinnabar fumigations of 
great service. Dr. Neligan* used to prescribe iron in infusion of hops, 
with the juice of conium in pretty large doses. He found in the 
prurigo of old people great benefit from the use of this remedy 
along with magnesia. Some years ago. Dr. John Waterfield com- 
municated to the Lancet and Medical Gazette a paper on the value of 
tar and charcoal pills, and he now tells me that he has treated 
several cases of prurigo very successfully with this remedy. Dr. 
Hilliert says that in some chronic cases diuretics, "such as the 
sweet spirits of nitre, decoction of broom, with the compound 
tincture of juniper and saltpetre," are of benefit. Dr. Purdon com- 
municated to the Journal of Cutaneous Medicine % three cases in 
which the bromide of ammonium in doses of from ten to twenty 
grains effected a very rapid cure. 

Hebra's treatment of prurigo is simply palliative, and even in 
this he does not appear to be very successful ; but the explanation 

• Practical Treatise on Diseases of the Skin^ p. 210. 

t Handbook of Skin Diseases, p. 79. * Vol. i. p. 326. 



The Prurigo of Hcbra. 1 7 

is, that the disease which he describes under this name is quite distinct 
from what we call prurigo^ and it has more than once struck me with 
surprise, that authors professedly familiar with his works had never 
noticed this. I sought to call attention to the fact in a paper written 
for the Medical Press and Circular some two years ago, and I had 
occasionally in conversation pointed out the distinction between the 
Austrian and the English disease ; but, so far as I know, the obser- 
vations fell to the ground. I was, therefore, not a little gratified, on 
reading Mr. Hutchinson's " Norwegian Notes,*' in the Medical Times, 
to find that he had, on independent grounds, arrived at the same 
conclusions as myself. Speaking of Hebra's account of the disease, 
he says : * — 

" I think it will be granted by English observers that cases fitting 
with this description are very rare. I have myself been carefully on 
the look-out for such, and have found very few indeed. Two recently 
under my care, to which I was disposed for some time to give this 
name, were afterwards proved to be attended by body-lice, and in 
all probability caused by them. Yet in Vienna Hebra speaks of the 
disease as frequent, and refers to an experience of thousands. 

" Dr. Bidenkap, who formerly studied under Hebra, showed me 
two patients in whose cases this diagnosis had been given. One was 
a girl of about fifteen, and the other a lad a year or two older. Both 
had suffered for years, and in both, from scratching, &c.*, the skin 
had become thickened, of a deep brown pigment, and spotted with small 
whitish but indistinct scars, 

" In both cases I thought there was good reason to suspect scabies ; 
indeed, in one it was known to have been present, and both were to 
me suspicious of pediculi. We talked over these conjectures, and 
Dr. Bidenkap alleged, with much force, that if any large proportion 
of the cases of Hebra's prurigo are really badly-cured scabies or 
pedicularia, then ought that malady to be very frequent in Norway, 
whilst, in truth, it is very rare. 

"The state of skin in Dr. Bidenkap's two patients, as regards 
pigmentation and evidences of scratching, very much reminded me 
of some of Hebra's plates illustrating the eruption consequent upon 
lice, and I cannot still help feeling some suspicion that, after all, a 
local, and not a constitutional, cause may possibly be at the bottom 
of the matter." 

• Medical Times and Gazette, 1869, vol. ii. p. 44. 

D 



1 8 The Prurigo of Hebra, 

Of course, observation alone can settle this point ; but in the 
mean time I may remark that Hebra denies that prurigo is, or ever 
can be, caused by any kind of insect {durch irgend eine Gattung 
Epizden *). It is a disease of the skin, he says, in the strictest 
sense of the word, and never arises from external irritation. It is 
the result of an inborn tendency to the disease ; the germ of prurigo 
exists in the child in every instance. ("Jede Prurigo ist schon 
beim Kinde vorhanden.") 

Hebra describes t prurigo as " a peculiar disease of the skin, 
characterized by the development of small papules of the same 
colour as the healthy skin or slightly reddened, and violent itching, 
corresponding to the description by Willan of prurigo mitis and 
prurigo formicans," the only forms which he recognizes. The symp- 
toms, as given by him, are an eruption of small sub-epidermal 
papules, rather to be made out by the feel than the sight, isolated, 
the skin between them intact, causing most severe itching, the 
summits occasionally crusted with blood. With the long continuance 
of the complaint ensues a dark staining of the scarf-skin, and the 
natural furrows, lines, and shallow pittings in the skin become 
deeper and stand further apart, particularly in the fingers, backs of 
the hands, and wrists. With time, the skin becomes harder and 
thicker. Many patients never suffer more than this, but in prurigo 
agria or ferox, the symptoms, though the same, are far more severe ; 
the papulae are larger, the itching more intense, the excoriation 
more extensive. The whole of the epidermis is converted into a 
kind of white, flour-like dust. Sometimes symptoms like those of 
eczema rubrum are added, or pustules may appear and even assume 
a confluent form, so that a tract of the epidermis may be undermined 
by suppuration. Many cases might be taken for ichthyosis, eczema, 
impetigo, or ecthyma. It may attack the face, but the scalp escapes ; 
the hair, however, of such patients is dull, quite without sheen, feels 
dry, and frequently looks as if covered with dust. The skin of the 
lower parts of the legs is often as rough as a file ; when the closed 
fingers are passed over it there is a sound as if they had been drawn 
across a short-bristled brush, such as a nail-brush for instance, or a 
piece of coarse pcuking-paper, and a pricking feeling is felt in the tips of 
the fingers for some time after f The extremities are generally the 

* Handbuch der speciellen Pathologie, 3er Band, 3e Lieferung, S. 490. 
f Op. cit., p. 478. 



The Prurigo of Hebra, 1 9 

parts most affected ; flexion surfaces, such as the armpit, &c., are 
seldom, if ever, attacked. When there are many pustules on the 
extremities the corresponding lymphatic glands swell. When the feet 
are thus invaded the glands in the groin may enlarge to such an 
extent that the mass protruding above the level of the skin is as big as 
a marCsfist^ (!) and they take on this change in a more symmetrical 
manner than in any other disease. 

The complaint begins to show itself in early life. It is often 
milder in summer and after a good deal of hot bathing. He has 
not found either that it tends to bring on dropsy, mania, and tuber- 
culosis, as imagined by some authors, or that it wards them off. The 
sufferings of the patient, however, are so atrocious that it is no 
wonder his mind gives way sometimes. Its tendency to induce 
suicide he thinks has been greatly overrated. That it should bring 
on weariness of life is only natural. " If we look," he says, " at the 
existence of a patient afflicted with prurigo, even as a child con- 
stantly harassed both by schoolmasters and playmates for scratching 
himself; if we view him later in life, especially if he belong to the. 
working classes and be not in a position to have a bed to himself, 
grumbled at by his bed-fellows, and even banished from their 
society — ^partly owing to dread of infection, partly to their sleep 
being broken by his incessant scratching — if we contemplate him in 
still more advanced life (particularly should he be in a good posi- 
tion) looking upon himself as an object to be shunned by all the worlds 
and dreading to make himself a home or take to himself a wife — 
the weariness of life in one so frightfully tortured can be easily 
understood." Yet, strange to say, the patient endures life even 
under these circumstances, and Hebra tells us that he has only 
known one case of suicide from prurigo. 

Prurigo altogether, as I understand Hebra, is utterly incurable, 
and he thinks* it is much to be regretted that this fact is not pointed 
out in a sufficiently emphatic manner in any dermatological work ! 
For incurable it is ; the patient may do what he likes, his malady 
will follow him to his grave, and only those who are unacquainted 
with the course of the disease would use such an expression as that 
of its being difficult to cure, seeing that this would imply the possi- 
bility of removing it in some few instances. Many other writers 
have drawn pictures of prurigo which are gloomy enough, but none 

* (7/. «'/., p. 4S2. 



20 ' The Prurigo of Hebra. 

that can be compared with this by Hebra, which is shaded in with 
such sombre hues that the mind can scarcely realize the idea of 
sufferings which might vie with those described in Dante's " Inferno." 
Hope is out of the question, and art, regarded as a curative power, 
is useless, whereas the two writers who, perhaps, after Hebra, take 
the gloomiest view of the inveteracy of the complaint, and of the 
little control over it exerted by medicine — Willaii and Rayer — ex- 
press themselves in a very different way. The former distinctly 
says * that even prurigo formicans is not unfrequently cured by a 
course of treatment (which he speaks of) in the short period of a 
month or six weeks, and that " sea-bathing has also, in some cases, 
entirely removed the complaint," while Rayer*s statements go no 
further than saying that prurigo senilis often resists the best-directed 
treatment. 

The only instance I have ever seen in which I thought I could 
detect even the germs of the disease described by Hebra was the 
following : — 
• Alfred B., aged 5 last birthday, was brought to St. John's Hos- 
pital, April 2nd, 1869. The skin was in hue almost like that of 
some mulattoes ; I could only compare it to a tint between citron 
and olive ; in texture and feel it resembled that seen in ichthyosis in 
the young. From the lower part of the back of the neck to the 
lowest part of the left scapula, and from the spine to the point of the 
left acromion, the skin was thickly sown with papules. They were 
small and reddish ; the tops had been torn off by scratching. But 
for this they might have been very fairly compared to the papules of 
prurigo senilis as seen in Willan's plate of that disease. The mother 
described the itching caused by these papules as being of the most 
rabid description ; it began to be manifest so soon as ever the lad 
was able to scratch himself, and since that time he had never passed 
a night without lacerating his skin. The papules had begun over the 
ridge of the scapula, and had never extended beyond the district 
which I have described. There was not a single sign of scabies. 
The boy had always enjoyed good health in every other respect, and 
had suffered from no illness except chicken-pox and measles, through 
which he passed very well. A brother, a year or two older, who 
had much the same peculiar colour, had never shown any signs of 
skin disease. 

* Ou Cutaneous Diseases, pp. 78 and 79. 



J 




PRURIGO IN A BOY. 

SUPPOSED INSTANCE OF THE PRURIGO OF HEBRA. 



The Prurigo of Hebra. 2 1 

He was placed on full doses of arsenic, which were continued 
three times a day with great regularity. By the beginning of August 
the disease had in a great measure yielded, and five or six weeks 
later it had quite disappeared, the itching of course going with it 
Since then the boy has remained well. 

It may be said that the symptoms here were due to pediculi, but 
I submit that there must be another and more potent factor in the 
case. When the patient was first brought to me I had his shirt 
taken off and thoroughly examined ; I believe I searched every fold 
of it, but I found no traces of lice. At a subsequent period, without 
giving the mother any warning, I repeated the process, but with the 
same result. There were some nits in the back hair, and the mother 
had occasionally detected a louse or two, but I need scarcely say 
how common such things are in the heads of children, whereas this 
is the only instance I have seen of these s)Tiiptoms in more than 
10,000 cases of skin disease. According to my experience, lice only 
set up irritation in their immediate vicinity ; here a distant solitary 
part was affected. The child was evidently, for his station in life, 
kept very clean and well attended to. Finally the disease passed off 
under internal treatment only, no external means whatever having 
been employed, so that its removal was not due here to the 
destruction of the parasite by topical applications. 

For the purpose of more clearly elucidating the point here dis- 
cussed, I give a photograph of the appearance presented by the 
patient. 

In some cases, particularly when prurigo attacks the pudendum, 
scrotum, or anus, the itching is so intolerable that something must 
be done locally for it, although it is rather a wild-goose chase, for 
the itching is the symbol of the malady, the one essential and 
tangible symptom, and the cure of it is the cure of the disease. 
Mr. Wilson recommends, in a general way, that the skin should be 
frequently rubbed with a damp sponge dipped in fine oatmeal ; after 
this, the tincture of croton, made by steeping an ounce of bruised 
croton-seeds for a week in four ounces of spirit, is applied, and after 
this has been done a few times a lotion of bichloride of mercury in 
almond emulsion, fifteen or twenty grains to a pint, will often prove 
very efficacious. Painting the surface with iodine is useful, as is 
also glycerine applied with a sponge. For the affection of the 
pudendum, Bateman recommends a lotion made of two grains of 
bichloride (" oxymuriate ") of mercury in an ounce of lime-water. 



i 



22 Connexion of Prurigo senilis with Lice. 

Mr. Wilson says the juniper-tar ointment is peculiarly valuable in this 
variety. In pruritus of these parts injections of very hot water, 
juniper-tar ointment, bUsters to the thighs, and small bleedings, 
seem, from all accounts, to be the most reliable means of cure. 
Mr. Wilson has found an opium injection relieve the irritation after 
all other means had failed. Strong nitric oxide of mercury oint- 
ment, and podophyllin in doses of one-sixth of a grain are said to 
have proved of great service in prurigo of the anus. Mr. Startin, in a 
case related in his lectures, where the scrotum was also affected, 
directed mucilaginous hip-baths, daily ablutions with yolk of ^gg 
and tepid water, the application twice a day of very dilute mercurial 
ointment with a few minims of creosote, strict diet, and one-sixth of 
a grain of bichloride of mercury in cold infusion of hops three times 
a day. The case was very severe and occurred in an old man, but a 
cure was effected in little more than two months. In the prurigo of 
old people generally Mr. Startin's prescription for external use is a 
liniment of glycerine and trisnitrate of bismuth, or powdered talc 
rubbed in with a flesh-brush. Dr. Frazer recommends * for trial finely 
powdered camphor mixed with six or eight parts of rice or potato 
starch, and a small quantity of acetate or carbonate of lead. This 
is dusted on the skin three or four times a day, its action being aided 
by calomel ointment. Latterly Dr. Neligan confined himself almost 
entirely to chloroform ointment, which seems one of the best, if not 
the best, ever introduced. It is made by mixing half a drachm of 
chloroform with an ounce of cold cream. I believe this and the 
lotion given below t are two of our most valuable remedies. 

Mr. Balmanno Squire considers % that prurigo senilis is always due 
to pediculi and we may naturally expect to find that his principal 
reliance is upon external means. That in some persons pediculi 
will induce symptoms which might very easily be mistaken for 
prurigio is possible enough, but that they ever bring on genuine 
prurigo, a disease in its severer form so generally associated with 
some deep-seated constitutional disorder, is a very different matter. 

* Treatment of Diseases of the Skin ^ p. 131. 
t R. Hydr. bichlor. gr. iv. 

Bismuth oxyd. 5ss. 

Acidi hydrocyan. dil. Ph. Lond. 3ss. 

Aq. calcis ad. J^U* ^* 
To be applied warm two or three times daily. 
X Medical Times and Gazette^ 1865, vol. ii.p. 211. 



Local Treatment of Prurigo. 23 

Mr. Naylor, who thinks * the insect cannot produce any form of this 
complaint, says he has known a very weak nitric acid lotion— half a 
drachm to eight ounces of water, or one of bismuth, a scruple to six 
ounces of water — prove exceedingly serviceable. • He also says that 
when prurigo is an idiopathic affection the use of chloroform is often 
of great service, applied either in the form of vapour or of an oint- 
ment consisting of equal parts of chloroform and camphor liniment. 

Mr. Hutchinson, t in fifty-five cases of prurigo senilis, found lice in 
fifty-two, and Dr. Hillier says that out of fifty-one cases under his 
care in University College Hospital the pediculus was met with in 
thirty-five. Dr. Drysdale also holds % that prurigo is almost always 
caused by the presence of the pediculus vestimenti. Still the exist- 
ence of intense itching from undoubted prurigo, in eczema, in dis- 
turbed health, from pregnancy, &:c., shows that the presence of the 
insect is not a necessary feature in the generation of this distressing 
symptom. 

Dr. Hillier speaks highly of stavesacre ointment, also of an oint- 
ment containing one or two drachms of the powdered pyrethum 
roseum (the persian insect-powder) to an ounce of lard. Dr. Cheadle 
has also found stavesacre ointment very useful. Dr. Van Buren 
strongly recommends a solution of sulphurous acid, freely applied 
two or three times a day. One part to two of water might be used. 
Iodoform ointment, a scruple to a drachm of the salt mixed with an 
ounce of cocoa butter (oleum throbromae), has been recommended. 

* Treatise on Diseases of the Skin^ p. 86. 

f British Medical Journal ^ 1870. 

X youmal of. Cutaneous Medic ine^ vol. iv. p. 79. 



( 24 ) 



CHAPTER II.— SQUAMiE. 

A, Lepra and' Psoriasis . B, Pityriasis, C. Ichthyosis. 

A. Le'pra {a, ce^ fem.) and Psori'asis {is, is, fern.) (XcV/oa, from XcTrpor, 
rough, scaly; psoriasis, from if'w/oa, the itch). 

Definition. — 'An eruption of ham- or salmon-coloured slightly 
elevated papules, often looking at first like scattered drops of tallow- 
grease, gradually becoming covered with thin, extremely dry, hard 
white scales, often coalescing into large irregularly-shaped patches, 
peculiarly prone to appear, among other parts, on the knees and 
elbows ; the scales becoming very light and silvery in some cases. 
Not accompanied or followed by vesication, ulceration or forming of 
pustules. Often a good deal of itching, sometimes accompanied by 
aching pain in the parts affected, heat, stiffness, and uneasiness, a 
brown state of the tongue and other signs of disorder. 

The sooner the word psoriasis is entirely omitted the better. It is 
really in the ordinary sense of the word a form of lepra, displaying 
the same features and requiring the same treatment. I have there- 
fore left it out altogether, and all that is said of lepra must be un- 
derstood as applying to psoriasis alsa Mr. Wilson, indeed, has 
proposed that the latter word should be used only for the dry, scaly 
stage of eczema, and that lepra should be known in future as alphos. 
I would suggest the entire expulsion of psoriasis, and should it be 
considered indispensable to use a greek word for the dry state of 
eczema, I would suggest that psora be retained, being classic Greek 
and a very significant word. 



Patfiology of Lepra. 25 

Pathology of Lepra. — I subjoin a few observations on this subject, 
which will not, I think, be found in any other work. 

In the AUgemeine med, Zeitung of Vienna for July i6th, 1867, 
there is a paper on the pathology of lepra by Dr. J. Neumann. 
Having quoted the statement of Gustav Simon, that the red 
spots which precede the formation of scales probably arise from 
chronic inflammation, and the swelling of them from inflam- 
matory deposit in the skin the nature of which has not yet been 
examined \ and that this chronic inflammation occasions the profuse 
formation of epidermic scales, in the latter part of which view Neu- 
mann himself coincides, and having mentioned that Hebra in his 
post-mortem examinations could not, either with the naked eye or 
the microscope, detect any adequate pathological appearances ; he 
goes on to say that Wertheim removed some of the affected pieces 
of skin from persons suffering under lepra (psoriasis he calls it) and 
found both the longitudinally and transversely placed papillae en- 
larged to twelve or fifteen times their natural size. He has also 
found that the vessels of the papillae take on the appearance of 
being more bent and twisted on their way to the top of the papillae, 
and he conjectures that the vessels may be enlarged. 

Dr. Neumann then proceeds to give the results of his own obser- 
vations. In his cases the portions- of skin affected with lepra were 
soaked in solution of glue for twenty-four hours, and then micro- 
scopically examined by Professor Wedl. The most successfiil 
sections, which were treated partly with vinegar only, partly with a 
preparation of ammonia (karmin-saurem Ammoniak\ yielded the 
following results. The epidermis cells, as also those of the rete 
Malpighii, were largely developed and hypertrophied. Both the 
corium and the papillae were filled with numerous cell-growths. 
These occurred especially along the course of the vessels, sometimes 
they appeared singly, and exhibited numerous continuations. They 
were met with principally in the upper layers of the corium and the 
tips of the papillae, where they are aggregated into little masses. 

If we take one of the larger vessels of the corium and trace it to 
the branches going to the papillae, we find, beside the cell -growths 
which gather round the wall of the vessel, the little twigs which run 
into the papilla in a graduated line, spreading themselves along the 
whole papilla ; in some we find the vessel winding round the tip of 
the papilla in such a manner that the cells lying on the wall of the 
vessel, which in its previous course held a position corresponding to 

E 



i 



26 Pathology of Lepra, 

its long diameter, now take on at the tip a horizontal or oblique 
direction. A transverse cut through the papilla gives a clear view 
of the cell-growths which almost fill out the stroma, forming a very 
visible ring in the middle of the section. 

Neumann therefore considers that lepra is to be ranked as an 
inflammatory process of the upper layer of the corium and the 
papillary bodies, but with exuberance of cell-growth and enlarge- 
ment of the papillae, an enlargement, however, which is not peculiar 
to lepra, for it is found in other chronic diseases of the skin, as, for 
instance, prurigo and eczema; but in these the enlargement is only 
found when the disease has lasted a long time, whereas it is met 
with in lepra at the very outset. The excessive formation of epider- 
mis scales is therefore only to be regarded as a hyperplasia of the 
cells of the Malpighian tissue. 

According to Wilson,* the papillae in lepra become congested and 
infiltrated, and there is possibly even in an early stage hyperplasia of 
the cell-tissue ; in the mature state the papillae of the cutis are hyper- 
trophied, so that when a scale is forcibly removed the heads of the 
papillae are torn off. They are sometimes so large and so closely 
surrounded by the substance of the scales in the central part of the 
matrix as to hold the scale almost as firmly as a nail. 

As to the pathology of pityriasis versicolor, there are very good 
grounds for relegating it to the tineae, but doing so would only 
increase the confusion on these points, already too great to admit 
of any addition until such time as some of the disputed points shall 
be set straight. Its predominant pathological character appears 
to be a change in the structure of the rete mucosum. 

The latter tissue loses its cell-form ; it no longer undergoes its 
normal change from an incomplete and albuminous tissue into a 
horny tissue, but retains its growing function, and instead of normal 
cell-growth, its component elements take on a linear proliferation, 
which converts them into independent fibres, simple and branched, 
and separate granules. When we look at this structure with the 
microscope, we see, in lieu of normally-formed nucleated cells, an 
abnormal growth of the constituents of the cells, a change in the 
direction of growth, and a substitution of abnormal growth for 
normal development and perfectibility of tissue. 

I have here to say a few words respecting the light thrown upon 

* jfournal of Cutaneous Medicine, vol. ii. p. 86, &c. 



Treatment of Lepra. 2 7 

the prognosis of this disease by the different forms which it assumes. 
Leaving aside the divisions and subdivisions set up by some writers, 
we may here trust solely to Nature, who points out four clear forms. 
1. An eruption of very large patches, few in number, sometimes 
solitary, seated on the front of the chest or abdomen, or on the 
outer part of the arm. This variety is often unaccompanied by any 
decided scaliness of the elbow or knee. It is rare, and generally 
rapidly removed, especially in young persons. — 2. A form of the 
disease, which only attacks the front part of the leg from below the 
knee downwards. It is composed of from two to six or seven large 
patches, seated on an elevated base. It is very rare, and its 
duration seems almost interminable. It shows no disposition to 
spread to other parts. Sometimes, too, it assumes, when scratched, 
an appearance closely resembling eczema, but the surface secretes 
only a very small amount of serum, while the silvery scales on other 
portions show it to be clearly lepra. — ^. Lepra affecting chiefly 
the knee and elbow, principally taking on the form of a few scat- 
tered small spots with extremely bright silvery scales, sometimes 
solitary ; intensely obstinate, yet generally remediable, especially 
when blistering is freely employed. — 4. General difiiised lepra, 
where patches come out in hundreds and run into large masses, 
a form in which art is only too often powerless. 

Treatment, — If I were to rely exclusively on my own experience, 
I should say that time was lost, at the beginning at any rate, in 
trying any remedy for this complaint except arsenic, which should 
be commenced at once and taken in the largest doses the patient 
can bear. Should the arsenic disagree with the patient the dose 
may be lessened, or when the stomach is considerably out of order, 
it may even be given up for a day or two, and a saline prescribed 
instead till the arsenic can be borne again, when it is to be at once 
resimied. It is given in the same doses and in the same way as for 
lichen and prurigo, but cases may occur in which it is as well to 
leave the beaten path and try what amount of this potent mineral 
can be supported, as nothing short of the maximum quantity will do 
good. Dr. Moriarty, in a case of inveterate lepra, gave ten-minim 
doses of Fowler's solution four times a day and effected a complete 
cure, though the disease had lasted seven years and four months. 
Dr. McCall Anderson also mentions a case in which a young girl 
took thirteen drops three times a day. 

Suppose, however, it should be absolutely necessary to suspend 



28 Treatment of Lepra, 

the arsenic, are there any other reliable remedies? 1 know, by 
experience at least, of none that can be depended upon as a 
substitute for the arsenic, but there are several which will improve 
the health, and when arsenic has done its work will often contribute 
to the disappearance of the eruption. 

Among these steel holds a foremost place. It may be given both 
when the patient is taking arsenic and when he has suspended it, 
but I would always advise that the two medicines should be pre- 
scribed separately, and independently of each other. I have not 
in practice found any preparation superior to the tincture of the 
sesquichloride (Pharmacopoeia Lond.), which may be given to even 
quite young persons, in doses of thirty minims, twice or three times 
a day, in a large wineglass of water a short time before meals. 
Another useful auxiliary is the iodide of potassium in tincture of 
bark, accompanied by small doses of biniodide of mercury. Some 
writers recommend the nitro-muriatic acid in doses of fifteen or 
twenty minims, with the same quantity of compound tincture of 
cinnamon and a drachm of tincture of gentian or calumba, two or 
three times a day a little before meals. In my hands such femedies 
have invariably proved perfectly useless as regards any power over 
the lepra, or even in inducing tolerance of arsenic. From a course of 
cod-liver oil I have often seen the best effects ; in fact, I may say, 
that as a rule I give it in every refractory case of lepra, and that 
means the great majority of cases. De Jongh*s oil has hitherto 
answered the best, and most patients can take it better than the 
pale oil. Generally moderate doses, such as a teaspoonful or two 
two or three times a day, are quite sufficient. The best vehicle 
that I know of for the oil is ginger-wine. Some persons, however, 
prefer coffee. Finally, I may add the Galium aparine, a remedy 
which has been highly praised by Dr. Winn. At one time in con- 
sequence of Dr. Winn's recommendation I gave it pretty freely, 
and though I never cured undoubted lepra with it, yet certainly the 
eruption, and. the health too, improved under its use. Mr. Hunt 
seems to have given it a very fair trial ; he procured the fresh herb 
itself from the fields near Kentish-town and had it boiled down. 
Considerable benefit resulted from the use of it, but in every case 
this was only temporary. The inspissated juice, when properly pre- 
pared, is so costly that it can never be jgenerally employed among the 
middle and lower classes. 

There are some other remedies of reputed efficiency but of which 



External Treatment of Lepra. 29 

I have no experience. Among these are dulcamara, considered by 
Bateman as one of the most effectual medicines in all varieties of 
lepra ; the great dock of India, or Asclepias gigantea, discovered by 
Playfair, formerly said to be possessed of such extraordinary power 
over the leprosy of the East, but now considered by many writers to 
be totally inert ; the great marsh-wort of India or Hydrocotyle 
asiatica, also said by Bazin to be powerless in cutaneous disorders,* 
though considered extremely efficacious by some writers. Psoriasis 
is also said to have been cured by the use of the turkish bath, of 
mineral waters, such as those of Harrogate, Purton Spa, and 
Bareges, and to have disappeared under the influence of vaccina- 
tion, tincture of cantharides, sulphur, frictions with juniper tar, with 
which Bazin says he has cured cases which had resisted every kind of 
treatment {toutes les fnedications)^ copaiba, and sundry other remedies. 

With regard to the statements respecting the curative power of 
these remedies I have Httle to say, as I have not tried them. I 
assume they are made in good faith, but I confess I am sceptical as 
to the curative power of the medicines themselves. It is to be 
remembered that the complaint will sometimes disappear under the 
influence of medicines which improve the health, and I am strongly 
disposed to beheve that with attention to the general condition, 
arsenic will cure any case likely to yield to simple means, and cure 
it, too, more quickly and certainly ; indeed, it is not improbable 
that some of the cures said to have been eflfected by the use of 
chalybeate waters were really due to the arsenic said to have been 
discovered in some of these solutions, t 

Of the external treatment there is not very much to be said. 
Vapour-baths are often extremely, useful, and where the circum- 
stances of the patient allow of their being procured, I should strongly 
advise their use. To be of any real service, however, they should 
be taken at least two or three times a week, and the use of the bath 
should be prolonged each time till free perspiration ensues. In 
order to watch their effects most carefully, I had a vapour-bath 
fitted up at St. John's Hospital, and after a great number of observa- 
tions, I think I am warranted in saying that these baths will always 
do good if perseveringly employed, and that they may be taken with 

* Lemons thioriques et ciiniqties, p. 79. 

t Address of the President to the British Medical Association. — Medical TifneSy 
1865, vol. ii. p. 149. 




30 Diet in L^a. 

impunity in every case, and in any state of the health or stage of 
the disease. A lotion of carbolic acid, beginning with five grains to 
an ounce of water, and gradually increasing in strength, is also 
useful. It should never be used so strong as to give pain, and 
probably a solution of ten or fifteen grains to an ounce is as high as 
the surgeon will require to go. The best plan of employing it is, I 
think, simply to rub it well in, once every day, with a piece of linen. 
When the smell is objected to, chloride of zinc may be substituted. 
It can be employed of a strength of one or two grains to the ounce, 
simply dissolved in water, with a very small quantity of mucilage 
added.* The zinc is peculiarly useful when the disease is seated on 
the face and head, although for the latter site the ammoniated mer- 
cury ointment thinned down with a little- almond-oil and slightly 
scented generally answers better. 

Diet, — ^A patient suffering under this complaint is sure to ask 
about his diet and particularly whether there is anything he must 
abstain from. So far as my experience goes I should say not in 
general, so long as anything like moderation was observed. It is 
quite as necessary in lepra as in any other disease to abstain from 
all very gross food, and from everything likely to produce a sense of 
heat, overloading, and constipation. I would therefore condemn too 
much pork, beef, sausages, curry, hard adulterated beer, and coarse 
spirits like new mm or whisky. I never saw high-feeding do good, 
and I have certainly seen cases where it clearly appeared to have 
aggravated the symptoms. When a patient suffers from dyspepsia,, 
irritability of the stomach whether induced by arsenic or otherwise, 
from catarrh, influenza, &c., I would restrict him to a light but not 
a low diet. 

In severe and obstinate cases, however, I would go much further, 
and utterly interdict animal food, especially in hot weather, restrict- 
ing the patient entirely to milk, eggs, light fish, &c. Beer, too, I 
think is always prejudicial. Of the beneficial effects of this restricted 
diet both surgeon and patient soon become convinced when it has 
a fair trial, and strange to say, patients so treated, instead of their 
health and strength giving way, as they generally fear will be the 
case, almost invariably find themselves at least quite as well, often 
much better, than when taking meat Occasionally at the first they 

• R. Zinci Chloridi gr. viij ad gr. x. 
Mist. Acaciae 5ss. 
Aquae Rosae 5vj. >n- ft. Lotio, omni mane leniter infricand. 



Diet in Lepra. 31 

flag a little, but this soon passes off, and so speedily does the system 
become reconciled to the change of diet that very often even a small 
quantity of meat makes them ill. 

At the time I am writing this I have under my care a gentleman 
who has now suffered for ten years froni lepra. Each year with the 
returning spring he has a fresh attack, and each year it has lasted 
with very little abatement all through the summer. He is a man of 
very active habits, extremely fond of cricketing and other out-of-door 
sports, and has always been in the habit of eating a great deal of 
meat with the view of keeping up his strength. Naturally enough 
he rather rebelled at the idea of being put on what he called baby's 
food. But he soon found the benefit. For the first time since I 
knew him the spots began to get less scaly within three or four weeks, 
there was no continuous eruption of fresh patches as had hitherto 
always been the case, he feels quite as well and as strong as when 
taking meat, and having been made rather ill by indulging on one 
occasion in it, he has quite renounced the use of meat as an article 
of diet during summer, as he now firmly believes it is injurious to him. 

I am indebted to Dr. Barker, of Brighton, for the suggestion of 
trying this kind of diet. This gentleman wrote to me as follows : — ' 
" It may be interesting to you to learn that for years I suffered from 
the latter [psoriasis] with which I was literally covered at times, and 
for which I have taken I may almost say some quarts of * Fowler's 
solution,' which always gave me a * splitting headache,' but seldom 
more than very transient relief. 

" Last year I was in the south of Italy during the hottest of the 
summer, and I never perspired more continuously for a whole month, 
nor did I ever subsist on so little animal food. However, I lost 
my old enemy most completely^ for I have since had no symptoms of 
return, which I am inclined to attribute to a more than usual 
abstinence firom meat. 

" Having a gouty history, I am in the frequent habit of taking 
twenty grains of bicarbonate of potash the last thing before bed, 
which also, I thinks has some influence over the other symptoms." 

This is nearly all I have to say on the subject ; but as others 
attach some more, some less, importance to diet, I proceed to give 
a digest of some of the principal points. 

Mr. Wilson* says nothing of diet in his chapter on "Alphos," but 

• Diseases of the Skin, sixth edition. 



i 



32 Diet in Lepra. 

in his work on " Healthy Skin," he advises as a general rule that we 
should look suspiciously at potted meats, sausages, game, &c., that 
variety at a meal should not be indulged in, and that children should 
have plenty of good wholesome food, and sufficient variety in it. He 
thinks that people who give their children invariably one kind of diet 
or too little of it, should be looked upon as dangerous lunatics, and 
made to understand that sickness and deficiency of food, with too 
little exercise and defective ventilation, are the cause of ringworm 
and scalled head being so common in schools. Mr. Wilson clearly 
thinks M. Soyer a better judge of diet than those mischievous obsti- 
nate people who starve children because they have been told by dear 
mamma, or have read in Buchan, that children ought always to rise 
from table with an appetite, and such rubbish. He has no particular 
views as to the efficacy of any particular kind of food in skin diseases, 
for the simple but rather pertinent reason that very "little is known" 
on the subject. 

Mr. Hunt seems to think that all restrictions whatever are un- 
necessary, and asks why the taste for so many different kinds of food 
was given to man unless it was right for him to enjoy them. The 
answer is very simple, for the case is not fairly put. Most likely man 
• living in a state of nature, leading the wild but anxious life of a 
hunter or fisher, sheltered at night in a cave or wigwam and seeking 
his food by day amid ceaseless care and danger, could eat any kind 
of food he was likely to find. But he is not living in a state of 
nature, he has elected to lead a life of restraint, and he has to 
bear the consequences. The advantages derived from civilization 
tend inevitably to induce a state of the system which requires from 
every person more or less self-control in respect to diet ; the evils 
of civilization create still more imperative demands, and therefore 
the great mass of mankind cannot be left to the unrestricted, sway 
of their appetites, and if control be necessary in health it is still 
more so in disease. 

Mr. Nayler * recommends a very strict diet in lepra, excluding 
salads, sweets, salmon, pork, and shell-fish, alcoholic and other 
fermented liquors. Dr. Hillier t adds coffee to the Index Expurga- 
torius. Dr. Neligan % says that a milk diet should, if possible, be 
enforced, and that when it cannot be adopted, farinaceous articles 
should, as far as possible, enter into its composition, fresh meat or 

* Op. cit.f p. 36. t 0/>. cit.^ p. 93. J Op. cit.^ 1852, p. 244. 



Treabnent of Lepra. 33 

poultry only, plainly dressed, being allowed. Dr. Willshire keeps 
his patients on a very strict 3iet, forbidding meat and limiting 
them to milk and bread, watercresses, &c. In Mr. Hunt's practice 
also, an exclusively vegetable diet has sometimes been found 
necessary. 

Mr. Hunt speaks "highly of the value of exercise in this complaint, 
and says that " many cases have occurred in which patients who, 
when pursuing a sedentary life, were martyrs to lepra, became com- 
paratively free from the disease when engaged in active occupation 
in the open air." I am quite disposed to believe that there is a good 
deal of truth in the statement, but I have at the same time seen 
several cases where lepra proved refractory enough in persons taking 
very active exercise. 

The influence of too much light is often very prejudicial in lepra, 
especially when accompanied by great fatigue or agitation of mind. 
I have several times known a long journey undertaken in bright, hot 
weather bring back within a few days an outbreak of lepra, when the 
disease had been for months steadily disappearing under the influence 
of treatment and quiet ; and this result has occurred too often to 
admit of its being explained by the supposition that it is a mere 
coincidence. 

Mr. Wilson gives arsenic for this disease in the form of Fowler's 
solution, and the ferro-arsenical mixture.* He begins with two or 
three minims of the solution and gradually increases the quantity to 
five minims, beyond which he does not often go. Mr. Wilson con- 
siders the white precipitate ointment very useful in lepra. 

Mr. Startin treats lepra with a great variety of remedies, relying 
little upon arsenic alone ; but there are so many ingredients in his 
prescriptions that an analysis of them is difficult. Chalybeates, both 
internally and in baths, arseniate of mercury dissolved in hydrochloric 
acid, iodide of mercury and opium, persulphate of iron and hydriodic 
acid, arseniate of potass with aperients, such as sulphate of magnesia, 
constitute the chief items of his treatment. When inflammation runs 
high, he gives sulphate and carbonate of magnesia with colchicum 

• R. Vini Ferri 5iss. 
Syrupi simpl. 

Liq. Arsenical U sine Tinct. Lavand. comp. pricparat. aa 5ij. 
Aq. destill. jij. rn,. 
Coch. min. j. ler quolidie sumend. 

F 



34 Treatment of Lepra, 

and Plummer*s pill ; for indigestion and clay-coloured stools, liquor 
potassae and mercury. 

Externally, Mr. Startin prescribes, when there is much inflamma- 
tion, trisnitrate of bismuth, Ave grains to an ounce of water, used 
warm ; later on he employs alkaline baths and ointment of the iodide 
of mercury. He also makes use of the sulphur-fume bath and 
creosote ointment. For the solitary form of lepra he employs blister- 
ing.* Glycerine is prescribed by some practitioners, others consider 
oatmeal gruel very useful. I have not noticed any very appreciable 
effect from either. 

Dr. Willshire in bad lepra gives decoction of elm bark as a vehicle 
for some more active remedy, such as bichloride of mercury. He 
also gives lemon-juice and tincture of cantharides. Bazin in arthritic 
psoriasis, gives a tablespoonful of alkaline syrup and some alkaline 
mineral water at meals. He also applies the huile de cade, and 
orders weak alkaline lotions with a little glycerine every three or four 
days ; also alkaline and vapour baths. For the herpetic form M. 
Bazin prescribes frictions with oil of juniper-tar and internally 
arseniate of iron. In the young adult, when the urine shows a 
continued low specific gravity, and a less than normal amount of 
urea, Mr. Nayler finds a combination of steel and arsenic very 
useful. Dr. Hillier gives liquor arsenicalis in large doses, beginning 
with five or six minims three times a day, and increasing the quan- 
tity to ten or twelve minims. He expresses himself as so well satis- 
fied with the result that he has not given cantharides a fair trial. 
He speaks favourably of the action of the empyreumatic oils, such 
as the tar of the Betula alba, after the scales have been removed by 
water-dressing, and considers that the diet should not be too rich or 
azotised. 

Hebra breaks loose in one overwhelming anathema against the 
drugs recommended for lepra ; root and leaf, bark and flower, acids 
and alkalis, sulphurets and muriates, old messes and new-fangled 
compounds, are all included under one common ban. The anthro- 
cokali, which was to cure every disease of the skin, is just as power- 
less as the Chinese Ethiop's mineral, or the stibium with which of old 
the Greek ladies painted their eyebrows. I wish some person in this 
part of the world would be as plain-spoken. There are positively 
hundreds of remedies recommended for diseases of the skin, of which 

• Medical Times ^ vol. xiii. p. 334. 



Treatment of Lepra. 35 

it is very doubtful whether one was ever subjected to such a test as 
it ought to have gone through before being admitted to the privilege 
of having a word said in its favour ; yet once it gains a footing there 
is little chance of getting rid of it. Year by year the journals and 
societies help to swell the huge aggregate of mischief, and when an 
honest investigator like Hebra sets fairly to work to see what will 
do good and what will not, he has to waste years in useless or 
dangerous experiments before he can make maison nette of all this 
rubbish. Mr. Wilson has arranged alphabetically upwards of fifty 
remedies employed in this complaint, every one of them useless or 
nearly so. 

Hebra uses arsenic internally in all the usual modes of giving it, 
but he also places great reliance upon external means, the principal 
of which seems to be a method very like that employed by Priessnitz. 
The patient is packed in a wet linen sheet, over which are laid a 
thick doubled blanket and a waterproof covering. He is allowed to 
drink water freely and is kept in this state of maceration for three or 
four hours. The patient is then plunged into a cold bath, and, if 
possible, a cold douche follows the bath, after which he goes out for 
a walk. This process is repeated twice in the twenty- four hours. A 
light diet is ordered and no spirits are allowed. Hebra also uses the 
potass soap, which is rubbed on each patch of lepra till a slight 
bleeding comes on, the tar oils, and the solution of pentasulphide of 
calcium recommended by Vlemingkx, which is rubbed on like the 
soap till excoriation is produced. The patient after using any of 
these takes a bath. 

As to the results of treatment or the prognosis of the complaint, 
I assume it is almost unnecessary to say that, however thoroughly all 
traces of an attack may be removed, the disease will tend to return. 
At the same time, under proper treatment, a long immunity can 
often be secured. 

B. Pityri'asis (m, is, fem.), from wiTvpov, bran, scurf. 

Definition. — A loosening and falling of the epidermis in the form 
of minute branny scales, accompanied by more or less itching, and 
sometimes in recent cases by heat and redness. 

Divisions, — i. P. simplex (dandriff, scurf), or that just described, 
generally seated on the head, but may also assail the beard, eye- 
brows, &c. — 2. P. rubra, in which, besides these symptoms, the true 



i 



36 Treatment of Pityriasis. 

skin is inflamed. May attack all the surface. Accurately con- 
sidered, it is a form of eczema, though sometimes it does not reach 
the serous stage. — 3. P. versicolor, often though wrongly called 
chloasma, in which irregular-shaped patches appear on the skin, 
sometimes almost of the colour of a withered leaf, again of a dirty 
clay tint ; generally beginning on the front and middle part of the 
chest, or in the armpits, accompanied at times by fine desquamation, 
and a good deal of itching. 

Treatment, — All forms of pityriasis, and especially the two first, are 
in the majority of cases connected with considerable disorder of the 
health ; in one person assuming the form of weakness, lassitude, 
and weariness ; in another of furred tongue, foul breath, loss of 
appetite, and so on ; a third person may suffer a good deal from 
indigestion and biliousness ; a fourth may be labouring under 
oxaluria, &c. Now there need be little hesitation observed about 
saying, that when any of these symptoms are present in an advanced 
stage, and very often when they exist to only a trifling extent, local 
treatment will be of little avail, and special treatment of no use at all. 
The first thing therefore is to attack them with their appropriate 
remedies, such as citrate of iron with an ample addition of lemon- 
juice, a mineral acid Hke the dilute nitric or aromatic sulphuric acid, 
in some bitter infusion or tincture, the action of which is often 
greatly aided by the use of small doses of mercury, such as four or 
five grains of grey powder taken three or four times a week, or a 
grain- of blue pill with an equal quantity of acetic extract of col- 
chicum, taken every night. It often happens that such disorder of 
the health is so slight as not to require the continuance of those 
remedies more than two or three weeks, but I believe patients are 
always better for a course of them. 

When this has been done, a long steady course of arsenic in small 
doses may be prescribed with every hope of benefit. Bichloride of 
mercury given daily to the extent of one-eighth or one-quarter of a 
grain, is an extremely useful adjunct. The nitric oxide of mercury 
may be applied every day in the form of ointment. The ointment 
should be thinned down with a little spirit of wine, or glycerine may 
be added. When the disease is seated on the head it is always best 
applied by another person, as the patient will smear the greatest 
part of the ointment on the hair, thus causing an unnecessary 
amount of dirt and discomfort without doing any good. I beg, 
however, it may be understood that I do not take upon me to say 



Treatme^it of Red General Pityriasis. 3 7 

the nitric oxide ointment is the best, but that it is the ointment from 
which I have derived the best results ; indeed, it is the only one the 
action of which I have been able to examine with such care as 
would justify me in giving an opinion ; the only similar preparations 
with which I have compared it are those of the chloride of mercury, 
the ammonio-chloride, and the yellow nitrate. 

When pityriasis rubra is severe and extensively diflfused, I have 
found no remedies so useful as a course of saline purgatives, 
followed by a combination of steel and arsenic. The saline, for 
which the formula below * will, I fancy, be as appropriate as any, 
should be given continuously for three or four weeks at the least, 
and in such doses as decidedly to affect the bowels every day. 
Along with this I generally order small doses of mercury and chalk, 
three to five grains every second night, or an aperient pill of colocynth, 
hyoscyamus, and blue-pill.f After these have done their work, the 
tincture of the perchloride of iron may be prescribed. It should be 
given in full doses, say thirty to forty minims three times a day in a 
large wineglassful of water before meals. Where expense is an 
object, the acid solution of iron used at St. John's Hospital may be 
substituted in doses of eight to ten minims three times a day. It is 
made by putting two ounces of iron wire drawn by the magnet into a 
pint of hydrochloric acid, 1,160 sp. grav., and allowing the mixture to 
stand for some time. It should always be taken freely diluted with 
water. After a little while I would suggest that the steel should be 
combined with arsenic ; but I would on no account give the two 
together, even when the combined remedy agrees perfectly well with 
the patient A fair trial will, I think, satisfy any one that arsenic is 
much better taken after or with meals, while steel has always ap- 
peared to me to act most beneficially when taken on an empty stomach. 
Besides some persons who bear arsenic very well do not always 
tolerate steel, and conversely it will sometimes happen that a patient 
who can support almost any amount of steel is peculiarly sensitive 

• R. Magnes. Sulph. ^ss. 

^lagnes. calcin. pond. 5iss. 

Potass. Nitratis 5iss. 

Tinct Zinzib. 5iss. 

Tinct. Cardam. c. 3"j« 

Aq. Menth. pip. ad 5iv. rn,. 

Coch. amp. j. bis terve quotidie sumend. 

t For formula, Jcvp. 12. 



38 Value of Tarragona Wine. 

to the action of very small doses of arsenic. By dividing them 
then the surgeon is enabled to proportion the dose to the exigencies 
of the case. I know I shall be told that this is a very inconvenient 
system, but I have generally found that patients soon fall in with it 
when once they have tried the plan. Along with this I would 
recommend the use of red wines, such as port, tarragona, and 
claret, which, judging from my own experience, surpass all other 
wines from whatever country they may come. Africa and California, 
Sicily and Greece, Hungary and Germany must in this respect yield 
the palm to France, Spain, and Portugal. 

Tarragona is a perfect boon to poor patients. Although it is so 
cheap that it is sold by the Wine Agency Company at seventeen 
shillings per dozen, it contains so much natural alcohol that the 
heavier duty is charged on it ; and I very much doubt whether any 
fluid of the kind used in this kingdom contains so much tonic power 
at so low a price. In my opinion it is far superior to any kind of 
beer, which is indeed in no way suited to most diseases of the skin, 
and in some, such as the disease now treated, eczema, rosacea, &c., 
is often perfect poison. Two or three glasses of tarragona daily 
impart more stimulus than twice their cost in the form of malt 
liquors, while at the same time the wine has the vast additional 
advantage of agreeing much better with the nutrition, as is evi- 
denced by the fact that it does not produce anything like such a 
discharge of phosphates as malt liquors effect in many persons. 
Even where expense is no object tarragona may be safely recom- 
mended in preference to any port kept in bottle, as, unless my 
observations have strangely deceived me, it .possesses much greater 
curative power. Indeed, considering that it really forms the basis 
of at least half the port wine sold in London, some of the benefit 
derived from the latter may fairly be set down to the account of the 
tarragona itself. The great point naturally is to obtain it pure ; 
indeed too much care cannot be taken on this head, as a great deal 
of what is sold as tarragona is nothing more than wretched claret, 
worth at the utmost eight or nine shillings a dozen, liberally 
sweetened. This rascally trick can generally be detected with ease. 
Real tarragona possesses a deep tawny hue, whereas the claret 
substituted for it is of a bright ruby colour. Tarragona was, I 
believe, first used at St. John's, but since then it has been largely 
employed in other hospitals, especially at Guy's. In summer it 
should always be taken diluted with water, and when at this season 



Treatmcfit of Pityriasis, 39 

of the year it tastes too strong even diluted, or if the patient have 
grown tired of it, for it is naturally too sweet to be quite agreeable 
to most persbns, claret may be substituted for it ; and here I may 
remark that claret at twelve or fourteen shillings a dozen is, so long 
as it can be procured sound and not too austere or sour, quite as 
good for medicinal purposes as if it cost a guinea a bottle. The 
oenanthic oil, which lends to wine what people pedantically call the 
bouquet, plays no part in the treatment of disease. 

This method of treating pityriasis, seconded by a very free use of 
the ointments mentioned, especially those of zinc and the yellow 
nitrate of mercury, has proved very successful in my hands. So 
far all the cases have done well, and I am consequently disposed 
to think it is a much more manageable and less dangerous complaint 
than it has been held to be by some writers. Even cases of long 
standing and great severity have yielded to this treatment. There 
is a patient now attending at St. John's Hospital, with scarcely 
a trace of the disease on him, who first came under my care a 
few months ago in a lamentable state, being obliged to have his 
arms nearly up to the shoulders and a great part of the rest of 
the skin constantly swathed in linen, as the irritation induced by his 
clothes touching any part affected was quite unbearable. Though 
very strongly made he was a very unhealthy-looking man, his colour 
being almost like that of putty, and I did not augur a good result ; 
but he began to mend very decidedly within the first month, and 
with one or two slight exceptions the improvement has gone on 
rapidly and continuously. 

In pityriasis versicolor, unless there be any signs of ill-health, 
arsenic may be at once begun with and given till a distinct impres- 
sion is made upon the disease ; should there be any disorder of the 
health it will be absolutely necessary to set this right, for it is of no 
use giving arsenic till the stomach is in a fit state to bear it. So 
soon as the patches begin to grow paler under the influence of this 
potent mineral local means may be put in operation. One of the 
best that I know is strong tincture of iodine, made by adding at 
least a scruple of iodine to an ounce of the ordinary tincture ; this 
may be painted on the surface with a glass brush three or four times 
a week. The sulphur-bajth taken once or twice a week is also a 
valuable remedy, but it is so often impossible to obtain it that the 
recommendation is almost nugatory. 

The sulphite of soda in solution, half apt ounce to eight ounces of 



40 Treatment of 'Pityriasis, 

water, well rubbed into the spots every day, is also useful. It may 
be employed when the sulphur-bath cannot be procured and when 
the iodine gives too much pain, but I have not seen any such 
superiority in its action as would justify me in recommending it in 
preference to them. At the suggestion of a friend I tried carbolic 
acid, but with very indifferent success, and I am disposed to set it 
down as much inferior to the others. 

For pityriasis, as also for red general pityriasis, Mr. Startin gives 
demulcent and slightly diuretic medicines. His external treatment 
is directed towards soothing irritation, being principally demulcent 
baths, such as glue in solution, linseed mucilage, milk, yolk of ^g%^ 
bran liquor, or quince-seed gruel thinned down with water. He 
also prescribes mild alkaline baths, and follows these up with the 
sulphur-fume bath. For local pityriasis Mr. Startin gives aperient 
chalybeates and small doses of bichloride of mercury, aided by 
lotions of borate of soda, by the sulphur-fume bath and by creosote 
ointment. For pityriasis nigra, a disease I have never seen, he 
prescribes lotions of bichloride of mercury, dissolved in a small 
quantity of hydrochloric acid. When the head is the seat of the 
disease Mr. Startin advises that it should be washed every third 
morning with yolk of tgg and tepid water. He is entirely opposed 
to the use of soap. Mr. Wilson, for red general pit)nriasis, gives 
nitro-muriatic acid with a bitter, citrate of iron and quinine and 
phosphate of iron. F^xtemally he has found the best results from 
warm baths, used daily and prolonged for an hour or more. The 
whole affected surface is afterwards smeared over with benzoated 
oxide of zinc ointment. He says pityriasis capitis, or rather erythema 
capitis, as he calls it, for no very valid reason so far as T can see, 
invariably yields to an application composed of one part of red 
precipitate ointment and three of lard, or to the white precipitate 
ointment diluted in the same proportion. For pityriasis versicolor 
Mr. Wilson recommends a lotion containing half an ounce of hypo- 
sulphite of soda and half a drachm of carbolic acid to the eight 
ounces. M. Hardy treats pityriasis of the scalp with soap and 
water and a solution of carbonate of potass, afterwards using an 
ointment of one part of sulphur to thirty of lard, or one gramme of 
nitric acid to thirty of lard.* When the disease occurs in old people. 
Dr. Frazer uses a weak solution of tannin in glycerine, t When 

* Lemons sur les Maladies de la Peau^ i860, p. 132] 
t Treatment of Diseases of the Skin^ 1864, p. 12. 



Contagious Nature of Pityriasis versicolor. 4 1 

crusts fonn in children suffering under this complaint, he directs 
that they should be got off with a wash made of equal parts of 
spirit of rosemaiy or brandy and strong vinegar. In diffuse pity- 
riasis, Dr. Neligan used to prescribe mild mercurials and alkalis, 
with taraxacum and hyosc3ramus ; for external use mild gelatinous 
baths. If the eruption resisted this treatment he ordered alkaline 
baths, the patient on leaving the bath being well rubbed over with 
fresh elder-flower ointment, containing glycerine. In local forms the 
dilute citrine ointment was rubbed in. In obstinate cases iodine 
and arsenic were resorted to. All stimulants were excluded from 
diet Dr. Neligan was strongly opposed to the indiscriminate use of 
stimulating appUcations, a canon of treatment in which I quite agree. 
Sir Wm. Jenner uses a solution of bichloride of mercury, four grains 
to the ounce. 

Respecting the contagious nature of pityriasis versicolor, we find, 
as we might expect, every shade of opinion. Mr. Wilson utterly 
scouts the idea and Mr. Startin is, I believe, silent on the subject. 
Mr. Nayler considers it contagious in, perhaps, one case in ten. 
Dr. HiUier says nothing about the matter. Some writers hold that 
it is contagious beyond all question. 

I at once admit that I have paid so little attention to the subject 
that I am scarcely qualified to give an opinion at all. At the same 
time, I am quite prepared to abide by the consequences of stating 
that the disease is certainly not contagious as a rule. Beyond all 
doubt* cases will occasionally occur which bear the appearance of 
having arisen from contagion, but in the great majority of them 
nothing of the kind can be made out And as in addition to this it 
does not matter one straw, practically, whether or not it is contagious, 
I make no further apology for disposing of the subject so briefly, but 
content myself with giving the facts of several cases admitted at 
St John's Hospital, and leaving the reader to draw his own con- 
clusions. It is, however, to be borne in mind that another series of 
cases might present a difierent set of facts. 

Out of more than twenty cases noted at the hospital there was no 
history of contagion in any except two. In the first a father and 
mother, middle-aged, healthy people, living a short distance from 
London, their two sons and two daughters were all admitted as out- 
patients, suffering under this affection, and at least two had it in a 
very severe form. Another daughter and her husband were also 
attacked by it and were admitted about the same time. The disorder 



42 Definition of Ichthyosis. 

was stated by them to have been given by a little girl suffering under 
the complaint, and who had been sta)dng with the family. The 
second case was that of a husband and wife, their history being that 
the husband had had the complaint for a long time and in a severe 
form at the time of m^age, whereas the wife had never shown a 
symptom of the complaint till she married, soon after which patches 
of pityriasis versicolor began to appear on the bosom, front of the 
abdomen and thighs. At the time they began attending they both 
had unmistakable symptoms of the complaint in question. 

As some of my readers may wish to examine the parasite, I quote 
from Mr. Nayler's work the recommendation to try the plan suggested 
by Gudden, of raising a blister on the skin by means of some vesi- 
cant, and removing the epidermis. The spores will be seen on the 
upper surface with mycelium penetrating between the scales of the 
epidermis. 

C. IcHTHYo'sis (/j, />, fem.), from Xy^vc^ a fish ; IxOvoeig, fishy, 

resembling a fish. 

* 

Definition, — A dry, harsh, warty or scaly state of larger or smaller 
portions of skin, attended by change of colour in the aflfected parts, 
and extreme deficiency of perspiration ; often congenital, unaccom- 
panied by pain. 

Divisions. — i. I. simplex. A general dryness and roughness of the 
skin, with fissuring of the epidermis, which is .of a dirty grey or tawny 
colour ; oflen beginning early in life. It ma}' assume a very aggra- 
vated local form, the papillae becoming covered with hard, tenacious 
scales, of a dull gre)dsh-green colour. 2. I. cornea (a form of scle- 
rosis) ; dry, hard, extremely tense state of the skin, beginning at one 
spot and gradually extending all over the body, greatly impeding 
movement of every kind, attended with diminished warmth and 
sensation. Very rare ; possibly of traumatic origin. 3. I. sebacea. 
Formation of small, hard, prominent, tenacious crusts, the skin 
beneath which is red, glazed and tender. The form of ichthyosis 
mentioned by Willan and accompanied by the formation of horns, is 
referred to that head (horns). The porcupine disease is simply a 
variety of ichthyosis simplex. 

Treatment — My experience of the treatment of ichthyosis is 
limited to that of the simple form. So, as far as internal treatment 
is concerned, the action of any remedy, even arsenic is so slow that 



Treatment of Ichthyosis, 43 

it is very doubtful whether the majority of patients will ever per- 
severe in the use of it Happily enough, I believe that local treat- 
ment will, in some cases at any rate, suffice to remove the complaint. 
I shall, perhaps, be able to make this more evident by the details of 
the following cases than by any argument : — 

Case I. — ^A. L. L., aged three, residing at 5, Clifton-street North, 
Finsbury, entered as out-patient at St John's Hospital, July, 1865, 
with general ichthyosis. 

The skin of the face was of a brownish red, and but for its sin- 
gularly cracked appearance, and for the thin figure of the child, she 
would have had the look of very high health. The skin, however, 
was superficially fissured in every direction, and the child looked 
attenuated. From head to foot the epidermis wore the same dry, 
cracked, harsh appearance, in many parts looking almost as if it had 
been recently dusted with flour. On the arms and legs the skin was 
almost of the colour of Bath-brick dust. About the lower parts of the 
legs it was remarkably harsh, and round each ankle ran a belt 
formed by elongated and enlarged, warty-looking, hard, dry papillae. 
These were most numerous and largest directly in front of and 
behind the ankle, the largest being as big as a good-sized pea. The 
child seemed of a most excitable temperament, with a thin shrill 
voice. She has never been seen to perspire except on the forehead. 
She is very subject to coughs and colds, but in other respects enjoys 
very good health. 

It appears, from the mother's account, that she noticed nothing 
particular the matter with her daughter at birth, but that within a 
month after the skin peeled off, and the cuticle which succeeded it 
was dry, harsh, and cracked, like that often seen on the hands of 
persons who have washed them in cold water during winter. This 
state of things seems to have gone on getting worse till the patient 
had ended her second year, by which time the ichthyosis had pretty 
well assumed its present form. At this time she was placed under 
the care of a gentleman whose treatment afforded her some relief; 
but the abatement in the disease was only trifling and of very short 
duration. After this it began to get speedily and steadily worse, till 
it had reached the aggravated fonn in which I found it. 

The mother says that no member of the family on her side ever 
suffered from the disease, but that the father and his brother are 
both afflicted with it. I examined the father, and found very decided 
ichthyosis on the back of the arms, and in the shape of a broad band 



44 Treatment of Ichthyosis, 

extending and sloping irregularly downwards from between the 
shoulders quite round the abdomen, the greatest part of which it 
covered, while it was much narrower on the posterior surface of the 
body. The skin here is dry-looking, hard, rough, fissured and 
dotted, and of a very pale yellow hue. There is no other part of 
the surface affected, but he thinks the skin of his hands is much 
rougher than it ought to be, and in cold weather it soon gets very 
dry and chapped. He has never been treated for the complaint, 
and has never noticed any change in it. He has felt no inconve- 
nience from it, and has never suffered in any way from ill health. 
He tells me that the affected surface perspires the same as other 
parts, and that when he perspires much the skin here peels off a 
good deal. The mother states that his twin brother is affected in 
the same way and at the same part ; but I have had no opportunity 
of verifying the fact Two other brothers, who are also twins, and a 
sister, are quite free from the disease. 

The little patient was ordered three-minim doses of liquor potassae 
arsenitis three times a day, at first alone, but subsequently accom- 
panied by an occasional dose of calomel or grey powder. The 
arsenic, however, was principally trusted to. It seemed on the 
whole to agree very well with her, and she took it very regularly up to 
December, when the dose was increased to four minims three times 
a day, and again in February, 1866, to about four minims and a 
third. This was continued, and though during the latter part of the 
spring and the summer the medicine was remitted for a few days out 
of each month, this was done with great regularity, and the patient's 
attendance was most satisfactory. In the autumn, however, the 
child lost her appetite and her tongue became coated. It was there- 
fore thought better to suspend the administration of arsenic and 
give an acid and bitter till these symptoms passed off. It was, how- 
ever, resumed in the following January, and the month after the use 
of small doses of mercury was again resorted to. These remedies 
were persevered in during the spring, summer, and autumn of 1867, 
when they were again given up, in consequence of loss of appetite, 
and the dilute nitric acid and quassia were substituted. In November 
recourse was again had to the arsenic, which was now given in the 
form of solution of the chloride, and in rather smaller quantities. 
It was not, however, taken very regularly, on account of her being a 
good deal troubled with cough and sometimes feverishness. In 
March, 1868, it was again given, and continued for the next six 



Treatment of Ichthyosis, 45 

months, generally for about ten days in each month, after which she 
again took the acid and bitters. 

Up to February, 1868, she had experienced a certain but slight 
improvement. The skin was decidedly softer, smoother, and healthier ; 
still, there seemed little prospect of any great amendment ; but at 
this time I resolved to put some local treatment in force, and after 
some trials I found reason to believe that the external remedies now 
to be mentioned would possibly be o*f service. 

The child was placed in a warm bath containing a scruple of car- 
bonate of soda to three and a half gallons of hot water, and ipme- 
diately after the bath the ointment * mentioned below was rubbed 
over the whole • of the affected surface, and allowed to remain in 
contact with it till the next bath was taken. 

The action of these was very rapid, and perceptible to the most 
uninstructed observer. In a few weeks all the more evident symp- 
toms of the disease had gone, and by the end of six months an 
apparent cure of the disease in most parts of the skin had been 
effected. At her last visit the skin of the face was still red, and on 
the nose slightly cracked ; that of the hands and arms and body 
quite natural, and looking at her, I should have had no hesitation 
in saying that a person unacquainted with her history would never 
have imagined that she had had ichthyosis. The only places where 
evident traces of the disease could be said to linger were the legs 
from the knee to the instep ; and even here all that was seen was 
a dry, rough, brownish state of the skin. The warty growths had 
quite disappeared. 

Up to the present time th6 child has remained quite well, and I 
feel sure that the mother would be very glad to show the case to any ^ 
one interested in the subject. 

Case II. — ^Julia J., a middle-sized, slender, pale young woman, 
entered at St. John's Hospital, October 24th, 1868, suffering from 
ichthyosis of the same form as in the preceding case. It extended 
over the t)ack of the arms, the lower part of the back, and over great 
part of the lower region of the abdomen. From the upper part of 
the front of the thigh to about three inches above the knee, the dis- 
ease was quite perceptible ; but it existed here in a very mild form. 

• R. Potassii iodidi 9j. 
Olei pedis bubuU, 
Adipis purificati, aa ^ss. 
Glycerini 5j- m fiat ung. 



46 Treatment of Ichtltyosis. 

It was, however, very fully developed from about three inches above 
to about three inches below the knee, where it disappeared, with the 
exception of a patch on each instep. She does not recollect having 
ever perspired, except occasionally during some of the hottest days 
of the summer. The disease has existed as long as she can re- 
member. She has always enjoyed good health. I asked her to 
inquire if any of her relatives had ever suffered fronj this affection, 
and she did so; but the answer was that neither her father nor 
mother knew of any such thing having been seen in any member of 
their family. 

She was at once placed on the solution of the chloride of arsenic, 
of which half an ounce was given weekly, in doses of rather less 
than five minims three times a day, to be taken either with or 
directly after her food. On the 17th of November soda baths of 
the same strength as in the preceding case were ordered, accom- 
panied by the daily use of the same ointment, and with the same 
effect. When last seen (1869) the disease had disappeared, except 
that on the lower and front part of each knee a small wrinkled patch 
was noticed. 

Case III. — A young lady wh6 had suffered from this affection 
almost since her birth was placed under my care by her mother in 
the spring of 1869. The disease was entirely local, being restricted 
to a band about an inch in depth which surrounded each ankle. It 
was a very well-marked instance of simple ichthyosis. As the child 
seemed in excellent health, and was extremely strong and well-made, 
I resolved to try the effects of purely local treatment. The same 
ointment was accordingly applied night and day to the patches, 
which were also steeped daily in the soda bath. A very rapid 
improvement took place ; the patches peeled right off, and within 
four weeks the disease seemed to be quite removed. 

It may therefore, I think, be legitimately inferred that these 
remedies are capable of producing a certain amount of benefit in 
ichthyosis, and I have ventured to place them before my readers 
because I consider carefully-detailed cases and experiments as the 
only foundation on which a really useful and progressive system of 
treatment can ever be based. Without such muniments, thera- 
peutics must ever tend to sink into routine or empiricism. They 
afford the only certain test as to the comparative value of remedies, 
and as to whether they have or have not been judiciously employed. 
One man succeeds with means which fail in the hands of others. 



Hereditary Nature of Ichthyosis, 47 

who want the industry and judgment to use them as they must be 
used to insure a fortunate result, and who perhaps do not always 
wish to succeed. But a clear and detailed history places both on a 
level, aqd gives no vantage-ground to the prejudiced and slothful. 
Convictions and tenets, the results of individual experience and the 
secrets of practice, too often die out with those who knew and taught 
them, but cases are always of value. A case related by Hippocrates 
or Celsus might perhaps be welded into some nineteenth century 
system of medicine, and those recorded to-day may find their fitting 
place a century hence. 

Nothing was observed in any instance which seems in any way 
calculated to throw light upon the pathology of the disease. As in 
most cases I have seen, the frame was, in the two first patients, 
slender, the bones were small, and the muscular system very 
sparingly developed. There was nothing amiss with any other 
fimction or secretion that I could make out, except the small 
amount of perspiration ; a condition noticed in all subsequent cases. 
In some patients suffering under this disorder I have seen an un- 
usual development of hair ; at the same time this did not amount to 
anything extraordinary ; it was nothing but what could be paralleled 
in persons not afflicted with any disease of the skin. I have never 
been able to connect the appearance of the affection with any kind 
of diathesis. 

We have in the first case an instance of the same affection appear- 
ing in the father and child. Should either of these children live to 
marry, it is possible, even probable, that some of their children, 
if they have any, may suffer in the same way ; after which, judging 
from the average of such histories, the disappearance of the 
ichthyosis may be predicted. In so far then as the term can 
be considered to express such a peculiarity or coincidence, the 
disease may be called hereditary, just as lepra or gout might 
be so designated. But the word hereditary is employed in two 
very different senses from this, and each of these meanings again 
differs widely from the others. By some it is used as though it 
cleared up some mystery or explained the phenomena of disordered 
action. Such a solution may satisfy the mind of an inquisitive 
patient ; indeed, most persons seem considerably relieved when told 
that their complaint is hereditary ; it might almost be imagined that 
the announcement had freed them from the burden of some crime. 
But it is difficult to see how persons acquainted with pathology can 



48 Treatment of Ichthyosis. 

suppose that any light is thus thrown upon the nature of diseased 
actions. Again, Mr. Darwin, if I understand him rightly, and certainly 
some of his followers, speak of hereditary affections, and malforma- 
tions as though they possessed such an irrepressible tendency to p^petuate 
themselves, that in course of time they must constitute species or varieties 
of the human race. But it is evident that with such a tendency one of 
two things must ensue. Either, when a disposition of this kind has 
once manifested itself, the offspring of those so affected must die 
out, and the appearance of any hereditary disease or malformation 
must be accordingly considered as the harbinger of more or less 
speedy extinction ; or they do not die out, and the abnormal pheno- 
mena are continued from generation to generation. Then, inasmuch 
as many of these affections are of sufficient antiquity to have been 
coeval with many generations of men, unless we assume that the 
presence of one disease or malformation secures the sufferer and all 
his future descendants against any other, of which there is no proof, 
it is evident, when we consider how often such affections spring 
up spontaneously, that, comparatively speaking, very few families can 
have escaped them all, while numerous families must have passed 
through many ordeals of this kind, that in course of time these affec- 
tions must so have increased in number and complexity, as to have 
produced a tolerably numerous race of monsters, such as the world 
never yet saw, and whose power to exhibit complications of disease 
and deformity would be only bounded by the extent of surface on 
which these abnormal phenomena could develop themselves. Yet 
this is not exactly the case. On the contrary, although throughout 
a large portion of England we find that in rural districts, where we 
can more readily and surely trace local and family history than we 
ever can in cities and towns, some families have always so multiplied 
as to outnumber others, yet we have still to learn that a race of six- 
fingered or ichthyotic, of gouty or leprous people have anywhere 
established themselves ; although such ought to have been the case, 
for these affections spring up, cceteris paribus, as often in a valley or 
a village as in the foetid courts and by-streets of London, and stand 
just as good a chance of being inherited in the one case as in the 
other. 

The sebaceous variety is, when the patient will give us fair play, 
by no means such a formidable affair. Warm baths, frictions, 
bichloride of mercury in emulsion of bitter almonds, with laxative 
medicines, are recommended by some authors. 



Treatment of Ichthyosis. 49 

In the chapter on eczema I hope to be able to give my reasons 
for referring to this disorder the two cases of sebaceous ichthyosis, 
so ably and lucidly related by Dr. Ogle in the " Transactions of the 
Medico-Chirurgical Society," and treating them as varieties of eczema, 
to be met with steel and arsenic. But the complaint is so rare that 
few men ever have had, or will have, much experience as to the real 
effects of treatment upon it 

j'"" ' '" ^ — For simple ichthyosis Mr. Startin recommends bichlo- 
ride of mercury and arsenious acid, with alkaline baths and lotions 
containing creosote. An instance of the local form of this affection 
seated on the cheek, is mentioned by the same author* as having 
been successfully treated by blistering with nitric acid and applying 
arsenical paste. The disease was to all appearance cured but a scar 
remained. 

Mr. Wilson recommends cod-liver oil and arsenic, Donovan's 
solution, frictions with fresh and sweet neafs-foot oil, brisk rubbing 
with the Indian flesh-glove or keesah, a tepid soap-bath once or 
twice a week, and the sponge-bath as often. Croton oil or ammonia 
may be employed in the form of friction ; sulphur and potass were 
given with great benefit in one case mentioned by him. The 
prognosis Mr. Wilson considers favourable. If we cannot cure 
the complaint we can restore the patient to tolerable health and 
comfort. 

Dr. Begbief found arsenic fail in the treatment of ichthyosis 
simplex, though in one case it produced some improvement. Mr. 
Hunt, on the contrary, has been extremely successful with arsenic. 
He tells us that after the skin has been for many years so rough and 
rugged that it scarcely wears a human look, it will become smooth 
and delicate. In some patients this novel state has been perma- 
nent ; in others the disease has returned. Still, Mr. Hunt maintains 
we can always give relief. If even we cannot cure the disorder we 
can ameliorate it and at least get rid of the fissures which torment 
the patient so dreadfully. For external use Mr. Hunt prefers glyce- 
rine with Fowler's solution diluted with water. 

Dr. Neligan quotes two cases, published by Professor Banks, of 
the scaly (or simple) form of ichthyosis which were successfully 
treated, cod-liver oil being used both internally and externally; 
vapour-baths were also employed. A flannel dress, thoroughly im- 

• Medical Times, vol. xiii. 

t Edinburgh Medical Journal, 1 86 1-2, p. I. 

H 



50 State of Urine in Ichthyosis, 

pregnated with oil, was constantly worn next the skin. Dr. Neligan 
himself employed the following plan with great success ; in three 
cases out of four the recovery was permanent. Iodine and iodide 
of potassium were given in decoction of elm-bark and the affected 
parts were dressed with an ointment containing, at first, twenty 
grains and afterwards a drachm of iodide of potassium to an ounce 
of lard and a drachm of glycerine. Alkaline baths, containing a 
drachm of carbonate of soda to a gallon of water, were used a quarter 
of an hour before the ointment was rubbed in and the flesh-brush 
was freely employed while the patient was in the bath. 

In the spinous or warty form, which, as I have said under the head 
of definition, I mean to be understood as an aggravated variety of 
simple ichthyosis, Mr. Wilson advises that the skin should be softened 
with warm alkaline washes and baths, and then stimulated with a 
lotion such as that of the tincture of croton.* Constitutional reme- 
dies may be tried and both Fowler's and Donovan's solutions will 
be found useful. He advises also a course of liquor potassae in 
decoction of sarsaparilla. Willan and Elliotson have both recom- 
mended pitch, to the extent of half an ounce daily. I have had no 
experience of it in this rare variety, but from what I have seen of the 
action of pitch in other complaints I should not expect much effect 
from it. I have, however, only had one case of this kind under my 
care. In this instance there were several complete ridges of long 
but rather soft spines. They were all limited to one side of the 
body, and were seated on the side, shoulder, upper part of the chest 
and neck. Many of the spines were two-fifths to half an inch in 
length. This patient was a lad of thirteen or fourteen years old. 
The case underwent no improvement, and I soon lost sight of him. 

Mr. Naylor says f that in ichthyosis there is generally a great 
excess in the quantity of urine which is, moreover, of a low specific 
gravity, and usually of the palest yellow colour. In a specimen 
which i examined lately (a portion of the whole bulk of urine passed 
during the twenty-four hours by a little girl six years old, labouring 
under this disease), the colour was decidedly pale and the specific 

* Mr. Wilson's formula for Jhe tincture of croton is : — 

R. Tiglii semin. contus., 5j. 
Spir. vini recti f., Jiv. 
Macera per dies quatuordecim et cola. The lotion consists of a drachm of the 
tincture to a half-pint of fluid. 
t Diseases of the Skin, p. 63. 



State of Urine in Ichthyosis. 51 

gravity i o 1 6. It was acid, and yielded a very small quantity of mucus. 
Half an ounce treated in the way recommended by Bird,* gave 
0*90 gr. of nitrate of urea and little more than traces of uric acid 
were found. The addition of nitric acid produced a greenish-grey 
colour. There was no albumen and no excess of bile. An ounce 
produced i 'So gr. of extremely hard white ash. Judging as well as 
one can from these slight indications it might be worth while to try 
the eiOfect of colchicum and acetate of potass. 

* Urinary Deposits^ fifth edition. 



( 52 ) 



CHAPTER III.— TINEiE. 

Ti'nea (dr, ce, fern.), from teneo, to hold. (Alope'cia (a, ce, fern.), 
properly alopekia (aXwireKia), from aXwirrjl, a fox, because the 
state of the hair was supposed to resemble that of a fox suffering 
from the mange, is included in this group.) 

Definition, — Dry, scurfy, reddened, or pale and shining patches, 
accompanied, when on the scalp, by shedding, twisting, loosening, 
and falling of the hair, and in some cases secretion of scales. 

Divisions, — i. T. areata (alopecia areata or area). Sudden falling 
of the hairs from small patches of the scalp, often nearly circular in 
form, leaving a white, polished, and often wasted state of the skin. 
After the epidermis has once been thrown off there seems to be 
scarcely any reproduction of it. General alopecia, a simple thinning 
and falling of the hair, may be classed as a mild chronic variety of 
this. 2. T. decalvans. An aggravated state of the former, the 
whole head of hair being swept off in a very short time, only a 
solitary patch or two, or hair or two, being left. 3. T. tonsurans, 
or scalp ringworm, in which patches of the hair, generally some- 
what circular in form, are cut down to stumps. 4. T. circinata or 
ringworm. An eruption of red, nearly circular, erythematous patches 
or groups of very small red papulae, generally seated on the head, 
neck or arm. The fungus, tricophyton tonsurans, when present, is 
found among the scales after the addition of liquor ammoniae. 
5. T. favosa or favus. Formation of red, slightly tender patches, 
generally on the scalp, which gradually become covered with 
small, yellow, adhesive tenacious crusts, marked by a peculiar 
mouse-like smell, accompanied by loosening of the hair, and wasting 



Parasitic Nature of Growth in Tinece questioned. 5 3 

and blackening of the roots. May also attack the face, thigh, nail, 
&c. Hardy gives as the characteristic signs of favus — i. The myce- 
lium, an assemblage of filaments, sometimes simple, sometimes 
branched. 2. Tubes, simple or celled, isolated or adhering to one 
another ; some empty, others containing spores. 3. White granules, 
oval or rounded, sometimes irregular, of variable volume. These 

* 

are supposed to be the spores or organs of reproduction of a parasite 
of vegetable nature, the achorion Schonleinii. With a magnifying 
power of two to three hundred diameters, numerous spores may be 
seen, and sometimes tubular filaments may be detected in these 
parts. 6. T. ulcerans or kerion. Inflammation of the hair-follicles 
of the scalp, with great swelling and puffing up of the portion of 
skin invaded, sometimes accompanied by great redness of the part ; 
very rapid falling out of the hair, followed by profuse suppuration 
in and gaping of the hair-follicles, with discharge of muco-purulent 
fluid like that seen in the declining stage of blennorrhagia. Intense 
tenderness of the skin. The Burmese ringworm seems to be clearly 
a local form of eczema.* 

As those who contend for the parasitic nature of tineae found their 
treatment upon the view that the parasite is vegetable, and as those 
who deny the vegetable nature of the parasitic structures uphold a 
very different kind of treatment, it becomes absolutely necessary to 
examine the contending views, howevef briefly. 

If I understand aright the view put forward by the former, it 
amounts to this, that the parasitic growths on the skin are as truly 
vegetable in their na-ture as the mould on an orange or melon, 
because we can distinguish the presence of cellulose externally, and 
can see internally the primordial utricle coloured by iodine, and 
because we find in the secretions of these diseases the tubed mycelial 
thread and a fructification unrepresented in animal structures. Ether, 
chloroform, and spirit of wine, do not affiect these parasites, while 
they make epithelial tissues transparent, and dissolve all fatty 
matters. The parasites mostly grow in places to which the air has 
free access, exceptions to this rule admitting of doubt ; they grow 
too, when removed from the influence of blood and living tissue, a 
separation which is fatal to animal life. A piece of favous matter, 
if fittingly nursed and tended, will take root and flourish ; the nuclear 
element will assume the sporular form and the sporules will gain in 

* See Journal of Cutaneous Medicine, vol. L p. 379. This is also Mr. Wilson's 
opinioiL 



54 Parasitic Nature of Growth in Tinece questionea. 

size, join, bud, and bring forth mycelium, while the very structure 
on which they are seated is decaying. The tricophyton tonsurans 
will blossom while the fibres of the hair on which it grows de- 
generate, and their place is supplied with delicate tufts of crystalline 
fatty matter. 

It is argued that if we take away the damaged hairs, &c., of 
tinea, nothing diagnostic of the ravages of the parasite remains, 
while if we remove all the eruptive, the parasitic element remains 
in its integrity : the necessaries remain, but the accidents are 
absent. The presence of the fungus increases the local irritation. 
Now, if the fungi be different, there must be different soils, and 
the treatment be different in kind. If the fungi be identical in 
nature, then the treatment is a matter of degree only ; if fungi be 
different, then ought they to be so many indices to certain con- 
ditions of the economy. 

Accordingly, to cure the disease and destroy the fungus, you 
must root out every diseased hair, by gentle means if you can, but 
pull it out. There can be no doubt that such views are now very 
widely accepted. Dr. McCall Anderson is unreservedly in favour 
of this system. " Considering as I do," he says,* " that its [favus] 
essence consists in the presence of a parasite, I hold that its 
destruction is the sine gud non of the treatment." He, therefore, 
has every hair removed with broad-pointed forceps, and clears three 
or four square inches of scalp at a sitting. Dr. Hillier says t that 
tinea tonsurans and tinea favosa cannot exist without their respective 
fungi. The diseases known as tinea, he says, essentially depend on 
the presence of microscopic fungi. M. Bazin, among others, adopts 
much the same view. 

To all this, Mr. Wilson replies that the parasitic bodies are 
produced by " granular degeneration " of normal tissues, and he 
refers for corroboration to such instances as the development of 
mucus and pus. He says that upwards of twenty years ago he 
came, after a very careful examination of the subject, to the con- 
clusion that the pathological elements resulted from aberrant cell- 
growth, consisting in the growth and proliferation of the primary 
granules of which epidermic cells and hair-cells are nominally 
constituted; that this growth and proliferation had the effect of 
arresting the granules at their embryonic stage, and in the per- 

* On the Parasitic Affecitom of the Skin, i86i, p. 32. 
t British Medical Review. 



Parasitic Nature of Growth in Tinea questioned. 5 5 

formance of their embryonic functions, and as a consequence that 
the cell-tissue (epidermis and hair), composed of these embryonic 
granules and imperfectly elaborated cells became, upon desiccation 
by the air, dry, spongy, and brittle ; that in trichosis this change 
alone took place in the hair, whereas, in favus, the granules com- 
posing the yellow disks around the mouths of the follicles, pass 
through a pustular stage, the consequence of a higher degree of 
inflammation, and in their pustular condition acquire their peculiar 
yellow colour. This morbid alteration he considered then, and 
considers now, to be granular degeneration. 

As regards the mode of increase and production, Mr. Wilson 
contends that "the granules are nucleated, separate or in groups, 
or adherent in moniliform strings of two to four or five in length. 
The great number of the granules are uninuclear; some, however, 
are binuclear or trinuclear. The binuclear granule is in process of 
separation ; the original nucleus has split into two, each moiety has 
become a separate nucleus ; the space between them has increased ; 
a septum has arisen in the interval, and the cell has become oblong 
— an oblong cell with two nuclei, or rather with two independent 
but adherent cells, cells that may subsequently divide and become 
separate cavities. This is the mode of all proliferation." At an 
early stage, and while in near contact with the vital tissues, the 
tendency is to the formation of granules, but " removed firom the 
source of nutrition proliferation weakens, the divided cells remain 
adherent, and either retain their globular and independent shape 
and give rise to moniliform filaments, or they grow in length at 
the expense of their contents, and form cylindrical and transparent 
filaments divided by septa, each intern odial segment representing a 
single original globular granule or cell." In the latter case they 
lapse "into an irregular and filamentary proliferation, giving rise 
to an inferior form of organization, neither so complete nor so per- 
manent, and which converts the higher animal organization into a 
lower and phytiform organization — an animal tissue into one which 
might be likened to a vegetable tissue." 

These quotations, then, give us as the sources of the so-called 
fungus elements : i. The normal tissues (epidermic granules), the 
nature of the disease of which is here looked upon pathologically 
as a granular degeneration. 2. The mode of increase by the divi- 
sion of the nuclei of the cells and the secondary di\asion of the cell 
itself. 3. The formation of the so-called mycelium by the division 



56 Parasitic Nature of Growth in Tinece questioned. 

of the nuclei and the breaking up of the binucleated cells into 
separate unities. These stages are best seen in favus. The granules 
are globular, uninucleated, bi- and tri-nucleated ; the mycelial forms 
are moniliform and opaque, cylindrical and transparent, with a 
branched and ramified filament. ** In the case of the trinuclear 
cell, a bifurcation is effected, and the proliferation of each part of 
the tissue-cell lays the foundation of a branched and phytiform 
growth." The peculiarity of favus " is due to a pustular com- 
plication ;" the layer of the favus mass, next the basement membrane 
of the derma, is made up of pus-globules; "these pus-globules 
contain from four to seven or eight well-formed nuclei ; and these 
nuclei, on their escape from the cell-membrane of the pus-globule, 
become the nucleated granules which are the chief constituent of 
the pathological product." The moniliform thread is produced by 
the coalescence of these escaped nuclei. We have then to notice 
the view that in favus the phytiform elements are derived from the 
nuclei of pus-cells. Mr. Wilson interprets the term granular degene- 
ration by " the idea of an arrest of development of the cell-tissue of 
the epidermis at its embryonic stage, and the production of a tissue 
constructed of crude and imperfect materials, which represent an 
earlier period of all generation than that which nature intended, and 
which, in consequence, is truly in a state of degeneration from the 
perfect type." 

Mr. Wilson further says,* that " every observation seems to show 
that this phytiform process takes place in the rete mucosum, in the 
shaft of the hair, situations which the humble seed-like spore could 
never reach by a process short of necromancy, having epidermis 
unbroken in both cases." I should have thought his experience 
had already taught him that such little difficulties never yet did 
stand in the way of a theory. He also observes that some of the 
phytiform affections — pityriasis versicolor, for instance — are sym- 
metrical, and that this must be an awkward stumbling-block in 
the way of " the gardener's theory." He points t to the fact that 
one of the early promoters of the theory of contagion by vegetable 
fungi is about to recant. To this may be added, that such careful 
observers as Dr. Carpenter and Mr. Erichsen deny that a vegetable 
parasite exists in the favus crust. Mr. Naylor, too, considers that 
the hair is only secondarily affected in favus, and that when it is 

* Journal of Cutaneous Medicine^ vol. i. p. 345. f Ibid. vol. ii. p. 106. 



Parasitic Nature of Grozvth in Tinece questioned, 5 7 

destroyed, this happens from the pressure from without acting upon 
the follicle ; a view, however, in which I cannot concur. It has 
always appeared to me that the disease extends down the sides of 
the follicle. 

To this it has been rejoined that Mr. Wilson's arguments are 
anatomical, that the botanical view of the question had been quite 
ignored, and the growths in question are vegetable. But, after 
all, the victory practically remains with the antagonists of the 
parasite doctrine. Its supporters unreservedly admit that ill-health 
yields the soil on which alone the fungus can root itself. Sir 
William Jenner says that parasitic diseases seem to take little hold 
on those who are constitutionally sound, and in a large number of 
cases of parasitic disease the general health of the patient is at 
fault. What part, then, can be played in the production of disease 
by a parasite which can only find suitable nourishment in a state of 
skin which would require setting right just the same were there no 
parasite at all ? 

So far, however, will passion for a prevailing theory blind men, 
that the disappearance of a tinea, after some strong local treatment 
has been applied, is triumphantly appealed to in support of the 
doctrine. The caustic has killed the parasite and the disease has 
disappeared in consequence. But the argument is not only useless, 
it is worse — it is delusive, for it would only hold good if it could be 
shown that the caustic destroyed the parasite without touching the ski?t ! 
It is just as likely that a powerful stimulant may do good in a 
so-called parasitic disease as in one for which a parasite has not 
yet been discovered, for instance, lupus and erysipelas, though how 
long they will enjoy such an immunity is doubtful enough. But 
when once the tide of reasoning has set in one particular direc- 
tion, it is useless attempting either to check or direct it; the 
only plan is to let it expend its force, which generally ensues 
spontaneously, and then perhaps the voice of reason may be 
heard. This state of matters is, I need scarcely say, not in 
any way peculiar to medicine ; it infects the whole empire of 
literature, those branches as well in which taste and feeling 
are the only arguments as those in which neither taste nor 
feeling is allowed a hearing. The rule of Mr. Tennyson is 
not more absolute than that of Mr. Darwin, Mr. Huxley, or Sir 
Henry Rawlinson, and any one bold enough to use his own 
reason about any of their respective views or theories, is at once 

I 



5 8 Parasitic Nature of Growth in Tinece questioned. 

treated by certain organs of the press as if he were a fool or a 
criminal. 

I admit at once that this question of the contagiousness of the 
tineae quite puzzles me. Favus boasts of a most luxuriant fungus ; 
it has all the qualifications necessary for giving the disease to any 
extent ; it is said to be highly contagious ; yet it is quite certain that 
children affected with this disease in a most virulent form remain for 
long periods at home in quite as close contact with parents , relatives^ 
friends^ 6^^., as is adequate to transmit scabies in a fraction of the 
time^ and that the extremely rare occurrence of the disease proves how 
very seldom it is communicated under such circumstances. Again, we 
find an advocate of contagion — Mr. Hutchinson, — driven to admit* 
that tinea circinata is very rare among the lower classes, where 
we generally find contagious diseases extend most rapidly and 
widely. It is very common in the upper classes, a circumstance 
Mr. Hutchinson can only attribute to the more general use of the 
same combs and brushes among the upper classes, when visiting 
at each other's houses, whereas the poor only use them at 
home. But it is difficult to understand how a brush or comb, kept 
in a cleanly family, can convey a disease more certainly than the 
wearing of each other's caps and hats by children, as is constantly 
done among the lower orders; or how it happens that servants, 
who are often not at all scrupulous about employing the same 
comb and brushes as the young ladies and gentlemen use, should 
escape. 

Now, considering that it may assail adults in a very severe 
form indeed, and that the same young ladies and gentlemen 
not unfrequently use papa's comb and brush, it is curious that he 
never gets tinea and propagates it through his club, where, perhaps, 
fifty or a hundred members use the same comb and brush in a day 
— ^a state of matters which ought to favour the diffiision of this 
disease to an extent, compared with which an occasional visit, 
at which, after all, it is only assumed that the practice is put 
in force, sinks into insignificance. Possibly we shall, some day, 
stumble on the truth, and find it lying midway between the 
extremes of scepticism and credulity. 

At the time of writing this, a child is under my care for tinea 
circinata. She is remarkably cleanly, as are her parents, and 

* Journal of Cutaneous Medicine ^ vol. i. p. 171. 



Development of Fungi. 59 

has been brought up in such strict seclusion that she was not 
allowed to play with any other children ; yet the complaint has 
established itself on the skin over the lower part of the scapula 
— a place constantly covered with clothes. It is difficult to under- 
stand how any fungus could have been conveyed here, and yet had 
this child been at a school where there were other children affected 
with ringworm, her complaint would at once have been ascribed to 
this source. 

Again, a boy was lately in attendance at St. John's Hospital, 
suffering from the same affection, which his mother said he had 
caught from the baby whom he was in the habit of nursing. On 
examining the infant I found there was certainly well-developed 
tinea circinata on the lower part of the belly ; in the case of the 
boy it was seated on the front of the wrist. The mother said the 
lad was in the habit of sitting with his hand up the baby's clothes. 
On further examination, I elicited that the tinea appeared in the 
latter (now several months old) soon after birth, whereas the boy 
had only had it a very short time, though he had constantly nursed 
the infant — a fact which seemed to be explained by the statement, 
that up to a recent period the baby had worn long clothes, as these 
prevented the boy from placing his hand in contact with the skin. 
I could find not a tittle of evidence to prove that any one suffering 
from ringworm had ever been in contact with the baby. 

I think, then, we are quite justified in concluding that there is not 

one jot of evidence to show that any form of tinea necessarily depends 

on the transplantation of a fungus or the diffusion of it by spores. 

That contagion may be conveyed in this way in some few instances, 

there seems reason to believe. But it is to be remembered that 

this point is not yet proven, nothing like a demonstration of it has 

"been attempted. I offered to give every facility for putting it to a 

crucial test at St. John's Hospital, but the offer was not accepted. 

These diseases most assuredly spring up spontaneously in some 

cases, and therefore those who assert that the fungus is the sole 

cause simply put themselves out of court. The fallacy of such a 

mode of arguing becomes evident enough when we deal with 

visible and tangible agents. It would be simple absurdity to say, 

that because cantharides will blister the skin, therefore every 

blister on the skin must be caused by cantharides ; yet this is not 

more illogical than asserting, that as contagion probably takes place 

in some cases it must be assumed to happen in all. 



6o Development of Ftmgi, 

Mr. Erasmus Wilson* considers that nervous exhaustion is the 
cause of the falling of the hair, in tinea areata at any rate. 
Neuralgia, anxiety, &c., bring on the exhaustion and anaesthesia 
accoinpanies it, the result being that the tissues of the skin waste 
from want of nourishment, and that the hairs, at a short distance 
outside the follicles, grow thin and brittle and break off. Moreover, 
this form of alopecia occurs at spots assailed by neuralgic pain; 
it occurs during pregnancy, and is in some cases hereditary — facts 
which he thinks clearly fatal to the fungus theory. But I would 
venture to hint, that, however adequate this theory may be to meet 
some cases, it does not explain others. Alopecia areata and even 
tinea decalvans are seen where there is no anaesthesia and no 
history of neuralgia ; children too, do not suffer much from neuralgia, 
and generally very little, except at the time, from mental agitation. 
Yet we see them victims to tinea of every kind and grade. The 
hereditary nature of any form of tinea may be doubted, although 
the coincidence of its occurring in both parent and child is probable 
enough. Finally, there is reason to believe that tinea is in all cases 
the result of a process analogous to that which produces eczema — 
a slow inflammation, often less the redness, under the influence of 
which the hairs and cuticle are killed and thrown off piecemeal — a 
process as thoroughly constitutional as that which occurs in cancer, 
phthisis or lupus. 

Dr. Purdon, who, I must say, although I dissent from his doc- 
trines, approaches the subject in the spirit of a true worker, sayst 
that favus is much more common in wet and rainy cities than in 
those of a drier atmosphere. But I never yet understood that 
Edinburgh is much moister than Glasgow, while favus is infinitely 
more rife in it than in the latter city. I lived for some years in 
one of the wettest counties in England (Cumberland), and never 
saw a case there. At the same time I feel bound to admit that 
Dr. Purdon's views merit investigation, containing, as they do, 
germs of discoveries infinitely more important than all the marvel- 
lous performances of fungi — for marvellous they are beyond the 
mind of man to conceive. In other instances where fungi develop 
themselves on decaying and fermenting matter, their form is deter- 
mined by that of the matter they assail and its condition at the 
time ; in diseases of the skin it is the reverse ; the fungi develop 

* Journal of Cutaneous Medicine^ vol. iii. p. 99. f I^^^^' vol. iii. p. 394. 



Diagnosis of the Tinece, 6 r 

the state of the matter, for otherwise they cannot cause the con- 
tagion and they are an accident. " A fungus," says Pouchet,* " is 
known which never grows except on the bodies of dead spiders ; 
another only appears on the surface of horses* hoofs in a state of 
putrefaction.'* There is one of enormous size, and always solitary, 
on the neck of a caterpillar of tropical countries ; another (Racodium 
cellare)y which has never been found except in the casks of our 
cellars ; and a third only met with on the drops of tallow which the 
miners, in working, let fall on the soil. Every form of fermentation 
has its particular vegetation, and every sick and dying plant is 
attacked by its special parasite.t Unless, then, we admit, that the 
forms assumed by these growths are, as I said, determined by the 
form and state of the structures on which they appear, in which case 
they are clearly results and not causes, they must spring from special 
germs. But these germs, to fertilize on such countless millions of 
objects, must exist in prodigious numbers, and yet we never find 
them till they have selected their site. To appear as they do, 
immediately that the conditions which permit of their existing 
set in, every form they assume must be present in every part of 
the atmosphere where we yet never detect them. But the most 
miraculous thing is, that though strictly vegetable in their nature, 
they must be endowed with intelligence and muscular power, for 
unless they existed in such inconceivable numbers as the pansper- 
mists would have us believe, in which case they would render the 
air opaque, they must have the faculty of perceiving — often, indeed, 
where it is invisible to mortal eyes — the object on which they are 
to fructify, and of traversing immense distances to reach it. 
. Diagnosis, — The first step towards forming a really satisfactory 
diagnosis of these affections is to eliminate all true pustular 
diseases — that is to say, those which begin with pustules, or in 
which pustules form the great predominant feature, and refer 
them to impetigo, which is, except in some very .rare instances, 
not a contagious disease at all. In some affections of the scalp 
pustules may form a complication of a true tinea, but they are not 
an essential element of any stage of the disease. Next, vesicular 
diseases of the scalp, if any such exist, for I never saw one, may be 
thrown out. Thirdly, true eczema of the scalp — that is to say, an 
inflammation of patches of the skin, followed by throwing off of the 

* The Universe, p. 715. t Ibid. p. 719. 



62 Treatment of Tinece. 

cuticle, weeping, and the formation of crusts, resembling dried 
honey, fragments of dirty green soap, mortar, resin, &c., may follow 
the same path. There then remain the true tineae — that is to say, 
dry, scurfy, reddened patches, accompanied by clipping, shedding, 
twisting, and loosening of the hair, and in some cases by shedding 
of the epidermis ; in others, by the formation of a secretion very 
closely akin to that of eczema as in favus, or even passing gradually 
into eczema as is occasionally seen in tinea circinata. 

Prognosis. — This must I think be looked upon as essentially 
favourable. Hair will not grow again after a certain period and 
scars are of course indelible, but the progress of the disease may 
always be checked even in favus, and in most cases success 
will follow proper attention. That tinea areata is perfectly and 
permanently curable, even in tolerably severe forms and of con- 
siderable duration, I have every reason to believe. In the latter 
part of 1868 a woman attended at St. John's, from whom I learned 
that her sister, whom I had cured of this affection four years pre- 
viously, had remained well ever since. In this case the disease had 
existed several months, and some of the patches, which were nearly 
as large as the palm of the hand, were perfectly devoid of hair. At 
the present time there are three patients attending at St. John's 
Hospital, in all of whom the complaint is progressing steadily 
towards a cure. In two of these it had lasted some years ; in bne 
I know this statement was substantially correct, because the patient 
had attended on a previous occasion for the affection, and a very 
considerable interval elapsed between the first and second course of 
treatment. 

Treatment. — Tinea areata and tinea decalvans ought, I think, 
to be at once attacked in the most vigorous manner by means of 
vesicants, such as Bullin's blistering fluid, or solution of cantharidin 
in glacial acetic acid, four grains to an ounce. These should be 
rubbed in to such an extent as to produce blistering, for it is to be 
borne in mind that the complaint has Uttle if any tendency to dis- 
appear spontaneously, and that if it be trifled with the hair will not 
return. Should there be anything wrong in the state of health, it 
should be set right as far as possible ; many of these patients are 
pale, delicate, and underfed children who require a long course of 
tonics and aperients. Steel is often very useful as regards the 
health ; whether, even in conjunction with arsenic, it possesses any 
real influence over the local complaint I am unable to say. Some- 



Treat77tent of Tinecr, 63 

times, however, the complaint makes its appearance in very healthy 
persons, and in these cases I think arsenic ought to have a fair 
trial ; but I have rarely succeeded in inducing a patient affected with 
one of these diseases to take it long enough to produce any effect. 
I believe it is beneficial, especially conjoined with steel, as it cer- 
tainly induces a healthier state of the skin in some not very dissimilar 
affections, but my observations do not allow me to assert this as a 
fact The grand practical point, however, is that, treated in this 
way, many patients are unquestionably cured. Many indeed neglect 
the complaint to such an extent that all attempts to benefit them are 
simply thrown away, while others only make their appearance when 
irretrievable mischief has been done. Not long ago a patient, who 
had lost all the hair from the back of her head twenty-five years 
previously, applied at St. John's Hospital to be cured of this com- 
plaint. Whatever applies to these affections applies also to tinea 
tonsurans. As to tinea circinata, it for the most part requires only 
some local application, of which the simple nitric oxide of mercury 
ointment, with a little glycerine,* and the ointment of the red iodide 
of mercury of the British Pharmacopoeia, are, perhaps, the best. 

Not long ago I showed several gentlemen a case which, so far as 
one case can be supposed to prove anything, showed that internal 
treatment has some, but not complete, control over this affection. 
The patient, a girl, suffered from tinea areata, not only on her head, 
but her arms, where the hair hadbeen removed in long strips. She 
'was treated with steel, arsenic, and blisters. At the end of a few 
months it was found that the hair was growing on the head where it 
had been blistered, as also on the arms where no external applica- 
tion had been used, while two spots on the back of the head, to 
which, also, nothing had be^n applied, were almost in statu quo. 

In all cases of obstinate or confirmed alopecia, my own experience 
would lead me to rely entirely upon two remedies and on these only ; 
they are the internal use of arsenic and the external use of the 
Spanish fly. A regular course of arsenic should be given as for an 
obstinate form of erythema or pityriasis. As to the cantharides, 
fancy or experience will readily enough dictate some form in which 
this potent ingredient can be applied. But the cheapest and most 

• R. Ung. hydrarg. oxidi rubri, 5ij. 
Glycerini, 5ss. wy 
Ft. ung. 



64 Treatment of Favus, 

certain method that I am acquainted with, is simply to powder the 
fly and macerate it in glacial acetic acid for a fortnight. The 
mixture at first should be almost as thick as printer's paste ; after 
a short time a clear fluid gathers at the top, and this, after being 
strained off and well brushed over the bald surface, or rubbed in 
with a piece of lint, is by far the most powerful vesicant for a cheap 
preparation that I know of. A piece of skin the size of a shilling 
is blistered every second or third day, and in this way the whole 
of the surface may be operated on without any great soreness being 
induced. Care should be taken to keep the fluid from the fingers. 
I have suffered severely from handling it carelessly. Bullin's blis- 
tering fluid is also a most valuable preparation, but on account of its 
cost is not so well suited for hospital or dispensary practice. When 
patients will not submit to blistering, frictions with a mixture of 
spirit of horseradish, tincture of cantharides, and Cologne water may 
be tried instead ; but this method is far more expensive and less 
certain than the other. 

But tinea favosa, or favus, demands much greater care. For 
the most part, a long course of internal treatment is absolutely 
requisite, and I cannot understand the persistency with which 
some writers dwell on the value of local applications to the 
entire exclusion of general means ; for, although these may possess 
little control over the disease when unsupported by suitable external 
means, they still form very useful auxiliaries. So far as my experience 
goes, it is quite in favour of the conclusion that good general and 
local treatment combined will cure these cases more speedily and 
effectually than local treatment only. Besides most of those patients 
are in a bad state of health and constitutionally weak. I have never 
seen favus in a sound, strong child. In three cases under my care, 
of which I took copious notes, the whole frame appeared feeble and 
unsound; the children were said to have always been delicate; their 
hones were small^ and their heads looked as if they had suffered from 
hydrocephalus when young. In all three the breadth cuross the parietal 
bmes was greater than natural, and the upper part of the frontal bone 
overhung the lower. In one patient there was, at each side of the 
forehead, a sulcus, which took its rise at the middle of the eyebrow 
and sloped upwards and outwards for a considerable distance. The 
features in two out of the three were thin and pinched. One girl 
had suffered from suppuration of the lymphatic glands below the 
chin. In all three cases the parents and the rest of the family were. 



Treatment of Faints. 65 

so far as I could learn, healthy ; certainly, all those that I saw 
looked so. 

In all cases of favus I would suggest a very free use of purgatives. 
I believe there is no step more imperatively called for. Purgatives 
should be continued till the stools become of a bright yellow, and 
this state should be maintained by employing them at least once or 
twice a week. It is surprising how well this treatment agrees with 
children, and how they make flesh on it. For children I believe 
scarcely anything surpasses grey powder, given three or four times 
a week, accompanied by a dose of a magnesian saline, or salts 
and senna, every morning. The only medicine which, in addition 
to this, I have seen do any good is a combination of steel and 
arsenic. Small doses of the saccharated carbonate of iron and 
tolerably large ones of the liquor potassae arsenitis, seem to me to 
answer best.* I never saw the slightest benefit arise from the use 
of any sort of tonic, either in my own practice or that of others. 

Favus, when remediable at all by external treatment, requires only 
mild means. The barbarous practice of tearing out the hair by means 
of a pitch plaster ought not to be suffered any longer. Indeed, if I 
had the power, I would put it down by the arm of the law. It is 
horribly painful, perfectly unnecessary, and in certain cases fatal. 
One case was communicated to me in which, to all appearance, 
death arose from this brutal i)ractice ; and Sir William Jenner saw 

• For a child two years old the following prescriptions may be used : — 

R. Hyd. c. Creta, gr. x. (vel gr. xv. ) 
Pulv. Cinnam. c. gr. v. rcy, 
ct divide in pulv. iij. ; i. alternis noctibus hori decub. sumend. 

R. Mist. Sennae comp. ^ss. 

A third part to be given on the morning following the administration of the 

powder. Syrup of senna in doses of 5ss. , or calcined magnesia in doses of five to 

ten grains given in milk, may be substituted if the child object to the mixture. 

Citrate of magnesia, albeit it is said to contain neither citric acid nor magnesia, 

answers very well in those cases, and children seem to like it. A teaspoonful 

may be given here in a wineglassful of sweetened water. Fox's ** palatable 

castor-oil, * which can be procured at the "Sanitary Institution," 2, Adelphi 

Terrace, might be tried. I have, however, had no experience of its use. 

R. Ferri carbonat. sacchar. 9i. Divide in pulv. xiv. 
One of these powders may be given twice daily mixed with a small quantity — 
about a quarter of a teaspoonful — of water. 

R. Liq. Potass. Arsen. nxxxiv. 
Aquje, 5xiss. 
Coch. min. i. ter quotidie sumend. 



66 Treatment of Favus. 

a case in which a child was nearly killed by the application of pitch 
to the scalp. All loose and diseased hairs should certainly be 
removed, but this should be done as gently as possible ; for the most 
part cutting the hair quite close to the scalp is sufficient The head 
or any surface affected should be washed occasionally with the trans- 
parent soap made for St.* John's Hospital, which I have no hesitation 
in recommending as the best I have ever met with. Only very hot 
water should be employed for this purpose. The affected surfaces 
should then be covered with freshly-prepared dilute nitrate of mer- 
cury ointment, thinned down with almond-oil to the consistence 
of cream, and over this a covering of linen should be worn night 
and day. 

Of the three patients alluded to above, one, a girl, made a very 
good recovery. She had been treated with cod-liver oil — in fact, 
almost fed on it at one time — quinine, steel, wine, jellies, and beef- 
tea for five months, and during the whole of this time had got 
steadily worse ; but so soon as she was put on a plain, wholesome 
diet, and was well purged, she began to mend. A continuance of 
this process, aided by gently removing all the hairs which were 
manifestly weak and loose, effected all that was requisite. A few 
months ago the mother, who, I feel sure, would be very happy to 
show the case to any one, called, after an interval of four years, to 
say that the child had remained quite well, and had now a famous 
crop of hair. The second case was hopeless from the beginning ; 
the child was ill cared for and ill fed ; she had suffered from suppu- 
ration of the submaxillary glands, and was of very delicate build. 
The disease, which had lasted several years, had already destroyed 
nearly all the hair-bulbs and great part of the upper surface of the 
true skin, which was white, shining, and scarred. Epilation could 
not be tried, for there were only a few scattered hairs left, and the 
child violently resisted every attempt to touch them. Lastly, I 
could not get her mother to attend regularly with her. The third 
case, that of a boy, was progressing favourably under the use of 
saccharated carbonate of iron and liquor arsenicalis, the favus 
having almost disappeared, when he suddenly left off attending. 

In respect to kerion, I can only suggest the same internal treat- 
ment as for favus. Externally, I believe nothing succeeds better 
than painting the whole of the affected surface with tincture of 
iodine, diluted the first time or two with an equal weight of water, 
and subsequently pure or even strengthened by the addition of 



Wilsons Treatment of Tinea. 67 

iodine. Should it begin to lose its effect a solution of nitrate of silver, 
five or ten grains to an ounce, may be substituted. The painting 
should be carried as far as practicable short of giving severe 
pain. 

For the simple falling of the hair in grown persons Mr. Wilson 
advises that the hair should be cut with great care, and by a person 
thoroughly skilled in the matter. The tips of all the hairs require 
to be cut off : this is the grand point. A secondary but still more 
useful one is the use of a spirit-wash and a stimulating ointment.* 
The same treatment, with free brushing, is applicable to general falling 
of the hair as also to area ; the head is also to be washed in cold 
water and dried with a hard towel ; it is then to be well brushed, 
the great point being, it seems, to brush the skin more than the hair 
— steel medicines and tonics being also requisite. 

His general directions as to the treatment of tinea and favus are 
to remove crusts and furfurae by thorough washing with juniper tar 
or petroleum soap, or by the use of a liniment consisting of equal 
parts of soft soap, juniper tar, and alcohol ; the diseased parts are 
to be washed daily with tepid or cold water, and. the skin of the 
head is to be gently stimulated ; the hair is to be combed and 
brushed when it is not too sensitive ; a little dilute nitric oxide of 
mercury ointment is to be rubbed in night and morning ; tonics, 
cod-liver oil, iodide of iron, and arsenic are to be given internally. 
Mr. Wilson says there can be no doubt that depilation disposes to 
the cure of the local disease ; the statements of Bazin that he 
succeeds in effecting this object cannot be ignored, but the removal 
of the fungus is not the proper explanation of the cure. Depilation 
is a valuable stimulant : it will transmute the white hair of age and 

♦ The unguentum stimulans is made by macerating six drachms of the powdered 
cantharides with a gentle heat for twenty-four hours, in three ounces of pure lard. 
It is then strained through blotting-paper. 
He also recommends for a wash this prescription : — 

R. Olei Amygd. dulc. 

Liq. Ammon. fort, aa 5j. 
Spiritiis Rosmarini, 5ss. 
Aquae Mellis, ^ij- lU ut fiat Lotio. 
I prefer the following : — 

R. Spiritiis Armoraciae, 

Rosmarini, 

Tinct. Lyttse, aa 5ss. 

Aquae Lavand. Jviss. x\ fiat Lotio. 



68 Frazers Treatmeftt of Tinea. 

sickness into the natural hue ; it is a successful mode of treatment ; 
but the success depends really on its power of producing deep 
stimulation of the cutaneous tissues, and of setting up a new action 
in the papillae of the hairs. It is in fact the only remedy by which 
we can effectually reach the fundus of the follicle. It sets up a new 
action, a healthy instead of an unhealthy inflammatory process — a 
process the natural end of which is resolution, instead of one that 
goes on to all perpetuity. In the place of morbid cell-genesis it 
establishes healthy plastic action, and sometimes healthy suppuration, 
in the midst of which, as Bazin avers, the fungus is starved or 
drowned. I must say, however, that I never observed this phase of 
the operation, and that I should consider suppuration an unnecessary 
evil to be avoided by every means in the surgeon's power. 

Mr. Wilson's particular treatment of tinea consists in giving 
sulphur and cream of tartar, cod-liver oil, especially if there be 
struma ; citrate, acetate, and hydrochlorate of iron, iodide of iron, 
iron and quinine, nitro-muriatic acid, a good diet, and plenty of 
porter. 

The hair is to be cut and the crusts are to be detached with water- 
dressing ; the head is then washed with old-fashioned yellow soap. 
After this the patches are well painted with tincture of iodine, or 
strong acetic acid, or vinegar of cantharides ; subsequently an oint- 
ment of one of the nitrates of mercury is well rubbed in. When 
ointments are objected to, a lotion of sulphuret of potassium, a 
drachm to a pint, or of bichloride of mercury, a grain to an ounce, 
may be used instead. The dry scurfy state of the skin which 
remains is generally removed by dipping the head in cold water and 
rubbing in some simple pomatum. 

Dr. Frazer recommends vesicating collodion and strong iodine 
paint for the patches of tinea; he also speaks highly of carbolic 
acid. Mr. Startin uses a compound sulphur ointment of his own,* 
and Sir William Jenner recommends one in all essentials the same 
as Mr. Startin's. For the strictly local form (area) Mr. Startin uses, 

* R. Sulphuris, Ibss. 

Hydr. ammon. chlor. 5ss. 
Hydr. sulphur, ^ss. 
Olei Olivae, 5iv. 
Adipis purif. ^xvi. 
Creosot. ntxx. v\. 
Ft. ung. 



Drysdales Treatment of Tinea; Bazins. 69 

among other remedies, a lotion composed of infusion of white 
hellebore, bichloride of mercury, sulphurous acid and glycerine, 
applied warm with a soft brush ; he has generally found a few 
applications of this prevent the falling of the hair, and extension of 
the disease from any patches which may happen to exist. The use 
of this lotion is followed or accompanied by friction with an oint- 
ment made of two ounces of fresh lard and the same quantity of 
cold-drawn castor-oil, half a drachm of tincture of kino, the same 
amount of Goulard's extract, and twenty mimims of oil of rosemar}-. 
Dr. Frazer employs a lotion consisting of an ounce of aromatic 
vinegar and six drachms of Spanish flies, united with six ounces of 
rose-water, and the same of either rum or whisky. Mr. Hunt does 
nothing for ringworm beyond keeping the head clean, and pre- 
scribing a moderately nutritious diet. Oiled silk caps and such 
things he looks upon with horror, and very justly. 

Dr. Drysdale, in a paper * in which he has done me the honour 
to speak favourably of my labours, gives us to understand that his 
practice is to use stimulant lotions and vesicants in area and tinea 
decalvans. He mentions one very severe case where these were 
employed. The patient left off attending in the middle of the 
treatment, and reappeared a year after, having grown a fine crop of 
hair, which he ascribed to the local use of rum and milk, recom- 
mended to him for this purpose by an old lady. The probability 
however is that Dr. Drysdale*s vesicants had a vast deal more to 
do with the result. The disorder was reappearing in some spots, 
but the persevering application of the liquor epispasticus of the 
British Pharmacopoeia checked it. Dr. Cheadle in tinea areata 
seems t to have been very successful with arsenic and steel, nitrate 
of silver lotion and strong creosote ointment. 

M. Bazin treats tinea as follows : — The hair is cleansed and 
cropped close, the crusts are then removed and the affected surface 
painted over with the oleum picis juniperi, which, according to him, 
not only renders the skin healthier and less sensitive, but loosens 
the bulbs of the hair and at the same time makes the fungus shrivel 
up and destroys it. I have repeatedly used the oil and a very good 
remedy it is, but / have never seen anything like such an action from 
it as loosening the bulbs of the hair^ or, indeed, from any remedy 

• Journal of Cutaneous Medicine^ vol. iv. p. 78. 
t Ibid, vol. iii. p. 442. 



70 Bazifis Treatment of Tinea. 

whatever. The day following the head is to be washed with soap, 
and then every hair is removed over the whole extent of the 
diseased surface. As this is far too painful a process to be borne 
for a long period at a time, it may have to be extended over five or 
six sittings, and to be repeated two or three times, or even more 
frequently^ (!) before the cure is effected. The epilator sits for this 
purpose on a chair and places the patient on a cushion at his feet, 
with the head resting on his knees. The hairs are then removed 
with tweezers, one or two at a time. When the surface is cleared 
it is brushed over with a solution of the bichloride of mercury to 
destroy the fungus. Four or five hours later the head is well 
anointed with the following ointment : — 

« 

R. Hydrargyr. subsulph. flavi, Jss. 

Olei Amygd. dulc. 

Glycerinae destillatae, aa 5ij. 

Adipis purificati, ^ij- 
Misce. 

Or with this — 

" R. Olei Juniperi pyrolignei, 5ij« 
Adipis purificati, Jiiss. 
Misce. 

M. Bazin, however, prefers the first. On the following day the 
depilation, the washing, painting with bichloride of mercury lotion 
and anointing with the ointments given above are repeated, and 
this is continued daily till not only all the diseased hairs, but a great 
many of those in the vicinity, are removed. The process is painful 
as the reader may easily imagine. 

When the extraction of the hairs is completed the surface is 
painted over, night and morning, with the solution of the bichloride 
of mercury. M. Bazin however does not say how strong this 
solution is. When the hair begins to grow it must, if unhealthy, 
be pulled out again, and it may be necessary to repeat this three or 
four times. 

M. Hardy's treatment is very similar to that of M. Bazin, except 
that he does not employ the empyreumatic oil of juniper. He 
extracts the hairs, and after this applies a lotion of bichloride of 
mercury, a grain to the ounce, and, in the latter part of the treat- 
ment, sulphur ointment, half a drachm of sulphur in the ounce. 



Treatment of Favus, 71 

Probably sulphurous acid lotion,* the solution of pentasulphide of 
calcium used in scabies,t or a lotion of carbolic acid, ten grains 
in two ounces of water, would answer the purpose intended equally 
well, at the same time be more cleanly and easy of application. 

When we analyse the treatment of favus as adopted by the most 
successful practitioners, we find that, in however many divisions it 
may radiate, however numerous and discordant may be the ele- 
ments of which the various systems are composed, they admit of 
being resolved pretty well into the following groups : — i. Tonics, 
such as steel, nitric acid, quinine, &c., remedies which, however 
they may improve the health, never appeared to me in a single 
instance to possess the slightest control over the disease of the 
skin. 2. Alteratives, such as cod-liver oil, iodine, and iodide of 
potassium, mercury, and arsenic. Cod-liver oil never seemed to me 
to do any good in favus. I have great faith in it in many diseases 
of the skin, but I never saw it produce even the most insignificant 
effect here. Iodine and iodide of potassium proved quite useless 
in my hands, and mercury was only valuable as a purgative ; the 
most valuable remedies, fluid purgatives, especially salines, appear 
to me little used. 3. Some means of softening the crust which may 
be more or less complicated, nothing, perhaps, being superior to 
wet lint. 4. The removal of the hairs, a practice which, kept 
within reasonable bounds and practised without cruelty, seems 
warranted by the results of combined experience. 5* The applica- 
tion to the denuded and diseased surface of some powerful antiseptic 
such as carbolic acid, bichloride of mercury, sulphurous acid, &c., 
followed or not by the use of various ointments containing some 
preparation of iodine, sulphur, or mercury, — remedies from which 
I have never in a Single instance seen such an amount of benefit 
as would justify me in preferring any or all of them to a simple 
blister. 

In favus Mr. Wilson gives tincture of the sesquichloride of iron 
even to quite young patients ; his dose for a child ten years old is 
ten minims. If too much heat be caused by the iron, he sub- 

* R. Acidi sulphuros. 
Glycerin, aa 5j. 
Aquae, 5ij. Ft. Lotio. 
The sulphurous acid should always he fresh made, as after a time it is converted 
into sulphuric acid, 
t The formula for the pentasulphide of calcium is given at page lo. 



72 Mr. Star tins Treatment of Favus. 

stitutes for it the nitro-muriatic acid. When there is a tendency to 
enlargement of the lymphatic glands Mr. Wilson uses cod-liver oil, 
and if the bones be slender and weak, lime-water or phosphate of 
lime. He advises a liberal diet, plenty of fresh air, exercise, 
sponging, &c. His local treatment is to get away the crust with 
Alison's lambskin, and then to apply the ceratum tiglii. 

Favus is looked upon as incurable in the Hospital for Diseases 
of the Skin in Bridge-street. Fortunately it is a very rare com- 
plaint, not being seen very often, though too frequently as it is. 
In more than fifteen thousand cases which I have entered at 
St. John's Hospital and elsewhere I have only met with three of 
genuine favus. At Aberdeen only 24 cases were seen in the Royal 
Infirmary during nine years, and at Glasgow only 15 were met with 
among a large number of patients in this space of time. It is true 
we find that 120 cases were admitted into the Royal Infirmary at 
Edinburgh in ten years. Such a very great excess may be due to 
some local peculiarity not yet accounted for, or it may be owing to 
difference of classification.* 

At one time Mr. Startint certainly did not consider favus as in- 
curable. True, he does not mention it in his lectures, but he takes 
a very different view of porrigo favosa and porrigo capillae crustata, 
affections which he separates, J but which appear to me simply favus 
in different degrees of severity. His treatment is to have the hair cut 
short but not shaved ; the crusts are then to be softened with very 
hot water, washed with tepid water and yolk of ^%g, and dried. 
After this the places are well anointed with an ointment of iodide 
of sulphur or bisulphuret or mercury and creosote. Iodide of potas- 
sium is given internally with infusion of quassia. 

Dr. Neligan says § he has never failed in curing favus permanently 
by the following plan : — He gives a tenth of a grain of iodide of 
arsenic made into a pill with manna and mucilage. A child ten 
years old may take one of these three times a day. When the patient 
is scrofulous cod-liver oil is also given, and if the arsenic disagree 
iodine is given instead with the oil. The hair is cut and a linseed 
poultice applied till the crusts are well softened ; the scalp is next 
washed with a strong carbonate of potass lotion, a drachm to a pint 

* Lancet^ i860, vol. i. p. 559. 

t Medical Times y vol. xiv. p. 235. 

X Ibid, 1857, vol. ii. 

§ A Practical Treatise on Diseases of the Skin^ 1852, p. 356. 



Bazifis Trcatmait of Fazms, 73 

of distilled water, and then slightly brushed ; it is afterwards covered 
with carbonate of potass ointment, a drachm of the salt and the 
same quantity of glycerine to an ounce of lard ; the head is then 
covered with a close-fitting oiled-silk cap. This process generally 
removes the crusts in two or three days, and the carbonate of potass 
ointment is then exchanged for the iodide of lead ointment, half a 
drachm of the iodide to an ounce of lard ; the head being alwa}'s 
covered with the oiled-silk cap, and well washed with the carbo- 
nate of potass lotion every time the ointment is reapplied. The 
patient is kept upon a mild and farinaceous diet, and the bowels 
are regulated by means of small doses of mercurials and saline 
cathartics. 

M. Bazin's special treatment of favus is to crop the hair down to 
the crusts, to paint with the oleum juniperi pyroligneum, and then 
to apply a starch poultice to soften the crusts. \Vhen this is 
eflfected, they are gently lifted with a comb and the juniper-oil is 
applied as before. After this depilation is begun with. 

When the body is the seat of the eruption and the latter is 
extensive, baths containing sulphur or the bichloride of mercury will 
be necessary : the patient should repeat these several times. After 
the bath the crusts are to be removed and depilation is to be begun. 
This process may last fifteen to twenty days ; during this time the 
subsulphate of mercury ointment may be rubbed in night and 
morning. In favus of the nail, the horny portion of the nail is 
scraped till the fungus is laid bare and the part is well soaked with 
the bichloride of mercury lotion. 

After the extraction of the hairs, the redness of the diseased skin 
gradually diminishes for about a month ; then possibly the hyper- 
aemia reappears, a few pustules are seen and favus cups begin 
again to develop themselves, but smaller and more scattered than 
at first. Depilation is now repeated in the same manner and to 
the same extent as before. The patient is then left for another 
period of five or six weeks ; if any favus crusts show themselves they 
must be removed and depilation be recommenced. Generally after 
this has been done a third time the disease is effectually cured. 

Dr. Bennett, of Edinburgh, treats favus with local applications of 
cod-liver oil, but Dr. Stewart, his assistant, told Dr. McCall Ander- 
son* that this treatment proved only palliative. Sir William Jennert 

• Medical Times, i86i. f Ibid, 1857, vol. iL 



74 Treatment of Favus, 

gets the crusts off with a piece of lint soaked in a solution of sul- 
phurous acid, and then applies sulphurous acid to destroy the para- 
site. M. Huet * seems to have had great success in the treatment 
of tinea favosa — which, I presume, includes favus, if, indeed, the 
term be not restricted to it — with the use of carbonate of copper, 
two drachms and a half of the salt to fifteen ounces of lard. 

Here, then, we find that, while several surgeons cure favus by 
totally opposite modes of treatment, it is considered incurable at a 
hospital where, perhaps, more cases are seen than at any institution 
in the British empire. All this disparity only confirms the views I 
have often expressed ; that, if we are to make any real progress in 
treatment, a series of special observations as to the comparative value of 
every remedy should be made, and that this can only be done, with any- 
thing like an approach to accuracy^ in an institution entirely devoted to 
such purposes. The special departments in general hospitals about 
which some persons write in the journals, as if they had been directly 
qualified by the Deity to decide on every point connected with 
medicine, have proved, and will prove, perfectly useless in this 
respect. 

• Bnllelin Geniral de Tkirapeuttque, 1861. 



( 75 ) 



CHAPTER IV.— ECZEMATA. 

A. Eczema (B. Ulcer, Ulcus^ -eris, neut, cXicoc, is included in this 

group). 

A. Eczema (neut.), from cVfcw, to boil over. 

Definition, — An eruption of red, low, flattened, usually very small 
papules, often assuming the form of a general congestion as in 
pityriasis rubra, or limited congestion as in tinea circinata ; the 
papules sometimes few and scattered, at others numerous and con- 
fluent, followed by death and shedding of the cuticle, infiltration of 
the cutis, discharge of serum, sometimes puriform, and formation of 
cnists. In some rare cases vesicles, ill-formed bullae or pustules, 
may complicate or take the place of the papules. Accompanied 
by great itching. Health generally somewhat disturbed. 

Pathology. — Up to a very recent period eczema was classed, with 
scarcely a dissenting voice, among the vesicular diseases.* When 

* ** It is characterized in its commencement by an eruption of very minute 
vesicles" (Rayer, Diseases of the Skin, 1835, p. 282). "It is characterized by an 
eruption of numerous minute transparent vesicles " (Neligan, Diseases of the Skin, 
^^53» P- 70)' "An eruption of minute vesicles" (Copland, Dictionary of Prac- 
tical Medicine, \o\. i. p. 547). **An eruption of minute acuminated vesicles" 
(Good, Sttidy of Medicine, vol. v. p. 629). "An eruption of small vesicles" 
(Burgess, Manual of Disorders of the Skin, 1854, p. 96). " Caracteris^ par des 
vesicules ordinairement petites" (Cazenave et Schedel, Abrigi pratique, 1838, 
p. 90). " Une inflammation de la peau caracteris^e par une eruption de vesicules 
ordinairement aplaties" (Cazenave, Le(^ons stir les Maladies de la Peau, 1856). 
"Les vesicules sont la lesion elementaire habituelle de I'eczema " (Hardy, Lemons 
stir les Maladies de la Peau, p. 3). " Caracterise par le developpement d'une 
eruption de vesicules" (Bazin, Lemons thioriques etcliniques, i860). 



76 Vesicular Nature of Eczema questioned. 

in a paper read some years ago at the Medico-Chirurgical Society I 
opposed this view, not a single writer, so far as I could then learn, 
with the exception of M. Devergie and Mr. Erasmus Wilson, had 
ever expressed a doubt as to the propriety of this arrangement, and 
even these two authors had not gone so far as to abandon the old 
classification. M. Devergie at that time seemed to be struggling 
against the conviction forced upon him by his own observations. 
Ii> 1857, after saying* that "if eczema be a vesicular disease by 
virtue of its morbid element, the development of the vesicles is only 
momentary, and appears, at the commencement of the affection, to 
disappear in a few hours ;" he in other respects left the classification 
where he found it. What M. Devergie really meant by eczema 
being " vesicular by virtue of its morbid element^^ I am quite at a loss 
to comprehend ; but as the fleeting nature of the vesicles is so fully 
acknowledged, we need scarcely be surprised to find him stating 
directly after, that it is very rarely the physician can see them [the 
vesicles], and that their covering is so thin that they can only be 
made out by tlie reflection of sunlight I a very difficult kind of 
vesicle, I should say, for any one to find. Yet a little further 
on, apparently mistrusting his own words, we find M. Devergie 
describing eczema as a punctiform, reddened state of the skin 
discharging serum very abundantly. He was evidently afraid to 
rely on the evidence of his own observations, which would soon 
have shown him that eczema, in the majority of cases at least, 
is not a vesicular disease at all, Mr. Hunt, too, at the very time 
he was classifying eczema as a vesicular disease, got very near the 
true facts of the matter, in one instance at any rate. He says,t 
in speaking of the symptoms of a case of eczema, " the vesicular 
character was not distinctly seen, the original eruption presenting rather 
t/ie character of papulce containing no visible fluids 

In the discussion which followed the reading of the paper alluded 
to, the view I had taken up, namely that eczema is really not a 
vesicular disease, was opposed very decidedly, and I need scarcely 
say that it would be opposed now by some'writers. Wilson, Hebra, 
M*Call Anderson, and others, however, now distinctly admit what I 
then contended for, nai7iely, that the elementary lesion of eczema is not 
fiecessarily a vesicle ; but, on the other hand, they go farther and 

* Maladies de la Peau. 
t A Guide to the Treatment of Diseases of the Skin^ 1857, p. 138. 



HebrcCs Claim to tfie Discovery. 77 

assert that it may be an erythema, a vesicle, a papule, or a pustule — 
a view which will beyond all doubt be ultimately adopted, and 
which is even now spreading pretty quickly, but which to my 
thinking requires considerable modification. 

This change of opinion seems, so far as I can make out, to 
be very generally attributed to the great influence exerted by 
Hebra. Not long ago, in a paper by Dr. Hugenberger, published 
in the St Peiersburger Medizin, Wochenschrift^ of which a condensed 
translation was given in the Journal of Cutaneous Medicine* the 
question was treated as if Hebra were the only person who had ever 
touched upon the subject. Till lately I believed that Hebra only 
published his views on the subject in December, 1862, in the Wiener 
Medizin. Wochenschrift ; whereas the paper I speak of, in which eczema 
was defined as an inflammation of the skin, followed by death of and 
throwing off of the cuticle, and discharge of serum, and in which I 
expressly denied its vesicular nature, and described pityriasis and 
tinea circinata as capable of passing into decided eczema, was read 
before the Medico -Chirurgical Society in i860 and 1861, and a 
translation of it appeared as early as May, 186 1, or nearly a year 
and a half prior to what I thought was the appearance of HebrcHs 
first communication on the subject, in the very journal in which Hebra 
made known his own views. I spoke under correction, and said 
that M. Hebra might have anticipated me, and that I could only 
judge from dates I had been able to obtain access to. 

I now learn that Hebra's views were published prior to this, or in 
1859, in the Wietier Allgemeine Medizin, Zeitung, and that they had 
been mentioned in his lectures in 1856. Dr. Foster Swift, Professor 
of Dermatology in the Medical College of Bellevue Hospital, having, 
in a very able paper on the pathology of eczema, t noticed the dates 
mentioned in the above paragraph, the statement was attacked in a 
very intemperate letter by a Dr. White,} who attributed the idea of 
preferring such a " claim " to " English conceit," and the desire so 
persistently manifested by English authors to appropriate the dis- 
coveries of other nations and reproduce them as their own ! ! This 
statement, however, found no echo in the journal. On the con- 
trary, the editor pointed out very forcibly the impropriety of bringing 

* Vol. ii. p. 204. 

t The American Journal of Syphilogtaphy and Dermatology^ edited by Dr. 
Henry, 1870, vol. i. p. 94. 
X Ibid. p. 282. 



78 HebrcCs Claim to the Discovery, 

such sweeping charges against a body of gentlemen, and stated quite 
plainly his opinion that Dr. White's scientific status did not for a 
moment justify his taking up such a position or speaking with so 
much authority. Dr. White, in a letter which the editor evidently 
inserted with great reluctance, replied* that he could not believe Dr. 
Milton was ignorant of a fact familiar to others, and that he " pre- 
ferred to refer this somewhat oblique view of dates to that well-known 
national trait which has so often prompted his countrymen to assign to 
themselves the most important share in modem scientific discoveries^^ &c. 
The only comment the editor deigned to make was, that he pub- 
lished the letter at the special request of Dr. White, and that if any 
additional evidence were required to prove the correctness of the 
strictures passed on his first letter, it would be " certainly furnished 
in the above communication.*' 

However, if Dr. White's attack upon English dermatologists in 
general, and upon myself in particular, met with no sympathy at the 
hands of Dr. Henry, it was received in another quarter with an 
amount of approbation which must have gone far to console him for 
the snubbing he got at home. The editor of the Archiv fiir Der- 
matologie und Syphilis says f he took no notice at the time it was 
mooted in the American journal of such a claim, evincing, as it did, 
the grossest ignorance (grobsten Unkenntniss) of literature, because 
he felt sure that the > journal would soon find out the piistake it had 
made. The editor winds up by saying that he has been too indul- 
gent in the matter, and that Dr. White's strong expressions were only 
called forth by a feeling of honest indignation (gerechte Entriistung) 
at Dr. Swift's strange attempt ! 

I am afraid the editor of the Archiv does not understand 
English, otherwise he would not, if he had consulted the original 
papers, have committed such blunders. Dr. Swift never undertakes 
to support my claim. He simply quotes from my paper in the 
Journal of Cutaneous Medicine^X Whatever blame, therefore, is to be 
attached to the statement he must clearly be exonerated. Again, 
if the editor had read the paper from which Dr. Swift quotes, 
he would have seen that I said there what I say above ; namely, 
that I spoke under correction, and could only judge from documents 
I had access to ; that Hebra might have anticipated me, but that I 

• The American Journal of Syphilography and Dermatology, vol. i. p. 385. 
t 1870, p. 659. X Vol. iii. p. 141. 



Possible Reasons for Belief m Vesicular Theory, 79 

had met with no account of his having published his views prior to 
1862. If it be gross ignorance not to have been aware that Hebra 
made them known in 1859, that is to say, in other words, not 
to have read the Wiener All^emeine Medizin, Zeitung for that year, 
then to that amount of gross ignorance I plead guilty. What is 
more, I fear the medical profession in England must be enveloped in 
the same charge; for I question if half a dozen men here were aware 
of the fact. I know that in i860 I had grown so tired endea- 
vouring to inoculate my friends with my views, and had met with so 
much opposition, that I resolved to bring the subject before the 
Medico-Chirurgical Society; but neither in the discussion there, 
nor in any subsequent discussion on the subject, did I ever hear 
it stated that these views had been anticipated by Hebra. There 
is another thing too that I fear, which is, that exclusive of Hebra' s 
own pupils^ the bulk of medical men, not only in England, but in otlier 
countries, and even in great part of Germany itself, were in the same 
state of " gross ignorancey 

However, though I feel perfectly justified in defending myself 
against any charge of unusual ignorance, or of having sought to 
appropriate the discovery of another writer, I take this opportunity 
of withdrawing, in the most unqualified way, all claim to priority of 
publication, which undoubtedly belongs to Hebra. 

It simply requires that surgeons should judge for themselves to 
be convinced that true eczema is not vesicular at any period of its 
course. It was not without considerable diffidence that I first 
hazarded this statement, standing, as I then thought I stood, quite 
alone in this view. Having sufiered from this complaint, I had on 
numerous occasions watched the development of the morbid process 
hour by hour from the very beginning, and had long ago satisfied 
myself that there was no real foundation for the opinion so very 
generally entertained. Being unwilling, however, to rely exclusively 
upon my own case, I examined a great many patients of all ages 
with a good lens and wrote down the observations as they were 
made, but I looked in vain for the vesicle of eczema. I found, it is 
true, vesicles enough, but none which passed into an eczematous surface. 
Again, on reading a paper in the Medico-Chirurgical Revieui in which 
eczema was mentioned, I repeated these observations with all the 
care I could, but with the same results. Some circumstances were, 
however, noticed, which probably contribute to support the view so 
generally taught. 



8o Possible Reasons for Belief in Vesicular Theory. 

1. The first is, that when the discharge comes from a part 
furnished with hair, as the leg for histance, minute accumulations 
of fluid form at the junction of the hair with the skin. These are 
possibly considered as vesicles — M. Devergie, for instance, seems 
to take this view ; — but on more close scrutiny it will be found that 
neither t/ieir course, situation, nor form corresponds with those of a 
true vesicle, and on touching one of them gently with a blunt-pointed 
glass rod, a minute drop of serum will be found adhering to it. I 
have always failed to detect the slightest trace of cuticle on these 
little drops of fluid ; certainly if there were any the pressure was 
much too slight to break it, whereas we know that the covering of 
vesicles will resist some force. When M. Devergie speaks of the 
fleeting nature of the vesicles of eczema, he overlooks the fact that 
genuine vesicles are not very fleeting even in such transient dis- 
orders as miliaria, and that those of herpes, with which eczema, 
if vesicular, must be classed, not only bear such distension as to 
become globular without bursting, but endure the friction of the 
clothes for days without rupture. Herpes may appear again and 
again without a single patch becoming eczematous ; eczema, so far 
as I have been able to observe, never becomes herpetic, nor have I 
ever seen an outbreak of vesicles on a patch of eczema. At times 
large patches of skin are seen covered with ill-developed vesicles, 
looking as if they would become eczematous. I have never observed 
them do so, but I do not impugn the accuracy of those who say 
they have ; they sometimes complicate or accompany genuine 
eczema, but if the latter complaint continue ever so long, or 
reappear ever so often, they do not make their appearance again. 
And these facts are, I submit, strong grounds for believing that there 
is a radical and unalterable differerue between eczema and herpes, the 
papule and vesicle, 

2. The second circumstance is, that in the vicinity of eczematous 
patches vesicles and even bullae are occasionally found ; the former 
not unfrequently appear about the knuckles or back of the hand. 
These vesicles, however, last but a very short time, and in most of 
the cases I have seen they did not return after being once removed ; 
in a few instances they did. No connection seemed to exist between 
the number of attacks of this kind of complication and of the out- 
breaks of eczema. One patient, who had had eczema continually 
breaking out for years, had never suffered from vesicles ; another, 
under the same circumstances, had had five or six attacks ; in 



Possible Reasons for Belief in Vesicular Theory. 8 1 

another case I was informed that each eruption of eczema had been 
complicated in this way, and so on. So far, however, as my own 
observation goes, I never saw it more than twice in the same patient. 
This eruption seems to be in no way dependent on the state of the 
eczema ; it will disappear when the latter complaint is stationary or 
getting worse. In all the cases I ever saw the vesicles were rare in 
proportion to the numbers and extent of the eczematous patches ; a 
patient might have thirty or forty of these and yet only one near 
which there were vesicles. These vesicles always healed quickly 
and did not become eczematous, nor was the disease in their im- 
mediate neighbourhood influenced either by their outbreak or their 
departure ; sometimes appearing afterwards in its usual form on the 
very spot where the vesicular eruption had been — a still stronger 
proof, it seems to me, than even any of the foregoing, that there is a 
wide distinction between the vesiculaf and eczematous inflammations, 

3. The third reason is that a disorder, which seems to me to be a 
form of herpes, has been confounded with acute eczema. It begins 
with heat, severe itching, and pungent, stinging pains. Vivid red 
patches form and serum is effused under the cuticle, which is raised 
up in firm irregular vesicles ; then the serum becomes of a whitish 
hue and grows turbid ; the vesicles break, the fluid oozes out, the 
cuticle is next thrown ofi", leaving the skin recj and tender, and the 
disease passes away, mostly, I believe, to return no more. In still 
more severe cases numbers of Uttle pustules form round about the 
vesicles, constituting really an impetiginous herpes. Now this com- 
plaint, seen when the cuticle has just given way and when the serum 
is pouring out freely, might be taken for eczema. But except that 
the vesicles run into a mass instead of reihaining separate, I see 
nothing that distinguishes it from herpes zoster ; it never tends to 
take on the one essential character of eczema, that of discharging 
serum for an indefinite period of time ; it disappears almost, if not 
quite, as fast when nothing is done as when it is actively treated ; 
the vesicles are firm, and only break when the fluid has become 
turbid and flaky. At the end of two months^ duration of the disease in 
a chronic form I have seen some of the vesicles still full of fluid ; how 
long they had lasted it was of course impossible to say, as I am 
speaking of the time the disease had endured when the .patient first 
came under my care, and the accounts given by patients or their 
friends of any particular vesicle, to which very probably their 
attention has never been previously directed, were not likely to be 



82 Herpetic Varieties of Eczema. 

very connected or reliable. Still there was every reason to believe 
that vesicles had existed for two months, and the very fact of their 
continuing to exist under any circumstances proves that the ten- 
dency to form vesicles predominates in these cases, and this we 
certainly do not find in eczema. 

On every ground of analogy as to anatomical and pathological 
features, course, and cause, eczema solare, eczema mercuriale, vesi- 
cular eruptions on the hands in bakers, confectioners, &c., and 
vesicular scabies ought, I think, to be referred to the variety spoken 
of in the last paragraph, and the whole group classed with herpes, 
of which they are only forms. They are simply instances of blis- 
tering induced by heat or some other irritant, and no more eczema 
than blistering with cantharides or boiling water would be.* There 
is, I may here remark, one form of solar eczema which might be 
mistaken for the genuine complaint. It is that affection in which 
a large portion of skin in an exposed part, as the back of the neck, 
is steadily invaded by a crop of vesicles which gradually turn flaky 
and yellow. It is very slow and will last a long time. I have seen 
cases in which it had not altered materially during two months. It 
is not always due to extreme heat. In children, during cold, dry 
east winds in spring, the vicinity of patches of eczema will some- 
times be invaded by vesicles in considerable numbers. For the 
most part these cases may be referred to the variety just spoken of. 
Eczema mercuriale I have never seen in the vesicular stage, but I 
think, from the description given, that it clearly belongs to this 
group, and that it is manifestly herpetic. The very course which it 
runs proves it to be different from pure eczema. It generally yields 
promptly if merely let alone or under any simple treatment, and 
shows rio tendency to come back again and again, which cannot be 
said of eczema. It is true this arrangement is quite antagonistic to 
all established views, and clashes with the pathology of Plumbe and 
Willan ; but the fact is that the eczema of Plumbe simply embraces 
the eczema solare and mercuriale ; he never alludes to the severe 

* ** I have no doubt that the minute vesicular form which the disease assumes, 
when occurring from exposure to the sun, is materially dependent on the degree 
of heat applied ; that a blister of the skin would occur if the heat were increased, 
while a minor degree of the latter would only be followed by erythematous red- 
ness; that it is therefore to be considered rather as an accidental injury, and 
treated on surgical principles in a manner similar to a slight burn or scald, than 
to be spoken of as a disease. " —Plumbe on Diseases oftheSkin^ 1829, p. 353. 



Acute Eczema not Vesicular, 83 

affection nowadays called eczema as being a form of that complaint ; 
possibly he was influenced by the old view which named our eczema 
scabies.* Any confusion, therefore, likely to ensue from the change 
I have proposed is due, not to a desire of introducing novelty on 
my part, but to the fact thai what we recognise as eczema is a very 
different disorder from that which was classed as such within quite 
a recent date. A new pathology has sprung up. 

The chronic form of eczema in the vast majority of cases begins 
as an eruption of papules ; in rarer instances as an erythema t or 
pit)aiasis. These may therefore for the present be laid aside, in 
order to examine acute eczema, which we might expect to find 
more closely connected, if any form of eczema can be connected, 
witli vesicular disease ; but the more narrowly we scrutinize it, 
the more certain does the conviction become that its course and 
symptoms ally it rather to an acute erythema, erysipelas, or kerion 
(scalled head). In this form of eczema a large portion of skin, as 
the forehead for instance, becomes red, swelled, glazed, and stiff. 
This is followed by desquamation of the cuticle and the formation 
of moist scales, or even crusts ; or there may be a slight though 
decided weeping. Now an observer, bent on finding out the truth, 
and not on merely supporting a theory, may see this over and over 
again in several persons, or several times in the same person, 
without ever finding a vesicle. I attended a gentleman for this 
complaint who was a good deal alarmed about it, as an intimate 
friend of his had been quite a martyr to eczema; for eighteen 
months the patient seldom passed any great length of time without 
an outbreak on the face, yet on no occasion could either he or 1 
detect a single vesicle. 

Pustular Origin of Eczema. — Mr. Erasmus Wilson and Dr. M*Call 
Anderson clearly assign the origin of eczema to a pustule, but I have 
never myself seen a true pustule pass into a surface secreting serum. 
To judge, too, from the way in which some writers speak of eczema 
impetiginodes, we must conclude that the pustule is only a stage in 
the process; that, in fact, the vesicle becomes developed into a 
pustule and this into a weeping surface, to be afterwards covered 
with crusts. If I am to decide from what I have been able to make 

* "The disease which the ancients described under the name of scabies is 
identical with that disease which at the present time we caireczema." — Dermal 
Pathology of Celsus. 

t (?) Purpura. 



84 Nature of Morbid Process in Eczema. 

out, no such process takes place, and two or three different stages of 
cutaneous affections have been confounded together. Eczema is 
here, at all events, not vesicular, and vesicles do not become 
pustular; the fluid in them may become turbid, flaky, and even 
contain a few pus cells. On the other hand, a genuine pustule 
never contains serum in its cavity ; the secretion is pustular from 
the time that it is a secretion at all.* Ragged, irregular vesicles, 
however, form alongside of patches of eczema as they will in other 
parts, grow turbid, flaky, and break. One or both of these symptoms 
then — that is to say, either pustules or irregular vesicles — may 
coexist with true eczema ; but in all the cases I have seen these 
were complications, not starting-points. 

Pustules, I need scarcely say, form in children on the head and 
face, and are followed by crusts which may be easily confounded 
with those of eczema;* but, unless I am mistaken, this is a much 
more manageable complaint, and ought, I think, to be referred to 
impetigo. At other times unhealthy bullae appear in children; these 
grow rapidly flaky, burst, and are also followed by crusts which bear 
a resemblance to those of eczema. But the course of these, too, is 
different ; and I think it would save confusion were all forms of this 
affection classed with herpes. 

Nature, of Morbid Process in Eczema, — The following appears to 
be the process which ensues in all cases of a truly eczematous 
nature. A portion of skin becomes red, inflamed and uneasy, stiff 
and itching, but rarely swollen except when the complaint attacks 
the ear. Some authors seem to think that itching is occasionally 
the first symptom, but I have every reason to believe that it is 
always preceded by a certain, if not very visible, amount of inflam- 
matory action. The cuticle rapidly dies, and is cast off or torn off 
by scratching. To this succeeds a discharge of serum, which seems 
to be poured out by the sudoriparous ducts, at which stage the 
disease may be considered fairly established. M. Rayer says " the 
follicles of the skin " are the parts essentially affected. Under this 
term he includes, I presume, the sebaceous ducts ; but unless my 
observations have misled me, there is no proof that they are actively 
concerned in secreting the serum poured out in such cases, although 
it seems difficult to understand how they can escape being involved 
to a certain extent. When the process is slower, the falling off of 

* Abrigi Pratique par MM, Cazcnave d Schedel^ p. 102. 



Nature of Morbid Process in Eczema. 85 

the epidermis is succeeded by a cuticle thicker and coarser in its 
texture, and gradually assuming the look of a soft scale. For the 
most part the redness starts from several points, or papulae, which 
are sometimes almost as pointed as those of lichen, sometimes not 
raised above the level of the skin. These may spread very slowly, 
or they may grow so rapidly as to coalesce within twelve hours. It 
often happens that a small spot will inflame and, without becoming 
either a pustule or a vesicle, will desquamate and secrete a crust 
which looks very like impetigo ; and if the patient be seen in this 
state it may be taken for that affection. But it is eczema ; and, 
though it may pass away and never be known as such, future obser- 
vation will verify what I state. This variety, too, may be compli- 
cated by pustules, and the combination of these two perhaps most 
frequently constitutes the affection called impetiginoid eczema, 
although the term really embraces every form of eczema complicated 
by pustules, and they may attend any severe case of eczema. 
Again, the serum, instead of being of its ordinary consistence, may 
be almost purulent in character, as constantly happens in persons of 
a pyogenetic tendency, and in weakly lymphatic women or children; 
sometimes even in healthy persons, as, for instance, when eczema 
is seated in the fold of the groin and the patient has had a good 
deal of walking. Now, although I have the greatest horror about 
inventing new names, yet as these two affections are so totally 
distinct, I would suggest, that if a name for each be thought essential, 
the latter of the two forms should be called pyogenetic eczema, and 
the former impetiginoid; the latter term, albeit so used, not being 
applicable to an affection in which there are no pustules. 

I have spoken above of pityriasis and erythema becoming starting- 
points for eczema. As long ago as 1853 I had quite satisfied myself 
of the former, as in my own case pityriasis of some two or three 
years* standing had become developed into eczema. Erythema in 
the form of intertrigo turns to a pyogenetic surface when seated 
between folds of skin, as in the groin, but I have not seen this 
pass through the intermediate stage of secretion of serum. In some 
cases erythema assumes a form which might be very easily mistaken 
for eczema. A portion of skin assumes a fiery-red colour, that is 
to say, becomes affected with a deep limited erythema. When seen 
at this stage and actively treated, it may pass away, and be con- 
sidered very justly as erythema. But again, in neglected cases, we 
find at a later period firm, brownish, yellow, adherent crusts, the 



86 Origin of Eczema from Pityriasis, &c. 

surface beneath which is tender and discharging very shghtly. It 
is at this epoch that the affection might so easily be mistaken for 
eczema, but certain rare cases, in which it is seen in a still more 
developed form, will betray its real nature. In these, when the 
crusts are removed, which is only done with some difficulty, 
ulceration is found to be going on beneath them ; sometimes super- 
ficial, sometimes so deep and painful, that the disease might be 
taken for impetigo rodens. I have repeatedly watched these cases, 
but I never saw either a proper pustule or vesicle precede the 
formation of the crust. The affection is not very common, and the 
cases I have seen were nearly all seated on the knee or calf of the 
leg. Suspecting syphilis might be at the bottom of the matter, I 
have always inquired very carefully after every symptom likely to 
betray such a history, but have never made any out. In purpura 
again the process is different. In pityriasis the whole or the central 
portion of a patch becomes moist ; generally from disturbance of 
the health, severe friction, as in scratching, the use of a hard hair- 
brush, or, lastly, from the employment of some irritating application, 
as tar-soap ; but in the few cases where I have seen purpura pass 
into eczema, it was a small outlying portion of a tolerably largp 
patch that discharged serum. All the instances I have observed 
were in elderly persons, and the seat of the disorder was in the leg. 

In some cases of old standing eczema the eruption, even at a 
very early period, particularly when seated on the backs of the hands 
and wrists, presents the appearance of numerous minute, detached, 
low elevations of thickened red skin, partly denuded of all covering 
and partly covered by discoloured but firmly-attached cuticle, and . 
sometimes indented so as to assume a cup-like form. Their appear- 
ance at this stage would scarcely show them to be eczema, but 
when torn or rubbed, and often in a short time spontaneously, their 
character is established by a discharge of serum, though this is 
seldom abundant ; indeed, I believe the appearances just spoken of 
indicate a declining state of the disease. 

In some few inveterate cases I have seen this indented, irregular 
state of the skin so strongly marked on the head and hands, that I 
have been tempted to ask myself whether favus is not a localized 
form of this affection in a bad ''constitution, especially as it is possible^ 
by keeping the crusts on a patch of eczema moist a considerable time, to 
induce a smell very like that which distinguishes favus, I do not 
allude to that rare form of the disease which begins with an eruption 



Divisions of Eczema. 87 

of pustules, and which I have never seen, but to favus as ordinarily 
met with. In all the instances where I have been able to trace the 
progress of the diseased action, it was, though much slower, 
essentially the same as in eczema ; that is to say, it really consisted 
of inflammation and redness of the skin and death and removal of 
the cuticle, followed by the formation of crusts. The reader will 
say that the presence of the parasite constitutes a distinction so 
strong that there can only be analogy, no community between 
the two, no passing of favus into eczema. But it is admitted 
that without a peculiar fitness of the soil the parasite cannot flourish 
at all; and there is something peculiar in favus. It is not a mere 
result of want, darkness, scrofula, dirt, or contagion, even if the 
latter be a factor (and its value is very doubtful), or of any 
conjunction of these causes, otherwise it would be common instead 
of [being extremely rare. Then there must be a variety of con- 
stitution — a variety which, peculiarly and alone, yields the proper 
soil for receiving and fertilizing the said parasite, and this variety 
may modify an eczema, 

MM. Cazenave and Schedel,* Bazin, and some other writers 
speak of a change in the vesicle quite as surprising as its being 
converted into a pustule, and one which I have been equally 
unable to detect. They tell us that in simple eczema the liquid of 
the vesicle is absorbed^ and that the vesicle fades and falls by an 
imperceptible desquamation. 

Divisions, — ^The reader will probably expect me to say something 
as to the number of forms into which eczema is to be subdivided, 
for it seems an established rule that an author can scarcely do 
justice to his subject without introducing some new varieties, ex- 
punging others, and re-christening and re-arranging those which 
he keeps. I have here a very simple answer ready. There are 
just as many varieties of eczema, as there are adjectives expressing 
a morbid state of the system, or a difference in severity in any one 
of the symptoms it exhibits, and all divisions and arrangements of 
them are equally useless. Like other diseases of the skin, eczema may 
soon be recognised under all its varying phases, but a knowledge 
of these cannot be taught in books, though it may be easily acquired 
by the same method as conduces to accuracy in other branches of 
research — the clinical study of disease. Beyond all question, there 

* Abrige Pratique^ p. 91. 



88 Divisions of Eczema. 

are vast and striking differences in the forms which eczema assumes. 
In one patient redness may predominate to such an extent that the 
denuded surface is darkly stained, and sometimes even discharges 
venous blood ; in another it may pour forth serum ; in a third be 
quite pale and coated with viscous or purulent fluid, particularly if 
it be seated between the folds of the neck or in the groin ; in a 
fourth covered with dry scurf; in a fifth there may be no discharge 
at all, but simply a cracked and stiffened surface, as we often 
see in eczema of the hands. There may be crusts of every 
thickness and hue which dirt and neglect can create. Inflam- 
mation may attack principally the interior of the sweat-ducts, 
it may assail the follicular plexuses, or show itself chiefly in the 
spaces between them. There may be little infiltration of the true 
skin, or it may extend even to the subcutaneous tissue; little or 
no pruritus or intense rabid itching. The disease may appear in 
any temperament and be complicated with many varieties of local 
or constitutional disorder. Yet amidst all these causes of obscurity 
it remains one and the same disorder, and therefore, though I can 
quite understand the value of each observer drawing up for himself 
a classification of its varieties, which may serve as a guide for 
diagnosis, I would expel everything in the shape of complicated 
nomenclature from books, and entirely eliminate all such terms 
as porrigo larvalis, porrigo Crustacea, tinea amientacea, asbestina, 
micacea, crusta lactea, &c. &c., regarding them merely as a display 
of so much valuable learning made to very little purpose, and 
indeed rather thrown away. 

I therefore leave the matter to others, and should be inclined to 
admit no divisions except the simple and convenient one of acute 
and chronic, with the addition of perhaps eczema impetiginodes. 
Papular and red eczema are simply different degrees of severity in 
the same affection ; eczema solare I would reject altogether, as I 
would any vesicular disease. I venture to suggest, too, that eczema 
should be entirely removed from the vesiculae, and either be made 
to form an order apart, or, for convenience-sake, be relegated to the 
order of papulae. I say for convenience-sake, because it evidently 
does not always begin as a papule, the starting-point being a form 
of inflammation of the skin closely allied to impetigo in some cases, 
to erythema in others, and to pityriasis in a third set of cases. But 
I would extend it so as to let it embrace some disorders which are 
at present otherwise classified. 



Ulcerative Eczema, 89 

And first, for reasons now to be mentioned, I think we might 
include under the head of eczema an exceedingly obstinate affection 
attacking the leg, and running into ulceration ; a complaint gene- 
rally seen in persons of middle age and advanced life. On as good 
grounds as have often been urged for giving a name, this variety 
might be called ulcerative eczema ; but as I have no wish to intro- 
duce any new terms, I shall confine myself to noticing it simply as 
a variety of eczema, the variation being, I think, due solely to its 
attacking a part peculiarly liable to ulcerate. 

It is attended by all the signs of an acute but local attack of 
eczema, and perhaps in no part of the frame is this malady more 
distressing than when it fixes on the lower part of the leg; the 
pain, heat, and itching tormenting the patient almost incessantly, 
especially at night. In very severe cases one or more spots will 
rapidly pass into ulceration ; indeed, this seems the natural ter- 
mination of the attack, and there is often some mitigation of the 
symptoms when it has ensued. This ulceration is very refiractory, 
often requiring months to cure even under the most careful 
treatment. It is peculiarly this stage which seems to stand so far 
apart from eczema, owing to the fact that a large proportion of 
patients suffering under the complaint are never seen by the surgeon 
till it has reached this epoch. I have, however, repeatedly traced 
it from eczema. In other cases the orifices of the sudoriparous 
and probably of the sebaceous ducts become so large that they 
can be easily seen. Eczema in this part, unless effectually cured, 
is very apt to return, the attack being heralded in as before by pain, 
itching, and redness, sometimes of a purple hue, and extending over 
a large part of the leg. 

It does not in any way follow from all this that ulceration of the 
leg or ancle is always due to eczema ; many ulcers are firee from 
any complication of this kind, the skin around being never more 
than merely red and tender, while eczema may run its course 
without being attended by ulcer; but assuredly out of a given 
number of cases of ulcer complicated by eczema, a certain pro- 
portion begin with the latter complaint; how many I am not 
prepared to say, but judging from the entries in the case-book 
at St. John's, the numbers are pretty evenly balanced. Perhaps, 
as a rule, it will be found that when the ulcer is seated about 
either malleolus it is the first in order, and when higher up the 
leg, especially if it be superficial, that eczema or erysipelas was 

N 



90 Sebaceous Ichthyosis a form of Eczema. 

the first to appear ; but I do not bring this forward in any way as 
an established fact. 

Occasionally a patch of old superficially ulcerated eczema is seen 
on the ancle, covered with a crust almost like dried gruel in colour 
and appearance, or even like nail or horn. The crust is naturally 
quite insensible, and not always calculated to reveal the nature of 
the affection, but if it be removed by macerating it for some time 
in solution of carbonate of soda and covering it with oiled silk, the 
skin beneath is found to be affected with the ulcerative form of 
eczema just described, being red or purplish, painful, and superficially 
ulcerated. These patients are generally in an infirm state of health, 
most of those I have seen having suffered from bronchitis. The process 
here is very closely allied to the obstinate purplish discoloration of 
the lower part of the leg, caused in many cases by eczema. 

In the forty-sixth volume of the Transactions of the Medico- 
Chirurgical Society, Dr. Ogle describes two cases of what is called 
spurious or sebaceous ichthyosis. The patients were two girls, 
sisters, and the symptoms consisted of a slow formation of hard 
crusts, much like what I have described, seated on the lower part of 
the leg and foot ; when these were removed the skin beneath was 
found to be red, glazed, and disposed to crack. Under the 
miscroscope the scales seemed to consist of layers of epithelium, 
with some round and reddish-coloured, solid-looking bodies, along 
with numbers of old and evidently worn-out epithelial cells. Now, 
I think, were this affection removed from ichthyosis and added to 
eczema or favus, it would be a step in the right direction. It is not 
ichthyosis and has nothing in common with it, while it has a very- 
great deal in common with eczema. The skin beneath the crusts is 
found in the same state as when those of old standing eczema are 
removed, and the crusts seem to form in the same way ; that is to 
say, a small patch of skin slowly inflames, the cuticle dies, and is 
thrown off, -and a crust is gradually formed. In one case which I 
examined with great care this seemed to me clearly the process 
which took place. The pathognomonic sign, therefore, is due here 
to accumulation of serum, &c. ; in ichthyosis it is the cuticle itself 
which is altered and hypertrophied, but still attached, or only thrown 
off when a new cuticle is formed. I have only seen one instance of 
this affection in 16,000 cases of cutaneous disease. The patient was 
a young girl and the disease was seated on the legs, there being 
some scores of these spots on each limb, giving them a most singular 



Eczema from Pityriasis and Tinea. 9 1 

appearance. It is true the secretion of eczema^ when microscopically 
examined, is different from what was seen in Dr. Ogle*s cases, con- 
sisting generally, when hardened into crusts, of laj-ers of albumen or 
l]rmph mixed with a few blood-^liscs or globules ; but this may have 
been due to the disease having, in the cases mentioned by Dr. Ogle, 
penetrated more deeply into the ducts of the sebaceous glands than 
eczema usually does. 

In the paper spoken of above I stated my reasons for believing that 
both pityriasis and tinea circinata occasionally form starting-points 
of eczema. Pityriasis rubra is indeed, so far as I have been able lo 
observe, an undeveloped eczema,* and, along \Wth that rare affection 
known as red general pityriasis, ought, I think, to be referred to 
eczema altogether. But tinea circinata \rill certainly also pass into 
eczema, though under what circumstances of health and constitution 
this transformation takes place I have been quite unable to deter- 
mine. Sometimes it is seen in healthy children, or again the very 
reverse may be met with. In the first instance of this which I ever 
observed, three children of the same family were placed under my 
care for impetigo, principally affecting the scalp. The eldest of 
these children, a boy, and the youngest, a girl, suffered only slightly ; 
the second, a boy, had it in a very severe form. A considerable 
time afterwards two children came to stay with this family for some 
little while. They were both suffering from tinea circinata. Whether 
as a coincidence or a result I know not, but the fact is certain that 
the other three children were very shortly also affected with ring- 
worm. The younger boy, who had suffered so severely from 
impetigo, displayed here a similar peculiarity, for one large patch 
became strictly eczematous, discharging serum very freely, while 
no symptom of the kind was seen in either of the others. Yet 
this boy was far the healthiest and strongest of the three. In 
another case, in which six young ladies, sisters, were affected with 
tinea, several of the patches in two of the patients turned to 
obstinate eczema ; yet there was no perceptible difference of consti- 
tution among these girls, nor have subsequent observations thrown 
any more light upon this point. 

The few cases of Burmese ringworm which I have seen appeared 
to me to be true eczema, beginning as tinea circinata, and developed 

• ** II est tr^s difficile, avons-nous dit, et meme impossible de reconnattre le 
pityriasis de I'ecz^ma arriv^ 4 une certaine p^riode de son developpcmcnt." — 
Hardy, Lfi^ons sur Us Maladies de la Peait, 



92 Burmese Ringworm. 

by friction into a discharging surface, the form called eczema mar- 
ginatum by some writers ; indeed, the disease has been described 
as such by Hebra, as also by Devergie but under another name. 
Kobner, however, looks upon it as a tinea due to the presence 
of the trycophyton tonsurans. But Mr. Nicholson, who has had 
ample opportunities of judging, describes* under this name a disease 
which is quite unknown to me, and appears to be a true vesicular 
disease marked by a tendency to ulcerate. He says it begins with a 
vesicle in each groin, which is scratched and broken. From this 
point it spreads by an advancing line of vesicles, which are followed 
by a free discharge of serum from the affected surface. Small 
irritable ulcers and patches of ringworm break out on the legs, 
armpits, and neck. Those on the legs sometimes degenerate into 
ulcers. The complaint in men invariably appears in the groins ; in 
women it may show itself in any part. Mr. Nicholson, who has 
tried tincture of iodine, nitrate of silver, nitric oxide of mercury, 
and many other remedies, has found none so successful as the 
nitrate of mercury ointment. 

I know nothing of the complaint in this form. I never saw any 
vesicles, and as Mr. Nicholson, who has himself suffered from the 
complaint, speaks positively as to their existence, as also to the 
existence of ulcers about the nates, I can only assume that the 
affection he describes is distinct from anything seen in this country, 
and is an ulcerative form or herpes. 

Mr. Erasmus Wilson recognises six essential varieties of eczema : 
— I. the erythematous; 2. the papular; 3. the vesicular ; 4. the 
ichorous ; 5. the pustular ; 6. the squamous. The arrangement 
seems to be essentially faulty. The erythematous is either very 
rare, or simply a variety of the papular form; the diffused red- 
ness arising from the coalescence of a mass of papulae is only a 
degree of the other, and is a different state altogether from 
genuine erythema. True eczema is not vesicular; the vesicle, as 
I hope to show, is an accident, a complication, as is the pustule, 
while the squamous and ichorous forms depend for their existence 
on the conditions incident to the mature state, not the origin, of 
the complaint, and, as such, should have been separated at the 
very outset from the others; unless under squamous Mr. Wilson 
comprehends those cases in which a dry, scaly state precedes or 

• On Burmese Ringworm^ by Edward Nicholson, Assistant Surgeon, Royal 
Artillery, Journal of Cutaneous Medicine, vol. i. p. 377. 



Hebrews Divisions of Eczema, 93 

even takes the place of the watery stage, as for instance, in eczema 
siccum of the hands, feet, and ankles. 

Hebra* divides eczema into five kinds : — i. eczema squamosum, 
or pityriasis nigra ; a complaint so rare in this country that I have 
not seen an instance of it in more than sixteen thousand cases of 
skin disease ; it is seen in children bom in India and brought to this 
country ;t 2. eczema papulosum, or lichen eczematodes ; 3. eczema 
vesiculosum or solare ; 4. eczema rubrum or madidans ; 5. eczema 
impetiginosum, or impetiginoid eczema. This classification is very 
similar to that adopted by Dr. M*Call Anderson.f Hebra does not 
view eczema as a vesicular disease, but classes it with prurigo. He 
does not, however, entirely reject the vesicular form ; on the con- 
trary, he not only admits eczema solare, but says,§ " while in one 
case the eruption of vesicles forms the starting-point of the ecze- 
matous symptoms, in another case we first of all see red scaly spots." 
He even recognises it as a necessary lesion in one variety. He 
considers as kinds of eczema all morbid appearances on the general 
covering of the frame which are peculiar either to the development 
or the decline of eczema. 

I cannot say that this arrangement is to my thinking quite satis- 
factory. The form of eczema which Hebra considers essentially 
vesicular is simply a form of herpes and totally distinct from true 
eczema. He only allows forty-eight hours at the utmost for the 
existence of the vesicles of acute eczema, whereas the true vesicle 
runs longer. Eczema solare itself undoubtedly lasts beyond this 
tune. Hebra maintains that eczema is still the same complaint 
whether it appears under the form of papules or vesicles ; and thi# 
view he upholds on the ground that an artificial eczema — as, for 
instance, one produced by rubbing in croton oil — will appear in the 
fonn of papules, vesicles, &c., according to the part it is applied to. 
■But, with all possible deference, I submit that the reasoning is 
feulty, seeing that it is as certain as any fact can be, that the papular 
form of eczema will appear on the very places where we at times see 

* Handbuch der specullen Pathologie und TAera/w.^'Dntter Band. Dritte 
Lieferung. S. 337. 

+ A Practical Synopsis of Cutaneous Diseases. By Thomas Bateman. Fifth 
edition, 18 19, p. 50. 

t Medical Times, 1863, vol. i. p. 472. 

§ Handbuch der speciellen Pathologie und Tkerapie.—Dniter Band. Dritte 
Lieferung. S. 337. 



94 What is Eczema? 

undoubted eruptions of vesicles^ for I need scarcely state that both are 
occasionally found on nearly every part of the frame. It is therefore 
clear that there must be a fundamental^ essential difference between the 
process which brings forth the papule and that which generates the 
vesicle^ and that difference in the eruption is not due merely to difference 
of site. There is another point on which I must also differ from 
Hebra. He looks upon the infiltration of the skin and the itching 
as the disease^ a view in which he is backed up by Dr. M'Call 
Anderson, who seems to have almost literally adopted his tenets. I 
consider the essential feature of eczema, the test of its nature, to be 
a chronic weeping surface, which I have never yet seen called into 
being by an eruption of true vesicles or pustules. 

Hebra says that he looks upon all diseased conditions which 
occur in eczema, whether in the advancing or declining state of that 
disorder, as varieties of that disease, I really cannot see on what 
grounds this proposal is to be considered tenable. I imagine that 
if a pathologist had made such an innovation with respect to better 
known diseases, e.g., if he had suggested that the diseased con- 
ditions which arose in pneumonia in the stage of congestion, 
solidification, resolution, &c., should rank as so many varieties of 
pneumonia, he would have met with some opposition to his 
views. 

What is Eczema ? We have, as yet, nearly everything to learn 
with respect to the nature of the complaint. We can put together 
some few scattered observations, and draw the fairest inference they 
admit of, and that is about all we can do. Up to the present time 
it has escaped the fate of so many disorders, for no parasite or 
fungus has as yet been discovered peculiar to it. Nor is it usually 
attributed to a blood poison, hereditary gout, tubercle, or inherited 
syphilis. We may therefore look upon it for the time being as a 
waif and stray, the pathology of which may thus stand some chance 
of being cleared up by a diligent observation of facts. 

I have long striven to show that the essence of disorder is 
excessive action of some part of a function, and I venture to class 
eczema thus. I have also in different papers endeavoured to combat 
the idea of scrofula, rheumatism, &c., having anything to do with 
the duration of severity of diseases. I am glad to find that Hebra 
has long been an active supporter of a similar view ; morbid inner- 
vation (krankhafte Innervation) is, according to him, the great agent 
in the generation of eczema, and we require no such machinery as 



What is Eczema? 95 

that which starts from a peccant matter in the blood.* Scrofula 
does not modify it for better or worse ; a scrofulous person throws 
oflf eczema like any other patient. Just as little faith has he in the 
belief that mental disturbances influence the outbreak of eczema. 

Eczema, though very often quite independent of any visible 
disorder of the health, is certainly to some extent due to impaired 
nutrition, because patients suffering from it improve under the 
use of red wines, cod-liver oil, fat meat, and medicines, which, 
judiciously given, increase the appetite and augment the weight, 
as tonics and purgatives undoubtedly do at times. It is, too, 
dependent to some extent on the state of the nervous system, for 
it is incontestable that great anxiety will bring it out in persons 
disposed to it. Cold dry winds, and great heat, especially if com- 
bined with much exposure to light, will both develop it. Contra- 
dictory as this may seem, it is not more so than the fact that 
excessive heat and cold will both bring on blistering of the skin. 
Chilblain is, when not an erythema, as essentially a low form of bulla 
as that produced by boiling water, and the irritant action of light 
is not more mysterious here than in small-pox. Eczema does not 
appear to have any essential connection with other diseases often 
seen in persons suffering from it. It is often met with accompanied 
by other diseases of the skin, such as lichen, scabies, pityriasis, tinea, 
lepra, lupus, boils, and impetigo ; and it may be seen combined 
with asthma, bronchitis, haemorrhoids, scrofula, gout, rheumatism, 
neuralgia, and dyspepsia ; but none of these or any combination of 
them exert the slightest influence on its course. It is met with in 
persons who perspire profusely, and again when the skin is ex- 
tremely dry. With the exception of the local forms, I have not 
been able to make out that it depends in any way on the nature of 
the patient's occupation. It is met with in half-starved persons, 
and in the overfed. Dr. Smith, of the Sheffield Public Hospital, 
considers that in eczema there is probably deficient renal secretion, 
in consequence of which urea and other waste products accumulate. 
In proof of this he adduces the facts : — i. That the urine of inve- 
terate eczema contains indican in pathological quantities. Indican 
is a very complex product, easily resolved into leucine, indigo, 
glucine, &c., and its presence is supposed to prove that the natural 
transition from the more complex to the more simple of the products 

• Handbuch der speciellen Pathologies &c., 3r B. 3e L. S. 386, 387. 



96 What is Eczema ? — Causes of Eczema, 

of secretion and function is going on more slowly than natural. 
2. That observation shows there is a very deficient secretion of urea 
and the chlorides in persons suffering from eczema. In three 
cases of the urine of persons suffering under eczema, it showed 
in one case 22 grammes of urea in 1,200 cc. of urine; in another, 
15 grammes in r,ooo cc. ; and in a third, 22 grammes of urea in 
1,200 cc. The serum of the blood of one of these patients yielded 
urea in considerable quantity. The urine in inveterate eczema. 
Dr. Smith says, is what may be called a constant quantity. It is 
either colourless or a rich cider colour, with a specific gravity about 
1*017 to I '022. It is acid, and remains so for many days, with, in 
well-marked cases, a peculiar odour like that of cider. We have 
therefore little or nothing to warrant us in going further than saying 
that eczema is a disorder of the secreting surface and nervous 
structures of the derma, and that as disorder means exaggeration of 
some part of a function or functions, so we find here excessive 
secretions, formation of defective cuticle, and defective secretion 
with extremely heightened tactile sensation. 

In conclusion, I would venture to define eczema as a non-con- 
tagious inflammation of the papillae of the skin, attended with 
increased nervous sensation in those parts, augmented and abnormal 
action of the perspiratory ducts, the contents of which often exhibit 
pus globules and plastic lymph, and increased secretion of veiy 
imperfectly formed epidermis, standing nearer to erythema and 
pityriasis than to herpes or impetigo, though capable of being com- 
plicated by both ; divisible in its natural state into two great forms, 
the acute and chronic, between which it is not always easy to draw 
a clear and positive line of separation, instances, out of both 
divisions, of cure under the same form of treatment being numerous 
enough. • 

Causes, — These admit of a very simple division into (A) the pre- 
disposing cause, a tendency to the disease, or eczematous diathesis 
if the reader prefer the term, which goes for everything in the pro- 
duction of eczema and is in effect the cause ; and (B) the exciting, 
meaning by this term every influence that can disturb the health or 
irritate the skin. Thus care, grief, privation, friction, the bites of 
insects, baths, and so on, may all, simply or combined, bring out 
eczema in a person predisposed to it while they do not effect any 
such thing in a person free from this diathesis. It need scarcely 
be said then, that the list of predisposing causes is merely that 



Causes of Eczema. — Anatomical Seat. 97 

of all injurious agents. It would, however, be overrating their 
influence to place them on anything like a par with the others. An 
eczema brought out by an irritating application, as for instance 
friction with croton oil, to the skin of a person not predisposed to it, 
will heal of itself or with the simplest remedy ; the same disorder 
breaking out sud sponte in a person of eczematous diathesis will 
resist all treatment for a long time. 

The only instances in which the exciting causes of eczema seem 
to me to rise to importance, are those in which, after a suspension 
of the noxious agency and consequent removal of the disease, a 
relapse is immediately induced by a return to the occupation which 
first of all brought it on. Thus women employed in the workshops 
of some of the large shipping clothiers, or in the Government store- 
rooms, making up uniforms, are very apt to suffer from a cracked, 
tender, peeled state of the skin of the hands, especially about the 
tips of the fingers ; playing on the harp will induce the same thing, 
and a very similar state is brought on in some persons by constantly 
handling acids, the pressure of tools against certain parts of the 
hands, &c. Grocers and bakers too suffer a good deal from 
eczema, not merely about the knuckles as is often supposed, but 
over the back of the hand and a considerable part of the radial 
surface of the arm. Now in scjme of these cases it might be worth 
the patient's while, not only to take particular precautions in the 
shape of local means, such as in respect to the use of pure soap, 
washing only with hot water, wearing gloves, Ac, but also to 
consider whether he would not gain by changing his employment. 

SecU. — According to Dr. Purdon,* the anatomical seat of eczema 
is the Malpighian layer, and when it is artificially inducted in animals, 
one of the first changes is rhythmical contraction of the vessels, fol- 
lowed by permanent stasis, the transparency of the part experimented 
upon being obscured, while there is increased serous infiltration 
and growth of cells. But I feel little hesitation in saying, that the 
structure of the corium is, in some cases at least, much more deeply 
affected, and that the morbid action may even reach to the sub- 
cutaneous cellular tissue. At the same time the superficial part of 
the derma + is the more usual seat. 

Eczema does not, except in very rare instances, permanently 
aflfect the derma, but there is one set of cases in which it does, and 

• Medical Mirror, April, 1870. f Or rete Malphigii. 

O 



98 Morbid Anatomy of Eczema. 

produces marks which I have seen endure so many years, that I am 
disposed to think them indelible. It is when the disease fixes on 
the comers of the mouth in unhealthy and delicate children. Long 
after I have seen the surface pale, furrowed, and bearing unmis- 
takable marks of erosion of the derma. 

Morbid AncUomy, — This is thus described by Biesiadeski.* He 
says that when papules and vesicles form in eczema, the papillae 
widen at their base and lengthen by infiltration with young cells 
and fluid blastema. From the cells in this latter (the blastema) the 
connective-tissue cells in the papillae are developed. Numerous 
spindle-shaped cells appear in the mucous or lower layer of the 
epidermis. These push upwards into the homy layer of the 
epidermis and separate its cells, forming a network which receives 
the swollen cells of the epidermis. A papule is thus formed. But 
if the growth of spindle-shaped cells take place principally within 
the papillae, then the young cells of the mucous layer become 
distended with fluid, burst, and form an eczematous vesicle. The 
spindle-shaped cells serve as channels for the passage of the semm, 
which accumulates to such an extent that the vesicle bursts. This 
fluid does not differ from ordinary serum. In chronic eczema this 
engorgement goes on till the papillae become so prominent as to be 
visible to the naked eye. This development of cells of both kinds 
is preceded by hyperaemia, and, it would appear, stasis in the 
capillary loops of the papillae. In this haemic change we may re- 
cognize three stages, i. Active hyperaemia, particularly noticeable 
when there is a punctate reddened state of the skin, disappearing 
under pressure and returning so soon as the pressure is removed. 
Such congestion as this may arise from a burn, scald, from internal 
irritation, as gout or rheumatism, or from the manifestation of a 
constitutional diathesis. 2. This state is rapidly followed by 
formation of minute evanescent vesicles, principally near orifices 
of sudoriparous glands : it may terminate by resolution, or it may be 
protracted, when the capillary vessels lose their power of contraction, 
so that the current in them becomes sluggish and fluid is poured out 
from them under the epithelium with different degrees of rapidity 
and extent, thus forming a vesicle, papule, pustule, or scale, as the 
case may be. 3. In the third stage there is, in addition to this 

• See also an excellent memoir on the pathology of eczema by Dr. Foster 
Swift, American Journal of Syphilography and Dermatology y 1870, p. 93. 



Contagiousness of Eczema, 99 

stagnation, a mechanical impediment to the free return of blood 
from the derma. The liquor sanguinis, exuded from the over- 
charged capillaries, becomes organized into cells and fibres, or the 
spindle-shaped cells become developed in greater numbers and 
permeate the corium in every direction, which in consequence 
becomes inelastic, cracked, and doughy, constituting serous in- 
filtration. 

Contagiousness of Eczema. — I presume that the question of whether 
eczema is contagious or not has been long ago settled in the negative 
among dermatologists, and that M. Biett was almost the last author 
of eminence who gave credence to such a phantasy ;* but, certainly, 
the belief in its contagious nature has not yet quite died out in the 
profession, and M. Bazin wants us to believe that it may be com- 
municated, not by any property inherent in the disease, but by the 
irrepressible parasite. Mr. Erasmus Wilson says that in such cases 
it is simply the fact of the discharge acting as an irritant that has 
given rise to such a view in these cases. Mr. Hunt also thinks the 
discharge acts as an irritantf All I can say is that I have never 
been able to meet with the cases themselves. I have made some 
scores of experiments, and have never met with a single fact that 
proved anything like transmission of real eczema from one person 
to another, nor have I been able to observe anything which showed 
that the serous discharge of eczema is an irritant. On the contrary, 
it proved quite innocuous in the trials I made with it Pieces of lint 
soaked in the serum were bound on the skin and kept there for 
twelve hours together without any effect being produced. Again, it 
was found that, however carefully the skin in the vicinity of an 
eczematous patch was defended from the action of the serum, the 
disorder still continued to spread, just the same as when the serum 
was allowed to come in contact with it. Long-continued contact of 
an eczematous siurface with a sound skin may bring on some irrita- 
tion, as any irritant would. I have not seen any cases in which I 
could satisfy myself that this process really ensued, but I can con- 
ceive it to be possible. The discharge from the eczematous eruption 
sometimes seen in persons bedridden from rheumatic gout is loaded 
with crystals of urate of soda, and this may be sufficiently irritating 

**"M. Biett," say Cazenave and Schedel, "a rapporte dans sa clinique 
plusieurs exemples d'ecz^ma qui s'etaient transmis par le coit." 

t ** They [the vesicles of eczema] pour out an irritating fluid which excoriates 
the surroundmg skin."— /r««/. Also Burgess's Manual, pp. 98 and 100. 



I oo Vaccination of Eczematous Patients, — Statistics, 

to set up a morbid action, as a very slight cause will bring out 
eczema in some persons strongly prone to it ; but the reader will see 
that all this is very diflferent from contagiousness as we understand 
the term. 

Should Children suffering from Eczema he Vaccinated ? — When the 
disease is extensive, I should say decidedly not. In a slighter degree, 
I see no objection to the performance of the operation, and have 
repeatedly sanctioned it without ever having had occasion to regret 
doing so. The vaccination takes perfectly well in such cases, and 
provided treatment be carefully pursued, the child scarcely ever 
suffers any relapse in the eczema. 

Statistics. — I have not meddled with the statistics of eczema, 
because I do not see that they throw light upon any point connected 
with either its pathology or treatment. Observations which would 
show the influence of certain trades and localities on the origin 
and severity of the disorder might yield something to deal with, 
but in their present form the accumulation of statistics seems to 
me simply a very harmless form of arithmetical amusement. Besides, 
it is impossible to make such calculations with exactness till men 
are a little more in unison as to the exact signification of the terms 
they use, and agree to accept one common standard of nomen- 
clature. 

I have heard it stated at a medical society that " in medicine 
you can prove anything you like with figures," and the statement 
passed without any dissent. I believe the first person who pro- 
pounded this caustic tenet was an eminent surgeon, still living ; at 
any rate it passed for his and in virtue of its distinguished birth was 
rather fashionable at one time. No doubt there is a great deal of 
truth in it. With figures, a man who contends only for victory can 
prove anything he likes to his own satisfcu:tion and that of persons who 
are very easily pleased or silenced. But he can really prove nothing with 
figures which is not true, and the fact that the former kind of proof was 
thai which was tacitly accepted as current with the profession speaks 
volumes as to the mode of reasoning adopted in medicine. Had a 
man maintained that in arithmetic you can prove anything you like 
with figures ; as, for instance, that the square root of nine or sixteen 
can be anything but three or four, it would have been considered 
sufficient to settle his pretensions to sanity, while in medicine 
such a statement would be thought rather clever, or, quite as bad, 
philosophical. The reader will therefore easily conclude Jthat it is 



Is Eczema Hereditary? loi 

not any scepticism of this kind which makes me underrate the value 
of statistics in eczema, but because I believe that they teach nothing 
which cannot be learned by simple observation. 

Is Eczema Hereditary^ as maintained by some Authors ? — Being well 
aware that I approach this part of the subject prejudiced against the 
view that any disease is hereditary in the meaning usually assigned 
to the word, I am naturally rather reluctant to say anything about it. 
However, as such a position is impracticable, I will endeavour to 
state, as simply and dispassionately as I can, my reasons for objecting 
to a doctrine which appears to me so untenable that I am quite at a 
loss to understand how it maintains its ground at all. When I find 
such names as Prichard and Holland ranged against me, I confess I am 
completely staggered, and disposed to admit that there must be some 
idiosyncrasy in my mind which prevents me firom seeing the matter 
in its true Hght. 

That a child inherits the tendency to eczema from its parents is 
true. It inherits this disposition with its life, and without its parents 
there would have been no life. That a child sprung from weakly 
parents, especially if bom and reared under unfavourable circum- 
stances, is more likely to have eczema than if descended from healthy 
persons is possible enough, and even probable. That eczema should 
spring up in some one, and, indeed, in almost every generation of 
persons so situated, is natural, inasmuch as it is a very common 
complaint, and in certain constitutions a natural result of all agencies 
which injure the health. But there is nothing in this, and, indeed, 
there is nothing in any statistics or arguments brought forward, which 
proves that a child has any more tendency to eczema because either 
one or both of the parents suffered from it. If there be any assump- 
tion justifiable here, I submit that it is, not that eczema begets 
eczema, but that weakly parents are apt to beget weakly children, 
and that weakly persons, whether parents or children, are more apt 
to suffer from eczema than strong persons are. 

I have spoken of statistics, but indeed they scarcely deserve the 
name, or indeed mention at all, were it not to show on how slender 
grounds some portions of this theory rest. Several children of one 
family are found suffering from eczema, or are known by the medical 
attendant to have laboured under the same complaint. By-and-by 
it is ascertained that the father or mother suffers from eczema, 
probably both. If the family be noble, so that there is a history 
of each generation, the presence of the disease is forthwith traced 



d 



I02 Is Eczema Hereditary? 

through three or four successive descents, and the theory is 
established to the satisfaction of all parties. 

But closer examination will reveal the weakness of the argument 
It is very seldom that the fact can be verified ' of eczema passing 
through even two generations. The statements of patients, on which 
reliance is often placed, should, I submit, go for nothing in such 
cases. But even were the fact attested, I do not see that it proves 
anything. It would be necessary to show not only that eczema occurs 
more frequently among the children of eczematous parents, but so much 
more frequently than it does even among the children of weakly parents^ 
though brought up under the same circumstances and exposed to the 
same deteriorating agencies, that we must admit eczema in the parent 
to be a factor of absolute value in the production of the same disease in 
the children. But this has not been done. On the contrary, all that 
can be said in favour of the doctrine of descent is, that a certain 
number of coincidences have been observed, against which it would 
be easy to set ofif at least quite as many cases where eczema exists 
in the children without either parent having been found to show a 
trace of it, and eczema in the parent while the children are free 
from it ; or, at any rate, if we admit Dr. McCall Anderson's con- 
clusion that scarcely any person escapes eczema, as free as the rest 
of mankind. Notwithstanding all this, it must, however, be admitted 
that the doctrine of such affections being hereditary will always be a 
favourite tenet, inasmuch as the mind of man naturally tends to 
grasp at familiar images. 

When Sir Henry Holland suggested,* as an explanation of the 
tendency of diseases to become hereditary, that it is simply an 
extension of the law discovered by Dr. Prichard, that all bodily 
pecuHarities tend to become hereditary, he overlooked one flaw in 
the argument. Either this tendency means nothing and is a mere 
figure of speech, or it means that all the children must inherit a 
bodily defect or disease, and each succeeding generation exhibit 
more and more of this particular development till disease or 
deformity becomes their normal state, or they all die out. In 
speaking of ichthyosis, I have endeavoured to show that this must 
end in a state of things never yet seen. Apply it then to eczema, 
which is such a common disease that it is quite certain two parents 
must often be eczematous ; the natural result of this would be 

• Medical Notes and Reflections, 1855, p. 16, &c. 



Is Eczema Hereditary ? — Diagnosis. 103 

eczematous families getting worse with each successive descent. I 
need scarcely say that such productions are not to be found, though 
we ought to be able to find them easily enough. Mr. Wilson says,* 
that eczema is transmitted to children because the tissues of children 
resemble those of their parents. But this is endeavouring to support 
an untenable assertion by another which requires to be proved^ for it has 
not yet been proved in any instance, and is palpably contradicted 
in a vast majority of cases. It is simply doubling the rope of sand 
— a process which may add to its bulk, but does not increase its 
strength. Children quite as often as not are a cross between the 
tissues and features of both parents. It must be a rare occurrence 
for a child so entirely to resemble one parent in either features or 
tissue as to exclude all likeness to the other. Whenever, then, a 
child inherited eczema from one parent only, as would be frequently 
the case, the disease would be a cross between eczema and health, or 
some other disease, and that is a thing yet to be discovered. Finally, 
the argument, that disease may be hereditary, because features pass 
through long lines of descent, is faulty, because the facts proving 
these cases of descent are, for the most part, simply random asser- 
tions, easily made, but from their very nature not easily refuted, and 
only too greedily caught at — very suitable material for the reveries 
of a dreamer like Oken or Darwin, but very unfit to be admitted 
into the rank of established facts. 

Diagnosis, — I should scarcely have thought eczema could be mis- 
taken for any other complaint, unless it were scabies, with which, 
indeed, it is often confounded. Its slowness, superficial nature, and 
the general absence of great constitutional disturbance, will separate 
it from erysipelas ; while the slower spread of the redness, and the pre- 
sence of itching at the commencement, distinguish it widely from ery- 
thema. It may attack several spots at the same time, which is not 
the case with these complaints. The eczema of infants is often mis- 
taken for infantile syphilis ; but in the former the little patients have 
not the look of premature old age, the snuffling hoarse cry, and the 
papules of syphilis. The eczema of grocers, &c., attacking the 
knuckles, is constantly mistaken for scabies, and no little care is 
often required to discriminate between them. The absence of the 
cuniculus, the history of the mode in which the complaint has arisen, 
and often the presence of fissured eczema on the palmar surface, an 

• Journal of Cutaneous Medicine^ vol. iii. p. lo6. 



A 



I04 Prognosis of Eczema. 

uncommon accompaniment of the other, ought to suffice to make 
the diagnosis clear. Eczema siccum on the palm of the hand is 
frequently confounded with syphilitic psoriasis palmaris (especially if 
the patient have a syphilitic history, although when duly investigated 
this ought to be an excellent guide) and lepra palmaris (psoriasis 
palmaris). It is exceedingly difficult to give any rules which shall 
serve as a certain guide. Lepra palmaris however is, I beheve, never 
seen unless there be lepra on other parts of the body, and the syphi- 
litic form is invariably preceded by other symptoms, and generally by 
a chancre, and no history of a bubo, or, at any rate, one that has not 
suppurated. Dr. Cheadle, speaking of these three affections, says,* 
" It may be stated generally, perhaps, that where the affection is 
limited to one hand or one foot, where the palms or soles are only 
partially affected by patches of eruption, where there is any great but 
very unequal thickening of the epidermis, which is exfoliated in thick 
plates, where the fissures are wide and deep, and the sensation of 
burning and aching extremely severe, independently of the history 
and collateral evidence, the eruption is a manifestation of tertiary 
syphilis. Where the palms or soles present one uniform sheet of 
thickened cuticle extending over the whole surface, furrowed by 
numerous fine cracks and desquamating in small scales but not 
peeling in plates, the eruption is a psoriasis or eczema depending 
upon some other cause, and generally excited by local irritation." I 
may observe here, with regard to the valuable . and suggestive hints 
contained in these remarks, that though many kinds of local irrita- 
tion undoubtedly possess the power of evoking eczema, it is very 
questionable whether such agencies ever yet called forth a patch of 
psoriasis (lepra). 

Prognosis, — ^This may, in a large majority of cases, be set down at 
once as favourable. When of great extent in delicate infants, eczema 
Tti^y prove fatal, especially if not carefully managed. Eczema of the 
leg, especially in elderly persons, is very obstinate. Red general 
pityriasis developed even partially into eczema is very serious in some 
cases, particularly'when the patient is old and infirm ; fortunately 
it is, comparatively speaking, a very rare disorder. There is 
an old woman who occasionally attends now at St John's Hos- 
pital, and who was cured of it quite four years ago, though it 
was difficult to imagine how any person could have it in a worse 

* Journal of Cutaneous Medicine, vol iii. p. 440. 



Danger {f) of Curing Eczema. 105 

form. In a more limited form, even when covering a considerable 
extent of surface, it may be removed. When the disease has existed 
through many years of early lif^, and is developed in an essentially 
feeble frame, and particularly when there is a pasty, putty-like look 
of the face, with superficial erosion of the derma about the comers 
of the mouth, eczema has in my experience proved very obstinate. 
Still as a rule I should say that the disease is essentially curable. 

At St John's Hospital it has been shown over and over again 
that eczema in every form and at every age can be thoroughly 
cured ; not, perhaps, in every case, but certainly with very rare 
exceptions, not amounting to above one in two or three thousand. 
And it is to be remembered that the observations on which this 
statement is based have been made in the presence of some scores 
of medical men, and that all possible publicity has been given to 
them. Eczema, indeed, is not so intractable as it has been repre- 
sented. If a steady and proper course of treatment be followed, 
without swerving to /right or left, it will almost invariably be 
successful ; but if the great guiding principles of treatment are 
every now and then to be abandoned for the sake of meeting some 
complication, or in deference to some theory, or out of dread of 
some imaginary danger, tjien good-bye to all chance of a cure. 

Is it ei'er dangerous to cure Eczema ? — Many authors recommend 
us not to do so too hastily in certain cases, especially in children, 
when the disease is seated on the head, and when of long standing 
in old persons, unless we open a compensating drain in some other 
part. Some even go so far as to denounce the closing of such an 
efficient outlet for the peccant humours, and startle us with the pre- 
cautions to be taken before we venture on such a step.* 

I should be sorry to speak with disrespect of any opinion held by 
men who rank among the leaders of professional opinion, but, in 

* M. Devergie says that in bad cases in children the duty of the physician is 
limited to mitigating the disease ; in curing it he might compromise the health and 
sometimes the life of a patient (p. 242) ; and that at a certain period of life eczema 
becomes a drain which must not be meddled with (p. 245). Mr. Wilson says, 
** When the eruption is of long standing, and there exists any reason for the belief 
that arrest of the secretion would be attended with injury to the health, counter- 
irritation should be established upon the trunk or limbs, or even on both ;" see 
also Rayer (pp. 288 and 385). ** No observant man can see much of skin disease 
without coming to the conclusion that the system of making cures of old-standing 
eruptions which prevails at the present day is fraught with danger. " — Tilbury 
Fox, p. 182. 

P 



i 



io6 Danger (?) of Curing Eczema. 

justice to myself, and in what seems only a fair defence of the 
doctrines I ventured to put forward years ago, I feel bound to 
maintain, not only that the doctrine is untenable, but that it ought 
never to have been put forward ; for it is not a question here of an 
apparently well-founded opinion being overthrown by some unexpected 
discovery^ but of a theory and practice inducing wide-spread misery 
which a very simple amount of observation would have averted. 

The more we examine the subject the more are we struck by the 
absence of all proof in favour of the theory itself. The experience 
of Rayer and Alibert has been vaguely alluded to, for a bugbear of 
this kind generally assumes a form which eludes our grasp the 
moment we attempt to grapple with it, but the cases are few and 
irrelevant. Rayer mentions a case given by Alibert in which 
insanity followed, not the cure, but the disappearance, of the 
eruption, and cites an instance from his own practice where a 
long-standing eczema disappeared during an attack of inflammation 
of the pulmonary and gastric mucous membrane ! Dr. McCall 
Anderson also says that he was attending two children for very 
severe eczema covering the greater part of the surface, when one of 
them was seized with measles, the effect qf which was that in two or 
three days the eczema had almost disappeared. The eruption on 
the other child continued to flourish for aTew days longer, when she 
was likewise seized with measles, and ii^ her case too the eruption 
disappeared. But it is quite certain that this does not always occur, 
and that internal complaints do not even always stop eczema. I 
have seen a child suffering under thi| disease complicated with 
ill^matured pustules, go through meaples without any particular 
check being given to either eruption. M. Bazin relates a case, 
which I give in his own words, in order that the reader may decide 
for himself how far it sanctions the precept laid down by this writer, 
that when a complaint of this kind has pxisted a long time, it is only 
to be touched with extreme reserve. The case is thus told: — "A 
man was attacked with extensive (g^n^ralis^) eczema, of which he 
wanted to be quickly rid. An energetic treatment was employed 
against the affection, which disappeared in fifteen days. Gastric 
symptoms soon showed themselves, apd a few months after the 
patient died of a cancer in the stomach." 

Possibly other cases may exist. I have, however, not been able 
to meet with any, and the reader will see at a glance that these only 
show that eczema disappears with the development of any internal 



Danger (?) of Curing Eczema, 107 

complaint. / have not found a single case proving that the cure of 
eczema could bring on any internal affection. Yet this is the induction 
drawn from such cases as those I have given, and I need scarcely 
say that it is essentially vicious. To argue that because an internal 
illness causes an eruption to disappear, therefore curing an eruption 
can bring on an internal illness is, mutato nomine, the same thing 
as to say that as a blister on the chest will relieve bronchitis or 
pneumonia, so healing a surface blistered for some other affection, 
may bring on one of these complaints. If the opinion have any 
definite meaning it means this. In whatever amount of verbiage it 
may be shrouded, with whatever weight of authority and experience 
it may be given to the world, the theory, stripped of superfluous 
matter, reduces itself to the form in which I have put it. 

Did the evil go no further than argument it might not be worth 
while to assail it. The simplest and perhaps best plan would 
have been to leave it alone and trust to time for its gradual ex- 
tinction. But the process would be too slow and the interests 
involved too serious for this. Mr. Locke calculated that on an 
average it takes about a century to extirpate an error ; in medicine 
he might have perhaps allowed a rather longer period ; and when 
all the great aggregate of suffering that must result from putting 
such a doctrine in force, and refusing, from a dread of a perfectly 
chimerical danger, to cure a disgusting and distressing complaint, 
the case passes out of the region of mere abstract discussion. 

/ challenge those gentlemen who tell us that it is dangerous to arrest 
t/ie eczematous discharge to produce a single instance in support of their 
views. Surely there can be no difficulty in their doing so. If serious 
results had ever followed such a practice, the records of those who 
have studied skin diseases would long before this have yielded some 
few cases. In England alone, if we were to estimate the number of 
cases of eczema yearly at a million, we should, I suspect, be con- 
siderably under the mark ; yet where is there a single history which 
in the least proves the fear of checking eczema to have any founda- 
tion? Men are fond of quoting Hebra, and he has well earned 
the distinction, for honesty and genius stand revealed in every page 
he has written. His practice ought to furnish us with plenty of fatal 
results from the suppression of old-standing eczema, as he not only 
cures the complaint out of hand, but utterly scouts internal means 
in nearly all cases. Yet Hebra tells us that he never saw disorder 
of any kind arise from arrest of eczema ! He asserts, too, that all his 



io8 Danger (f) of Curing Eczema. 

experience never yielded him a single instance of ophthalmia, disorder of 
the digestion^ or any serious affection relieved by eczema I I will venture 
to go further and predict that such cases never will be found, for the 
simple reason that they never happen. 

Besides, it may really be stated, without in any way qualifying the 
assertion, that it is not possible to check eczema except by such 
means as improve the health and thus directly lessen the tendency 
to any disease. If by repelling the eruption be meant causing the 
discharge to cease suddenly by some astringent local application, I 
can only say that / am totally unacquainted with any agetU possessed 
of the power to produce such an effect. It must be immensely difficult, 
if not impossible, to effect such a purpose. I have in my own person 
made more attempts than I care to mention, in order to check the 
discharge of serum. I have used for this object solution of carbonate 
of soda, dilute sulphuric acid, strong solution of sulphate of zinc, 
nitric acid, chromic acid, nitrate of silver and nitrate of mercury, 
collodion, pressure, &c., but in no one instance did I succeed in 
procuring more than a short respite from the nuisance. Indeed, the 
influence of remedies in this respect seems to me only too limited. 
As to the power of medicines to effect such an extraordinary process 
as transplanting eczema from the skin and transmuting it into an 
affection of the brain, lungs, or bowels, I can only say that I should 
be glad to be made acquainted with the remedies themselves. Till 
then, I must take the liberty of saying that I consider such attributes 
purely imaginary. What effect an issue may have I know not, and 
the information given in books amounts to a vague direction to use 
one in long-continued discharge before closing this up. I should 
think nothing but harm could come from such a practice. At one 
time, in compliance with this time-honoured piece of humoralism, I 
used small blisters, and kept up a discharge from the surface by 
means of irritating ointments, but I never saw any result beyond 
distressing the patient. 

Further, it may be asserted that if a surgeon were so reckless as 
to try and remove eczema at the risk of setting up an internal affiec- 
tion of this kind, he would certainly fail ; for ordinary remedies and 
ordinary doses clearly produce no such effects, and extraordinary 
ones would be speedily followed by such fatality as would cause 
them to be discontinued. Besides, it is quite certain that the medi- 
cines which do most good in eczema, effiect this only when given in 
such a way and in such doses as to improve the health. Medicines 



Danger (f) of Curing Eczema, 109 

— such as purgatives, diuretics, mercury — are continually taken to 
such an extent as to set up considerable irritation in the stomach 
and bowels. I have noted down a good many cases where this had 
happened, but the excessive action set up was never attended by a 
corresponding amount of influence on the eczema. 

Perhaps the reader will say, as men certainly have said, " But 
there are cases where eczema acts as a safety-valve ; it is a salutary 
effort of nature, and ought not to be interfered with ; you don't 
follow these cases up, and, for anything you know, the most serious 
results may follow." 

To all this it may be replied that the discharge is not salutary, 
but morbid, and would appear so to any one whose judgment was 
pureed from the grossness of humoral theories. It always disappears 
so soon as the patient gets quite well; it never exists when a 
patient is really in perfect health. The more discharge there is, the 
lower and more exhausted does the patient feel. An outbreak of 
eczema does not in any way relieve a morbid discharge, nor does 
the establishment of a morbid discharge, by means of a blister, 
seton, &c., in any degree relieve the eczema.* 

For years past I have, in every instance, done my best to check 
the discharge of eczema as quickly as possible. During that period, 
about five thousand cases have passed under my notice, and, as 
I have never seen or heard of any injurious results, I can only 
conclude that treatment cannot produce such an effect as bringing 
on internal disorder by relieving eczema. Properly employed, treat- 
ment is either innocuous or beneficial, I can scarcely help thinking 
that, in such a large number of instances, if injurious results had 
been at all common, I must have heard something of them. On 
the other hand, it is quite certain that a number of patients cured of 
profuse discharge, often of years'-long duration, are at the present 
time not only well, but all the better for being freed from such 
a disgusting nuisance. I laid before, the Medico-Chirurgical Society 
the particulars of a case, where the discharge from an eczema, 
covering the leg from the calf to the sole of the foot, was so 
profuse, that the patient, an old man in shattered health, said 
that often, after a day's work, he returned home with his shoe 
half full of water. This state of things had gone on for three 

* Devergie justly says, the renewal of a suppressed discharge will not remove 
the eczema. — Maladies de la PeaUy p. 247. 



no Danger (?) of Curing Eczema. 

years, and yet the speedy removal of it, so far from bringing on 
any internal affection, was followed by a decided improvement in 
the patient's health. This old man was very well known in the 
part of the city where he resided, near I^ondon Bridge, and some 
years after was certainly quite as well as he had been previous 
to having the eczema. At the same time another instance was 
quoted, where a case of long-standing eczema of the ham was cured, 
and four years after the patient was in excellent health. This man, 
too, could have been easily identified, being a signalman on the 
Great Eastern Railway. I could easily add to the list, were I not 
afraid of making this chapter — already too long — still longer. 

No doubt if a patient suffering under eczema be attacked by 
some malady assailing the surface of the skin and the internal 
organization at the same time, as one of the exanthemata, for 
instance, the eczema may be suspended, or perhaps removed, as 
would many other complaints, such as gonorrhoea ; but I presume 
it would scarcely be considered the proceeding of a rational being 
to leave a gonorrhoea to take its own course, lest the removal of 
it might cause the development of some internal malady. 

In all the cases I have seen where eczema was complicated by an 
internal disorder such as bronchitis, an exacerbation of this, so far 
from relieving the eczema, either had no effect or made it worse ; 
while in no case did the increased discharge, when the eczema was 
worse, in any way mitigate the internal affection. A poor weaver 
suffering from eczema of the leg came under my care. The disease 
of the skin was cured, and the patient remained well till an attack of 
bronchitis at the beginning of the ensuing winter prostrated him. In 
a very short time the eczema returned as bad as before, but without 
in the least relieving the bronchitis. A few years ago an old man 
came under my care for eczema of the leg. He was cured, and 
after an interval of quite four years, he again applied with the same 
complaint in both legs. I questioned him closely, and learned that 
he had fallen into bad health ; that then the eczema came on, and 
that the worse it grew the worse he became in other respects — a 
statement quite borne out by the results of treatment, for the 
eczema disappeared as he improved in health. A poor woman was 
recently in attendance at St. John's Hospital who had been four 
times the subject of a bad attack of bronchitis ; each time she was 
prostrated in this way, an old eczema of the ancle relapsed and 
passed into a state of ulceration. 



Danger (f) of Curing Eczema, 1 1 1 

1 could have added many more cases, but I now no longer note 
them down, as I have found no evidence on the other side of the 
question, and to heap together facts merely to swell the bulk of 
testimony, without adding to its real value, seems to me sheer waste 
of time. My experience is, that if tivo or three cases will not induce 
men to reopen a question^ Pivo or three hundred will not. I shall 
therefore content myself with adducing the evidence of M. Rayer, 
an observer who supports the view I have endeavoured to combat 
respecting the connection between the healing of an internal 
complaint and the cure of eczema. M. Rayer, then, says* that he 
treated a patient for gastro-enteritis who had already been pre- 
viously suffering from eczema, and that during all the time the gastro- 
intestinal inflammation lasted the eczema was worse. Again, he says,t 
of another patient, "the appetite fell off remarkably (a certain 
sign that the health was not so good as formerly), an occurrence 
which was followed by a notable exacerbation of the eczematous 
affection." 

I think, then, we may conclude that the fear of curing eczema, 
of however long standing it may be, and however delicate the 
health of the patient, is not warranted by either proof or analogy ; 
that no known agent possesses the power of repelling eczema ; 
that we can cure it only by means which improve the health at the 
same time, and that it is as justifiable to arrest its discharge as that 
of diarrhoea or cholera. All that has been said of eczema may be 
said of ulcer ; there is no danger in healing it up, no bad symptoms 
ever followed from doing so. Those reported to have occurred 
were the offspring of prejudice or faulty observation, and offer only 
a too painful comment on the mode in which surgery has often been 
studied and taught. 

The doctrine that it is never dangerous to cure eczema or ulcer, 
that 'discharge from either is never a salutary outlet but a morbid 
exhausting drain, and that neither can be repelled into the system, 
or be cured in any way except by improving the health, was very 
unpalatable when I put it forward years ago. So radical a change, 
however, has occurred in the views of some of our writers, that 
now, after appropriating these tenets wholesale^ they speak in calm 
derision of humoral pathology, as though they had never believed in 
it or indeed had utterly scouted it from the very beginning. Dates, 

• Treatise ^n Diseases of the Sl^in, translated by Willis, second edition, 1 835, 
p. 3 '6. t Ibiii. p. 322. 



i 



112 Treatment of Eczema. 

however, are awkward things, and a reader who is sufficiently 
interested in the matter to seek out the pro and con^ might be apt 
to think there is something in this sudden change of opinion yet to 
be accounted for. 

Treatment, — 1 now proceed to examine the treatment of eczema, 
and I need scarcely apologize for devoting a great deal of attention 
to this subject, when it is remembered that the question affects the 
health and comfort of hundreds of thousands ; that it is no uncommon 
occurrence for patients to be reduced to utter destitution by this 
complaint \ that till quite lately medical men were unanimous in 
regarding it as only too often utterly intractable; and that little 
more than half a century ago it was pronounced, when inveterate, 
beyond the reach of art and only to be palliated by treatment, — 
views which are unhappily only too widely current yet among the 
profession, and which are certainly likely to remain current under 
some kinds of treatment* 

As always happens with severe chronic maladies, more remedies 
have been recommended for the cure of eczema than any one person 
could examine in the course of years, at least in such a manner as 
to form a reliable opinion upon their value. It is not uncommon to 
find an author speaking of twenty or thirty powerful medicines, some 
of which — such as saline cathartics, antiphlogistic remedies, neutral 
salts, and emollient diluents — may mean almost anything. It is 
rarely that even an approach to striking a correct balance is made ; 
a list of remedies is given, to be used on general or particular prin- 
ciples, as circumstances may direct, till we arrive at tincture of 
cantharides, mineral waters, and change of air, as our last resources. 
All knowledge of such a kind must, of course, consist to a great 
extent of conjectures, which only great experience can render useful 
and safe, but which, in the hands of the uninitiated, may be scattered 
to the winds by the first difficult case met with in practice. Such 

• Dr. Neligan speaks of eczema lasting five-and-twenty years ; Dr. Copland, 
of its resisting every known method of cure. M. Devergie says he knows nothing 
more intractable than eczema; Cazenave and Schedel give the same account. 
** Some forms of this eruption baffle for a long time every remedy and every kind 
of treatment." — Burgess. Dr. Anderson says he has been consulted by persons 
whose lives had been rendered so burdensome to them by the itching of eczema, 
that they had wandered from town to town^ and from country to country^ in search 
of relief I ** EUe recidive souvent, finit par devenir permanente et par se g^ne- 
raliser .... Nous devons dire que I'afTection arrivee k ce degre est placee 
ordinairement au-dessus des ressources de I'art. " — Bazin. 



Disparity of Opinions. 113 

experience, too, means simply conviction — the principle which guides 
the nurse and the empiric. The form in which it is clothed may be 
more scientific \ the spirit is essentially the same. It is gleaned too 
loosely, and in too wide a field, to admit of the tenets on which it is 
based ever being proved. No lasting structure of therapeutics, no 
enduring system of treatment, can ever be erected on so unstable 
a basis \ and without a far more extended and accurate series of 
observations than we possess, we shall have to arrive at an estimate 
of the comparative amount of success and failure rather by collateral 
evidence than direct proof. Convictions and sweeping assertions 
do not serve us here, and have indeed nothing to do with the 
subject No man's opinion respecting medicines commonly used 
in eczema — such, for instance, as sulphate of magnesia and calomel 
— ^has any more influence upon what ought to be really the question 
at issue than it has upon the qualities of matter ; and can no more 
limit or alter their action on the nervous and vascular systems, than 
it can affect the proportion in which sulphur combines with oxygen 
to form sulphuric acid, and this, again, with water and magnesia to 
form Epsom salts. 

The discrepancy in the statements of different authors as to the 
power of medicines over eczema, the irreconcilable differences in 
the results arrived at by diffierent observers, are proof enough that I 
am not making out a case against the present system. While the 
most experienced surgeons in England declare that it is often a 
difficult complaint to manage, requiring a long course of treatment, 
and sulTOunded by complications which frequently demand a variety 
of remedies to subdue them, the firench physicians seem to remove 
it by means which I should have supposed possessed no control 
over so refiractory a malady, and some of which in my hands proved 
quite inert M. Cazenave quotes a model case, cured, apparently, 
by the use of a little marsh-mallow infusion, and M. Bazin's treat- 
ment, when we come to individual cases, is equally simple. Alkaline 
syrup and starch baths form the entire sum of his rules in one case, 
while starch baths and arseniate of ammonia fill up the formula in 
another. Dr. Kempster, of Utica, cured a case of neglected eczema 
of the scalp by simply applying a weak lotion of carbolic acid. In 
London men rely to a great extent on internal remedies in eczema, 
and employ external applications principally as adjuncts \ in Vienna 
they trust almost entirely to outward applications, and profess to 
have scarcely any faith in medicines. 

Q 



J 



J 14 Antiphlogistic Treatment. 

If there be one skin complaint in which this discrepancy of opinion 
is more injurious than in another, it is eczema \ for it comprises nearly 
or quite one-third of all the cutaneous affections seen in practice, so 
that the surgeon who can most thoroughly master eczema has already 
overcome the most frequent difficulty, and one of the greatest he 
has to encounter. For all these reasons I resolved to watch the 
action of several drugs successively, restricting myself, as far as 
possible, to one drug or one group at a time, eliminating as well 
as I could all those which seemed superfluous, owing to their not 
possessing equal curative powers to those reserved for more special 
observation. Thus, for instance, tar, antimony, guaiacum and 
sulphur were soon given up. The results were as follows : — 

I. Antiphlogistic treatment, taken as a whole, failed entirely in 
every case of severe eczema, both as to its power of curing the 
complaint and of preventing relapses. Calomel, antimony, and 
cathartics, in large and repeated doses, as advised by some authors, 
did no good in any case and made many patients much worse. 
Bleeding either local or general was only tried to a limited extent. 
The patients generally contrived to evade bleeding from the arm, 
and the results, as given by those who advocate it, are not very 
encouraging. Sir William Jenner, however, M. Bazin, and Mr. Hunt 
still recommend venesection, though Mr. Hunt admits that of late 
he has rarely found it necessary. Leeches never seemed to do any 
good, and the low regimen which, according to all orthodox rules, 
ought to go hand in hand with antiphlogistic treatment, was quite 
as injurious as the use of depressing medicines ; whereas a good 
diet, accompanied in all cases of exhaustion by a moderate use of 
red wine, such as claret or tarragona, singly or mixed, and plenty 
of fresh vegetables, proved of the greatest service. 

If the reader will analyze the results of this anti-inflammatory or 
devastating treatment, taking them just as they are given by those who 
employ ity I think he will confirm what I say. Bleeding, leeches, 
salines, antimony, and mercury, employed in the most vigorous 
style, rarely produce much effiect on a sharp case of eczema in less 
than three or four weeks. Now, my experience is, that rest from 
toil and worry, fresh air, good diet, and mild aperients, followed by 
the use of steel, will do the same good in the same, if not less time, 
and do it, too, much more agreeably, perhaps also more safely and 
effectually. Mr. Hunt, however, devoutly believes in the virtue of 
owering treatment. Besides bleeding and leeching, he gives large 



Mercury : Sudorifics, 115 

doses of antimony and salines, accompanied by a vegetable diet 
and no stimulants ; a plan which, at any rate, is energetic and con- 
sistent, but for which I do not see the necessity, as I have never 
met with severe eczema unaccompanied by a certain feebleness of 
health. He stands, however, almost alone, and two of our leading 
authorities, Mr. Startin and Mr. Wilson, are both averse to the use 
of lowering means. 

2. Mercury, even in the doses recommended by Dr. Elliotson 
and MM. Cazenave and Schedel, never seemed either to arrest the 
progress or hasten the disappearance of eczema. Except where an 
aperient was required, or where it was necessary to stimulate and 
unload a sluggish liver, no great benefit resulted from its use in 
whatever form it was employed^ when given in purgative doses ; and 
in some cases where it was pushed so far as to produce a decided 
action on the system, an aggravation of some of the symptoms took 
place. It seemed only useful as an adjunct ; but, employed for this 
purpose, it was most valuable. Calomel, mercury and chalk, blue 
pill, biniodide, and bichloride were all at times most serviceable, the 
two latter as alteratives : the mode of giving them will be stated 
farther on. Children were found to bear mercury very well, and a 
long course of it, in doses which just purged mildly about every 
second day, was almost always beneficial and often effected a 
cure. 

3. Sudorifics did not produce much effect in eczema, and, according 
to my observations, are next to useless in almost every case of this 
kmd, as, indeed, with few exceptions, they are in skin diseases 
altogether, generally failing, I think, most completely where they 
are most requisite ; that is to say, where the skin is dry and harsh. 
I have tried them all, of pretty nearly so, — my observations being, 
however, principally confined to sulphur, antimony, guaiacum, spirit 
of nitric ether, and warm drinks internally, turkish baths, vapour- 
baths, and packing in a wet sheet — and failed with all, not only to 
do good, but even to induce free perspiration, which, however, was 
often frequently brought on by a medicine from which I should not 
have expected such a result; namely, the iodide of potassium in 
tincture of bark. Five grains of this salt, given twice or thrice a 
day in a teaspoonful of the tincture, often made the skin quite moist. 
But however given, or for whatever purpose, it produced no beneficial 
influence on the eczema. Indeed, to give medicines simply to pro- 
duce perspiration appears, so far as I observed, simply equivalent to 



i 



ii6 Sudorifics : Sulphur. 

so much waste of time and money. The benefit they induce is rare 
and problematical ; the mischief they do is abundant and palpable. 
Sir Henry Holland says* that no more beneficial change has occurred 
in modern practice than that of abandoning the system of trjdng to 
force perspiration ; and, so far as eczema is concerned, I quite assent 
to his views. 

Giving sudorifics is a practice founded on misconception. Men 
saw that sweating often accompanies the resolution of certain dis- 
orders, such as typhus, ague, the exanthemata, &c., and therefore 
gave medicines to produce perspiration, with a view of accelerating 
resolution in this, and subsequently in other, complaints. They 
forgot, however, to observe that pyrexial disorders are often thrown 
off without any particular outbreak of sweating ; whereas, on the 
other hand, this may occur most profusely and yet not be followed 
by any relief, even in the exanthemata, while it is often attended by 
manifest aggravation of the symptoms in other cases. They called 
this treatment " following Nature's indications," but it really meant 
misinterpreting Nature and following their own theory. They looked 
upon a person in a fever as a disordered body, clogged and over- 
loaded with peccant matter, to be drained off as an engineer would 
drain water from a morass, or evaporated as a chemist would 
get rid of superfluous fluid — by raising the temperature ; for 
beyond material processes gross enough to be visible they could 
not go. 

Mr. Nayler finds f sulphur useful in those cases where eczema is 
both acute and general, and when the urine is scanty and loaded with 
crystals of urate of soda. He gives a drachm of precipitated sulphur 
and bitartrate of soda, with fifteen grains of bicarbonate of potass, 
in a cup of milk every morning, half a grain of calomel, and three 
grains of James's powder every night, being added in severe cases. I 
have never tried those remedies exactly as given by Mr. Nayler, but 
I have used some so closely resembling them, such as the compound 
calomel pill at night and the phosphate and tartrate of potass, sul- 
phate and exsiccated carbonate of soda in the day, that I can scarcely 
imagine there was any substantial difference, yet I was never able to 
satisfy myself that they possess any control whatever over eczema. 
Indeed, so far as my own Experience goes, 1 am rather disposed to 



• Medical No/es and Rcfleciions. By Sir Henry Holland. 1855, p. 510. 
t Diseases of the Skilly p. 1 01. 



Iodide of Potassium : Salines. 117 

agree with Dr. Frazer, who says* that "sulphur is worthless for 
eczema." However, as Mr. Nayler's work is very carefully and 
impartially written, and is evidently from the pen of a man who 
has paid great attention to his subject, perhaps the best plan will 
be for me, after indicating his views on the matter, to recommend 
the reader to consult the original work, which I most gladly do. It 
possesses far more merit than some of the pretentious things about 
which so much fuss has been made. 

4. Iodide of potassium proved inert except in cases complicated 
with rheumatism, and the same result attended the observations on 
iodine ; but there was considerable difficulty in coming to any definite 
opinion on the latter point, as the iodine was only given in scrofulous 
cases. 

Having now eliminated those remedies which seem to exert no 
influence over the disease, or to be useful only as adjuncts, I pass 
to the consideration of those on which more reliance can be placed, 
and which will, given singly, produce a very decided effect on certain 
stages of eczema ; but in order to bring all the conclusions arrived 
at into as compact a form as possible, I propose to lay down certain 
general rules, and append to them more full observations on the 
action of particular remedies in their proper places. 

In eczema, then, the remedies which succeeded best in my hands, 
and which, as a whole, appear to have been most useful in the 
practice of others, are : — 

I. A saline aperient containing magnesia, preceded by a dose of 
mercury. + In acute cases, as where the face has suddenly become 
partly red and glazed ; in the first stage of the ulcerative form ; in 
sudden and severe relapses of chronic eczema, especially where the 
patient has been living too freely ; at the commencement of treat- 

* Journal of Cutaneotis Medicine^ vol. i. p. 67. 

t For formula of saline aperient, see p. 37 ; for that of a pill containing mercury, 
j-^p. 12. 

The following may also be used for adults : — 

R. Pil. hydrarg. subchlor. co. 5ss. 
Divide in pil. vi. i. pro re nati hord somni sumend. 
R. Hydrarg. subchlor. gr. xij. 
Conf. opii q. s. ft. pil. viij. 
i. omni secunda nocte sumend. 

R. Magnesioe levis (Henry's), 5ss. 
Coch. min. i. omni secund. mane ex lactis cyatho sumend. 



1 1 8 Aperients. 

ment in almost every case when the tongue is coated ; where the 
patient has been nauseated with tonics or arsenic ; and lastly, when 
progress, after being satisfactory for some time, begins to flag, those 
remedies generally prove very serviceable. The reader may here 
object that the instances in which benefit flowed from this system 
were cases of cure by antiphlogistic treatment ; to which, however, 
it may be replied that, on the contrary, these medicines were never 
given to such an extent as to produce any depression or severe 
purging ; that they were not aided by leeching, bleeding, or anti- 
mony ; and that a good diet and wine were always ordered along 
with them. 

Of all the aperients I have tried, those containing magnesia- seem 
to answer best. Henry's calcined magnesia is an excellent pre- 
paration ; a teaspoonful taken in milk before breakfast will produce 
an action of the bowels which few other agents can effect. If by 
any chance the patient happen to be suffiering from acidity, the 
beneficial action of the remedy is twofold. I know it may suit the 
tactics of mere theorists, or some anonymous critic in a weekly 
journal, who considers it infinitely better that a hundred persons 
should die under orthodox treatment than that one should be cured 
by such improper means, — to denounce this preparation as a secret 
medicine — a cry which always ensures a certain amount of appro- 
bation. My answer is, that the cure of disease is a more important 
matter than their opinions. Its efficacy, however, is very decidedly 
increased by the addition of a drug which is as unpleasant as it 
is valuable — the sulphate of magnesia. I know of nothing which 
effectually disguises its taste or entirely prevents the griping which 
is apt to follow the use of it in some persons ; perhaps the com- 
pound tincture of cardamoms, tincture or essence of ginger, and 
peppermint-water are as useful in this way as anything. Peppermint 
lozenges, made with the real english oil, are also of service \ but 
the high price of the oil, which is, I believe, about ten times as 
much as that of the french, renders them liable to adulteration. 
Many persons, too, object to the taste of peppermint as much as 
they do to that of the sulphate. I always add the nitrate of potass 
or the spirit of nitric ether, though I cannot say that I have in any 
way satisfied myself as to the value of either. A dose of a mixture 
of this kind before breakfast and dinner, or lunch, is generally 
sufficient. Its administration should, I think, always be accom- 
panied by the use of a dose of mercury, two or three times a week, 



Aperients; Astringents. 119 

in the form of calomel or mercury and chalk,* in a powder for 
children, and for grown persons in pills. It is not necessary to 
carry the remedies to such an extent as to bring on any severe 
purging ; about two loose stools a day will be quite sufficient In 
the case of infants at the breast, the mixture may be given to the 
mother, as it acts very gently and yet actively enough through the 
medium of the milk. 

Except in some slight cases of eczema in grown persons and in 
eczema in children, in which forms these remedies often suffice of 
themselves, it is of very little service to continue them beyond two or 
three weeks, a period, however, which is generally long enough to 
admit of their doing a great deal of good ; the tongue getting cleaner, 
the stools of a brighter colour, and the patient feeling altogether 
better under their influence. 

2. An astringent, accompanied by an occasional aperient or by 
an alterative. When the appetite is bad I would suggest the free 
use of a mineral acid, such as the nitric or nitro-muriatic, in tolerably 
large doses, in some bitter tincture or infusion. I believe drachm 
doses of tincture of calumba and ounce doses of infusion of quassia 
are equal to anything yet discovered. Fresh-made infusion of 
valerian, serpentaria, or cascarilla answers very well when the 
patient is low and nervous.f It is, however, to be borne in mind 

• I would suggest giving an aromatic along with the mercury and chalk when 
it is prescribed for children. 

R. Hydrarg. c. creta, gr. xviij. 
Pulv. cinnam. co. gr. xij. n\. 
et divide in pulv. xij. 
One of these powders may be given to an infant of almost any age to begin 
with ; it wiU scarcely ever distress even the most delicate, and generally for 
children approaching a year old the dose must very soon be raised. Patients 
between one and three years old may commence with twice the dose. These 
powders may be taken in a little of anything thick, or simply laid on bread-and- 
butter. One should be taken at least two or three times a week. 

t R. Acid, nitric dil. 5iss. 
Syrupi aurant. ^ss. 
Infus. chiratse 5iij- (Infus. valerian. 5^U-) 

quassiae ad 5vi. tn 

Coch. ampl. ij. bis terve quotidie sumend. 

R. Acidi nitric, dil. 5ij. 

hydrochlor. dil. 5i. 

Tinct. cinnam. c. "^viy 

calumbae 5vi. in. 

Coch. min. i. ter quotidie ex aquae cyatho vin. sumend. 




1 20 Steel, 

that these remedies do little more than improve the appetite and 
health, and that their control over the eczema is very Umited. 

3. A course of steel. When the discharge is profuse, when even 
in the dry form eczema has existed for a long time, and in all cases 
when improvement has come to a standstill, I would advise a course 
of steel ; a remedy which, in my hands, has proved of more use 
against eczema in this stage, and under these circumstances, than 
any other I have tried or seen tried. 

Steel wine, carefully prepared, and given in doses of one or two 
drachms two or three times daily^ will remove most cases of eczema 
during the first year or two of life. The wine should be procured 
from a really good chemist ; I have tasted specimens of it so harsh 
and acid that I could not wonder at children disliking it. Some of 
them seemed to me compounds of rusty iron and the worst kinds of 
acid sherry. A very agreeable preparation is made by Messrs. Bell, 
of Oxford Street. When children have passed this age steel wine 
requires to be given in large doses to produce any effect, and there- 
fore becomes rather an expensive medicine, especially in hospital 
practice. Here the saccharine carbonate may be substituted, two 
or three grains being given twice a day. Should its effect not cor- 
respond with the surgeon's anticipations, I should recommend that 
the tincture of the muriate in doses of five to fifteen minims three 
times a day, sweetened, be given instead. In hospital practice the 
acid solution of iron, mentioned at page 37, from three to five 
minims in water three times a day, though not quite so pleasant, is 
quite as useful as the tincture. 

From puberty to the decline of life, I would most decidedly 
recommend the tincture of the sesquichloride, or the acid 
solution spoken of in preference to any other preparations.* 
Indeed, I can safely say that I have seen no internal remedy 
influence the discharging stage of eczema, or eczema siccum of 
the hands, so rapidly and effectually as these. When properly 
aided by aperients, ointments, exercise, and suitable food, nearly 
every case of eczema in the stages I have mentioned will be cured 
or relieved by a steady, persistent use of them, as I have had the 
pleasure of demonstrating to several gentlemen at St. John's. 

* Whichever be selected, I would strongly advise the use at the same time of 
one of the pills prescribed at p. 12, given to the extent of at least three or four 
a week. 



Tincture of Sesquichloride of Iron. 1 2 1 

There are, however, some precautions with respect to the mode of 
taking them which are of vital importance. 

In the first place it is essential that the tincture should be 
prepared, not only according to the London Pharmacopoeia, but 
with such care as to ensure that no great amount of free acid is 
present, seeing that this frequently preponderates to such an extent 
that the tincture cannot be given in the proper doses \ indeed, the 
fluid part of a good deal of the trash sold under the name of tincture 
is composed almost wholly of hydrochloric acid : it is sold to 
patients at a price for which a surgeon could not buy it from 
a respectable chemist. When properly made, a drachm or more 
may be given at a time, whereas half a drachm of the coarse 
acid tincture will set the teeth on edge and make the patient feel 
sick. I have often known a patient who was taking the pure 
tincture with benefit turn quite ill after a dose of this stuff : severe 
vomiting has followed in several instances, and in once case where 
I was consulted, the patient was so sick and was purged so violently 
from taking two drachms of the common tincture in divided doses, 
that his friends thought that he had got english cholera. This kind 
of thing has now happened so often that I always beg of patients, 
if they run short of the genuine tincture, rather to do without it for a 
day or two than get it from any source they are not certain about. 
The tincture of the perchloride of the British Pharmacopoeia is a 
much inferior preparation. With whatever care it be made the 
iron speedily precipitates, and as druggists do not like to send 
out a thick-looking tincture, they pour off* the clear fluid and make 
use of that only, rejecting the greatest part of the iron. But it is 
only too often not prepared with care. In making the solution of 
the perchloride, instead of evaporating this in a water-bath the 
ingredients are simply mixed and the spirit added subsequently ; 
an addition which is the signal for approaching precipitation of the 
metal. Indeed, I would in every way recommend the acid solution 
in preference, giving the spirit separately and in a more palatable 
form. 

The tincture must be given in pretty large doses and for some 
time. It is of no use prescribing fifteen or twenty drops for two or 
three weeks; as well not give it all. The patient, if an adult, 
should begin with half-drachm doses at least, and increase this as 
rapidly as ever he can to a full drachm, beyond which it is rarely 
requisite to go. The dose should be measured out in a minim 

R 



122 Constipation and Dyspepsia. 

glass ; for, as a drachm is equivalent to quite a hundred and fifty 
drops, the surgeon who prescribes a certain number of drops is 
evidently not giving the quantity he wishes to do. 

Now and then, if the patient grow sick of the medicine, or suffer 
from dyspepsia, loss of appetite, headache, &c., the steel may be 
given up for a day or two till these symptoms pass off; but so soon 
as they have vanished it should be resumed. The constipation 
which generally accompanies its use may be easily remedied by 
the occasional use of a mild pill, which should^ however^ always 
contain aloes* This symptom frequently passes off when the steel 
has been taken for a little time, and especially when the larger 
doses have been reached. I have so repeatedly noticed this, that I 
have been obliged to conclude that a small dose of steel constipates as 
readily as a large one, and that the constipating action begins almost 
as soon as the patient begins with the medicine ; whereas the purging 
induced by the cuid is in exact proportion to the quantity taken, and 
comes on more slowly. The dyspepsia — the most frequent form 
of which is marked chiefly by coldness at the stomach, nausea, 
griping, and flatulence, is generally soon got over by leaving off the 
steel and giving some mild aromatic and antacid, such as carbonate 
of soda, along with compound tincture of cardamoms or aromatic 
confection, or the aromatic spirit of ammonia in some bitter 
infusion.t Should the appetite flag very much, the patient may 
give up the steel for a week or two and take the nitric or nitro- 
muriatic acid, as previously suggested, for a few days. In some 
extremely rare instances it may happen that the patient cannot 
take either of these preparations, in which case it should be aban- 
doned in favour of the ethereal tincture or Griffiths* mixture ; but 

* R. Pilulse aloes et myrrhae 5j. 
divide in pil. xii. i vel ij altemis noctibus sumend. 
Or the colocynth and hyosc3ramus pill recommended at p. 12. 

f R. Sodae carbon. 5j. 

Tinct. lavand. c 5ij. 

cardam. co. 5iij' 

Aquae menth. pip. ad ^vi. n. 

Coch. amp. duo bis terve quotidie sumend. 
R. Spin ammon. arom. 5iij. 

Acidi hydrocyan. dil. (Pharm. Brit. ) m. xviii. 
Infus. rhei ^iij* 

calamb. ad 5vj. t\, 

Coch. amp. duo bis quotidie sumend. 

See also formula at p. 11. 



Control of Steel over Eczema, 123 

neither of these is equal to the former. Indeed, in my hands the 
ethereal tincture proved perfectly useless. It is altogether a medicine 
not to be trusted to, and the dose usually given (5 to 30 minims) is 
far too small. The first-named dose would be about the right strength 
for quieting the nerves of a hysterical baby. I have never seen 
anything exert so much control over eczema as the acid solution 
and the tincture of the sesquichloride. At one time I believed 
that, provided steel were given in a soluble form which would sit 
lightly on the stomach, it did not much matter what preparation 
was used ; and I believe that in the discharging stage almost any 
preparation of steel, perseveringly given, will effect a certain amount 
of good ; but I consider my observations warrant me in drawing 
the conclusion that those I have recommended are among the most 
potent we possess. I have frequently treated two similar cases of 
eczema — one with the acid solution and one with some some other 
preparation. I have also, in such cases, given one patient the 
acid solution and one the nitro-muriatic acid or a saline. I have 
suspended the acid solution, and given something else ; and 
sometimes, when a patient has returned with a fresh outbreak, 
I have tried this time to do without the solution, but always with 
the same result. Even in the dry furfuraceous state of the skin, 
with firm, thin, adherent crusts, the solution of iron, properly 
seconded by aperients, often proves useful. I have seen lichen too, 
which had improved under salines, develop into eczema under the 
influence of the biniodide of mercury and again improve directly 
the acid solution was given. 

These preparations of steel, given in this way and aided by an 
aperient, will cure a great many cases without anything further 
being required ; but in some cases the dry stage itself of eczema 
demands a particular course of treatment, and in others not only 
does improvement cease without any manifest cause, while the 
patient is taking the steel with every possible precaution, but an 
unmistakable relapse ensues. In the latter case the best plan seems 
to be to give up the steel altogether for a week or two, to purge the 
bowels well and then resume the steel in increased doses, by which 
means the surgeon can generally succeed in bringing the disorder 
up to the third or dry stage. The health almost always improves 
visibly under the use of these remedies, the skin grows clearer and 
the muscles become firmer, while the face frequently loses to a great 
extent the careworn look it had acquired from long ill-health. 



124 Arsenic, 

4. A course of arsenic, aided occasionally by cod-liver oil and 
an alterative preparation of mercury. — Arsenic properly given, that 
is to say, just in such doses as the patient can bear without being 
made really unwell by it, will cure a great many, perhaps most, 
cases in the dry stage, in which alone it is useful. In other phases 
of eczema it has always appeared to me inert or injurious ; but 
when the skin is simply red and tender, with a quick reproduction 
of unhealthy cuticle or scales, it is often of great benefit. Given 
alone in eczema before steel has been tried, and in the weeping 
stage, it makes the patient sick, languid, and weak, destroys the 
appetite and purges the bowels.* Should, however, the surgeon 
only see the patient first of all at this stage, and ascertain that 
he has not taken steel, then I would suggest that the patient 
should either go through a short course of steel, or that this 
medicine should be combined with the arsenic ; for though the 
statement may excite scepticism, I feel justified in saying that many 
patients bear arsenic decidedly better after a course of steel. I 
have repeatedly observed that, where patients could not tolerate 
even five-minim doses of liquor arsenicalis without so much irritation 
of the stomach, nausea, and purging, sometimes even followed by 
a very disagreeable result — peeling of the skin of the hands and 
feet — that the medicine had to be given up, even at the risk of 
seeing the worst symptoms return ; these doses, after a course of 
steel, excited no discomfort, except in the conjunctiva, and not 
much even there. I believe, however, that this toleration of arsenic 
is quite artificial ; after a respite of a few months I have seen the 
same quantity of it produce the same disagreeable effects.t 

» In the Ditblin Quarterly Journal of Medical Science (May, 1870) there is a 
case by Drs. Benson and Smith in which the patient's debility steadily increased 
under quinine, iron, mineral acids, &c. ; whereas the use of arsenic was followed 
by immediate and lasting improvement. 

t As a formula for giving arsenic in pills is sometimes useful, I subjoin one ; — 

R. Arsenici albi gr. j. 
Pulv. piperis nigr. 9j. 
Olei cinnam. m. ij. 
Ext. hyoscy. 5ss. 

anthem. 9ij. nt ft. pil. xxiv. 

i ter quotidie sumend. 
When it is considered necessary to add steel, 5ss of the magnetic oxide of iron 
may be substituted for the extract of hyoscyamus ; but I should not anlicipate 
any great results from either arsenic or iron taken in this way. 



'Arsenic; Cod-Liver Oil. 125 

One of the fashions or crazes of the day is that of giving arsenic 
in every form of disease of the skin. The extent to which this has 
grown of late years is almost incredible, and is perhaps only known 
to the druggists who supply the material. A few years ago arsenic 
was scarcely employed at all internally, and was given with great 
caution or even altogether withheld in complaints like lepra, which 
could scarcely be cured without it. Nowadays it is constantly given 
in every case that proves the least refractory, and very often before 
any other medicine is tried. Indeed, medical men often adduce 
as evidence of the refractory nature of a particular case, that the 
patient has taken a quantity of arsenic without doing any good. 
Why, I don't know, as certainly it never was recommended in every 
disease of the skin, and especially in the weeping stage of eczema, 
by those who are supposed to lead opinion. But there are some 
affections of the skin which never require arsenic, and many which 
only tolerate it at a certain stage. Among the latter is eczema. So 
long as ever there is a discharge of serum, arsenic never does any 
good, and often does a great deal of harm by inducing sickness, 
purging, headache, and general irritability. // is ottly of use when 
the dry stage has set in, and is not always called for then. Attention 
has often been directed to the injurious nature of such treatment as 
that of acute eczema with preparations of arsenic, but so far without 
result ; indeed, the practice seems largely on the increase. 

5. Cod-liver oil is one of the most valuable remedies in eczema, 
and perhaps it would hardly be going too far to say that every 
chronic case is more or less benefited by it, if taken long enough 
and in a proper way. Eczematous patients are generally very 
sensitive to cold, and means calculated to evoke heat seem to agree 
best with them. The great obstacles to its use, the nauseous taste 
and the idea of swallowing a coarse, animal oil, are soon overcome, 
and the result quickly compensates the patient for any disgust felt at 
the outset. Should the dfficulty of taking it be insurmountable — 
as when it always brings on sickness, or when the patient is an 
infant at the breast,— a broad fold of linen or flannel, steeped daily 
in the oil, may be worn round the waist. The worst of this plan is, 
that it makes such a filthy mess that one can only employ it in the 
case of children and persons who are or can be confined to bed ; 
but it certainly does good and patients get well and fat on oil used 
in this way. 

I give the preference to Dr. De Jongh's oil over all I have tried. 



126 • Cod' Liver Oil; Mercury. . 

A pretty wide experience has satisfied me that the opinion I 
expressed some years ago as to its superiority, both in diseases 
of the skin and neuralgia, is well founded. I have heard men say 
that it cannot and ought not to do any more good than the 
pale oil, because the colour and taste are simply due to the blood 
and bones of the fish being pounded up with the liver. But a fair 
trial of its powers will soon dispose of such puerile objections ; and, 
whatever the taste may be due to, most persons certainly find it less 
disagreeable and mawkish than the pale oil. Its cost, too, is less, 
as such a much smaller quantity of it is required. The dose should 
not be too large, never more than the stomach can bear com- 
fortably. Grown persons seldom require more than five or six 
teaspoonfuls daily, often not so much ; children bear relatively 
a much larger quantity, and may take, even when quite young, 
two to four teaspoonfuls a day. It seems to sit best on the stomach 
after plain food, not always digesting so well after soups, stews,, 
hashes, curries, &c. I think also it answers best when given 
directly after meals; but this is purely an affair of individual 
experience. The most agreeable vehicle for taking it in is a small 
quantity of wine, like manzanilla, orange, or ginger, or coffee ; the 
last suits some persons very well. Winter and spring are the most 
suitable times for taking it, and patients who cannot retain it 
on the stomach during hot weather, or lose their appetite for food 
under its influence, bear it perfectly well so long as the cold lasts. 
If the patient is to derive lasting benefit from its use, it should be 
given for quite three to six months. Should circumstances require 
a trial of it to be made during the summer, I would suggest 
the use of the cod-liver oil chocolate made by M. Lebaigue, of 
9, Langham Street, Portland Place. Each pound of it contains 
four ounces of the oil. Should all these resources fail, I would 
recommend a trial of cream, from four to eight ounces daily, or of 
the pancreatic emulsion prepared by Messrs. Savory & Moore. 

6. But there are some stubborn cases which resist all these 
remedies, and in these a course of mercury will often give the 
coup de grdce to a disease which has defied everything else. The 
biniodide and bichloride of mercury seem to be the most powerful 
salts of this class. I at once admit that after many trials I have 
been unable to satisfy myself as to which is the most potent of 
the two ; but on the whole I think the bichloride, and Mr. Startin 
seems to have had great success with it. The biniodide, however, 



Mercury, 127 

is also ati excellent preparation. About one-twelfth, steadily in- 
creased to one-eighth to a sixth of a grain of either, will generally 
prove sufficient for a dose. This quantity may be taken once, 
twice, or thrice a day, according to the severity of the complaint 
or the age of the patient. I have repeatedly given young boys 
and girls a sixth of a grain daily, with the best results. If given 
in a pill, the mercury should always be combined with the 
compound extract of sarsaparilla, or else with a sedative and 
aromatic, such as the extract of lettuce and the essential oil of 
peppermint or cassia, to prevent griping.* When much pain of 
any kind complicates eczema, or when there is a tendency to 
diarrhcea, a quarter of a grain of pure opium may be added. If 
the form of a pill be objected to, it may be given in some bitter 
tincture, such as cinchona or calumba ; syrup of some kind or 
other should always be added when these salts are prescribed, 
dissolved in water. The biniodide can always be given in solution, 
by mixing bichloride of mercury and iodide of potassium in proper 
proportions.t But such adjuncts as tinctures and syrups cannot, 
I need scarcely say, be procured in hospital practice, and accord- 
ingly I have found that these preparations of mercury do not always 
answer so well, and that the patients without exception complain of 
their depressing effect. 
Almost the only complication likely to be met with in the 

• R. Hydrarg. perchlor. gr. j. 

Extracti sarsse comp. liq. ^iU* '**l' 
Coch. ij min. bis quotidie sumend. 
R. Hydrarg. perchlor. gr. j. 
Extracti sarsae comp. 5ij. x\. 
et divide in pil. xxiv. ij nocte maneque sumend. 
R. Hydrarg. iodidi rubri gr. j. 
Extracti lactucae gr. xlviij. 

anthem. 5j. 

Olei cassise m. ij. n\. 
et divide in pil. xxiv. ij nocte maneque sumend. 

t R. Hydrarg. perchlor. gr. j. 
Syrupi rosse 5ss. 
Tinct. cinnam. c. 5j« lU- 
Coch. min. i bis quotidie ex aquae cyatho vin. sumend. 
R. Potassii iodidi gr. xxxij. 
Hydrarg. bichlor. gr. j. 
Syrupi zingiberis 5ss. 
Aquae cinnam. ^njss. ni- 
Coch. min. ij ter quotidie sumend. 



A 



128 Rhetirnatism, 

treatmemt of eczema, that is, so far as one can be considered 
incident to the other, is rheumatism, the remedies for which are 
the same as in other cases ; hydrochlorate of ammonia, iodide of 
potassium, colchicum, and embrocations, of which by far the best 
I have seen is a combination of strong tincture of opium, containing 
quite four times as much opium as the ordinary tincture, or of 
the same strength as Cooke's black drop, chloroform, camphor 
liniment, and soap liniment.* The rheumatism of eczema seldom 
resists these. 

The pressure of inflamed lymphatic glands induced by eczema, 
and of the troublesome thickening of the skin, sometimes even 
extending to the subcutaneous cellular tissue, and ending in the 

* When the attack is severe and the pain very great, I would advise the 
following : — 

R. Ammon. hydrochlor. 5iij. 
Syrupi simpl. J^s. 
Aquse menth. virid. ad ^vi. m. 
Coch. amp. duo tertiis horis sumend. 

R. Liquoris morphise bimeconatis m. xx. 
Mist, camph. Sj* '"I. 
hori somni sumend. 
Chlorod)me m. xxx. may be substituted for the latter. The hydrate of chloral 
proved in my experience a most unsuitable medicine, bringing on, especially after 
the first or second night, excessive cerebral excitement, inability to lie down, and 
a beating like that of a hammer inside the head. At the same time, the part 
affected should be dry-cupped with any materials at hand for quite an hour, and 
the following embrocation applied by means of a flannel steeped in it : — 

R. Guttae nigrae (Cook) 5ij. 
Chloroformi 5J« 
Lin. camph. c. 5iy- 
— saponis 5vi. rn.. 
ft embrocatio. Over the flannel should be laid a pile of soft cotton -wool, — 
medicated cotton-wool, as it is commonly though erroneously called, — kept on by 
a bandage. 

After the pain has yielded the patient may take — 

R. Potassii iodidi 5ij. 
Aquae ^iij. '^' 
Coch. min. ij bis quotidie sumend. 
The simplest way of taking this is to put the dose into the first portion of the 
fluid dnmk at any meal. 

R. Extracti colch. acetici. 
Pilulae hydrarg. aa gr. vi. 
Extracti hyoscyami gr. xii. r\. 
et divide in pil. vi. i omni noct. sumend. 



Change of Air. 129 

formation of abscesses, are complications over which we have little 
control. Scalding with very hot water, followed by the use of ice 
or evaporating lotions, and subsequently painting with tincture of 
iodine or a solution of nitrate of silver, ten grains to an ounce, are 
nearly all the remedies I know of which are likely to be of much 
service. In unhealthy children, swelling of the glands at the back 
of the neck, from eczema of the posterior part of the scalp, is 
extremely apt to end in abscess, unless much stronger measures are 
employed than we can generally adopt. 

Change of A ir. — Supposing all this has been done, and that the 
eczema, though better, is not quite well^ or, after being over and 
over again cured — so far, at least, as external symptoms are con- 
cerned — it perpetually shows a tendency to return, what is to 
be done ? Shall we send the patient for change of air to some 
mineral spring, or give tar, cantharides, or some other drug recom- 
mended as a last resource ? 

To judge from my own experience, I should say most decidedly 
not. / never yet saw such agencies^ under such circumstances^ effect a 
cure; and I believe the best plan is to leave the case to nature, feed 
the patient as well as possible, and give no medicine whatever for a 
period of (several months ; at the end of which time it will often be 
found that the health has improved, remedies long previously given 
perhaps aiding somewhat in the work, and then very slight means 
will frequently remove all visible traces of the disease. Almost the 
worst case I ever saw was set right in this way. The patient had 
been in a most deplorable state from eczema and exhaustion for 
years, and at the end of a long course of treatment was still worried 
by the perpetual recurrence of the complaint. I recommended him 
to take no medicine whatever, to have meat twice a day, fat ham or 
bacon once daily ; at least four or five glasses of port wine and 
one or two of old whisky every day ; to eat brown bread in place 
of white, and to take work as quietly as he could. These in- 
structions he faithfully carried out. In the course of two years 
he had increased above a stone in weight, and for several months 
he had only suffered occasionally from a stray patch of eczema, 
which invariably disappeared under the use of the dilute nitrate 
of mercury ointment. One year later his condition had improved 
still further, and at the present time he continues well. 

External Applications, — In acute or very slight cases of eczema, 
almost any mild astringent will suffice. Perhaps among the best 

s 



A 



1 30 External Applications ; Lotions, 

we may rank subnitrate of bismuth in elder-flower water or camphor 
mixture, or Jkjuor of the diacetate of lead, two drachms to ^vi 
of either fluid. When expense is not an object half an ounce 
of glycerine should be added, as from its faculty of retaining 
moisture it powerfully aids the purpose which lotions are intended 
to serve. ' When there is a large weeping surface, particularly 
in children, or of long standing in adults, the reader may try 
Dr. Hughes Bennett's plan.f It consists in applying a solution 
of carbonate of soda, half a drachm to a drachm in eight to 
ten ounces of water, by means of a piece of lint soaked in the 
liquid and laid upon the part affected. The lint must be covered 
with thin gutta-percha or oiled silk, to prevent its getting dry, 
or else the management of the affair must be entrusted to the 
care of some person who will see that the lint is kept moist, 
for which purpose it should be sprinkled continuously with cold 
water, the lotion being only occasionally applied. If this plan 
be properly carried out, if the linen be kept wet all day long, 
and still more if this can be effected day and night, the effects 
are often marvellous ; but if it get dry, the soda speedily irritates 
the surface. The addition, however, of glycerine, half an ounce 
to eight ounces of fluid, will mitigate this to a certain extent, 
but nothing compensates for want of attention. Dr. Wallace has 
reported J some cases in which the beneficial results of this plan 
were very marked. My experience of it is that, though it gives 
great relief, yet it has very little curative power; that it is only 
suitable for a large wet surface, and that it is apt in eczema of 
the head to give a bad cold. 

In chronic eczema, a lead lotion — the same as above — can be used. 
In many cases, where the surface is very irritable, it answers best 
when gently warmed previously. So soon as the discharge and in- 

* R. Bismuthi subnitratis 5ss. 
Glycerinse 5ss. 
SpiritAs lavandulse 5iij. 
Aquae flor. sambuci 5vij. t\ ft. lotio. 
R. Liq. plumbi subacetatis 5ij. 
SpiritAs rectificati 5iij. 
Glycerinae 5iv. 

Mist, camph. ^v. tn. ft lotio. 
When the soluble essence of camphor can be procured, it may be substituted 
for the rectified spirit. 

t Lancet^ 1863, vol. ii. p. 259. :|: Ibid, 



Ointments. 131 

lamination are checked, zinc ointment forms an admirable dressing. 
[t should be gently melted down, or rubbed down with an eighth 
)art of spirit of camphor, and smeared like thin cream on the 
)art All surfaces to which ointment is applied should also be 
:overed with old linen. When once ointments are begun with no 
nore watery applications should be used, nor should the part 
)e washed, except when the eczema is seated on the head and 
s discharging freely, as happens sometimes, especially in children, 
)r when it is seated in parts where washing cannot always be 
ivoided, as the hands, face, &c. At such times the discharge, 
vhen the eczema assails the head, is sometimes retained under 
;he crusts, or the hair gets matted with it. Here it is very useful to 
poultice the crusts with mashed turnip or bread and water, till 
they are thoroughly softened, and then remove them by very gentle 
washing with hot water and yolk of t^gy or, what I prefer to 
anything else, the St. John's Hospital soap. Mashed turnip is 
the best poultice I know of; it possesses the great advantage of 
rapidly removing any unpleasant smell. In some cases a weak 
lotion of chloride of zinc, a grain to an ounce, with the addition 
of half a drachm of mucilage, is a very valuable application to 
the head : it is only here that I have found chloride of zinc useful. 
But for the entire removal of eczema in the dry stage, especially 
f obstinate, we must turn to a more potent remedy, one of the 
litrates of mercury. I have never seen the oxide of zinc ointment, 
ven that prepared by Messrs. Bell, of Oxford Street, really cure 
his disease when severe, and I have repeatedly treated in the 
a.rne patient one patch of eczema with the dilute nitrate of 
"Mercury and one with the oxide of zinc, the result being invariably 
^ost decidedly in favour of the former ; I have also made similar 
tials with the ointment of the nitric oxide with the same result, 
ndeed, in my hands the yellow nitrate, diluted, has proved 
uperior to any application I have seen tried. Two or three years 
^o I showed several surgeons the effects of its action compared 
^th those of chloride of zinc, as recommended by Dr. McCall* 
Anderson, and the zinc ointment. Three patches were selected 
on the same patient, pretty nearly of the same size and in the 
same stage. One was treated only with the solution of the chloride, 
3ne with the zinc ointment, and one with dilute citrine ointment. 
\i the end of a few days it was manifest to every one that the 
Lction of the nitrate was superior to that of the zinc ointment, 



i 



N 



132 Nitrate of Mercury Ointment. 

and this again to the action of the chloride; and by the time 
that the patch treated with the nitrate was healed, that to which 
the zinc ointment had been applied was much better, while that 
treated with the solution might be roughly computed, so far as such 
computations hold good, at only halfway towards a cure. These 
applications were now abandoned, and the diluted nitrate was 
alone resorted to, under the influence of which the progress of the 
two remaining patches was soon visibly accelerated. 

But if the application is to be useful, it is indispensable that it 
should be properly made up and properly employed. In the 
first place, pure, well-made nitrate of mercury ointment only should 
be selected. A great deal of that which is generally used is totally 
worthless, being dry, dirty green, and rancid, spoiling almost as 
soon as it is made ; whereas, when properly prepared, it retains its 
bright yellow colour for months. The dilute ointment should only 
be prepared when it is wanted, and the best plan is simply /^r/>^ 
patient to rub it down with a little sweet-almond oil till it is of the 
consistence of cream^ and always to throw away what is left. If the 
eruption be seated on the head in children, the hair should be cut 
off and the ointment applied night and morning; a linen cap 
should also be worn day and night. But grown persons cannot 
or will not submit to this; the hair should therefore be parted, 
any crusts gently detached, and the ointment rubbed carefully but 
not roughly in, the cap being worn at night only. Should the 
hands be affected, soft leather gloves, with the tips of the fingers cut 
off, should be worn during the night, and if possible, the day also. 
AVhere there is very little hair, and the eruption is only slight, the 
ammoniated mercury ointment of the British Pharmacopoeia may be 
tried : it is one of the cleanliest and least offensive preparations 
that we possess, but in point of efficiency I would place it decidedly 
below the nitrate ointment. Some persons with a strong tendency 
to eczema, pr after the cure of the worst part of their complaint, 
suffer a good deal from a chapped, red, and tender state of the 
skin. Cold cream is often very useful in relieving this. A powder 
composed of equal parts of rice powder or American com flour 
and oxide of zinc with camphor, dusted over the face during the 
daytime, especially when the patient is going into cold east winds, 
is also of great service. Whatever theoretical objections may be 
made, ointments cannot be too sedulously employed in eczema, 
even during the day and when the eruption is seated on the face 



•^N 



Eczema Siccum. 133 

and hands. When the hair is falling from eczema, I know of no . 
remedy so effectual as cutting it quite short, and blistering the skin, 
as for alopekia. With regard to the itching, I never yet saw any 
remedy materially affect it. The cure of the itching is the cure 
of the disease. The same statement holds good of another dis- 
agreeable but rare symptom, — a kind of neuralgia or rheumatism of 
the skin, sometimes seen in eczematous patients. Mr. Wilson says 
he has found no remedy for it equal to a solution of nitrate of silver, 
a grain in an ounce of spirit of nitric ether. 

Dr. McCall Anderson seems to think that the lard is the chief 
agent in the benefit said to be effected by mercurial ointments. It 
happens that .1' not only have subjected, but am every day sub- 
jecting this doctrine to a test; for it is a constant practice with 
me to prescribe at the same time pure lard and ointment of the 
nitrate of mercury, the former to be used when the nitrate sets 
up much irritation, and I have reapeatedly had occasion to 
satisfy myself that the ointment is much more powerful than 
the lard'. 

There is one form of eczema which is peculiarly refractory, — ^viz., 
eczema siccum of the hands. It is seated on the palms of the 
hands, and both palmar and dorsal surfaces of the distal phalanges, 
which are fissured deeply and extensively. The skin often looks 
as if pieces had been chipped or torn out. Sometimes a small 
patch on the palm of the hand discharges for a time, especially in 
workmen when fretted by the continual pressure of the tools they 
use; more frequently it is only red, tender, stiff, and partly 
deprived of cuticle. It is often seen in those who have to handle 
a good deal of cloth, and is widely different from the grocer's itch, 
which attacks the backs of the knuckles, hands, and wrist, often 
discharges serum, is occasionally complicated with impetigo, and is 
easily curable. The treatment which has succeeded best in my 
hands is to give a course of steel and arsenic for some time, to 
steep the part all night by means of a piece of wet lint wrapped 
round it, and over this a sponge-bag, with a cloth tied over the 
bag again, and to rub in the ointment of the red iodide of mercury 
of the British Pharmacopoeia, with at least eight or ten grains of 
veratria to the ounce, raising the quantity of the iodide, if the 
patient can bear it, till a drachm to an ounce is reached. These 
are the only remedies I have ever seen effectual. Mr. Gay, I 
believe, has used the decoction of hellebore for this affection with 




134 Eczema Siccum. 

great success. He directs it to be strongly rubbed in, and uses 
no particular general treatment.* 

This is the only form of eczema in which water-dressings, espe- 
cially when covered with oiled silk or other waterproof materials, 
are not decidedly injurious. Indeed, a skilful application of this 
method will not unfrequently develop an eczema where there was 
none ; as for instance, round a small ulcer or boil. 

Eczema siccum, when it fastens on the tips of the fingers and 
palm of the hand, is often a very serious affair for those who have 
to gain their living by manual labour. I have had many patients 
under my care whose earnings had been materially diminished 
from this cause. One patient, a seamstress, forty-four years old, 
had, in the course of ten years unbroken suffering from this affection, 
been at last brought to such a state that she was incapacitated from 
following her employment. This woman had been at five hospitals 
and under different medical practitioners. I have reason to think 
she gave their treatment a fair trial, as she was so extremely regular 
in her attendance at St. John^s. The measures I adopted were of 
very little service. I was not at that time acquainted with the value 
of the acid solution of iron and the biniodide of mercury ointment ; 
but two or three other forms of mercury in ointment failed, as did 
the biniodide internally, arsenic, &c. The caustic potass solution, 
as recommended by Hebra, was tried, but no good resulted from it. 
The acid nitrate of mercury seemed to do some good, but after the 
second application I lost sight of the patient. The remedies that 
would have answered best are undoubtedly the acid solution of iron, 
followed by arsenic or bichloride of mercury in pills, with the binio- 
dide of mercury ointment of the Pharmacopoeia and veratrine. The 
biniodide of mercury in pills sometimes acts very well in eczema 
siccum of the lips, especially if free use be at the same time 
made of the compound senna mixture, so as to keep the bowels 
rather loose. 

Patients suffering from eczema should never wash in cold water ; 
on the contrary, I think they cannot use it too hot. If expense be 
no object, a sixteenth to an eighth part of glycerine should be added 

* Mr. Gay's prescription is — 

R. Hellebori rad. 5ij. 
Aquae bullient. Ibj. 
Coque ad ^viij et adde 

Eau de Cologne 5ij. •t\ ft. lotio. 



Soaps. 135 

to the water. When the surface is too tender to bear even this, 
I would recommend a decoction of Unseed. The uncrushed seed 
only should be used : four or five tablespoonfuls are put into a 
quart of water, and boiled down to a pint. The fluid is then 
strained, and used hot. Thin gruel boiled for quite twenty minutes 
is also very useful; it seems to soothe the irritation in the skin 
when nothing else is tolerated. 

Soaps should, I think, with one exception, be abolished. As a 
rule, the best kinds are imperfect and contain free alkali. When 
the soap is dissolved in the water still more alkali is set free, and 
this acts on the acid fats in the cutaneous secretions. Bad common 
soaps and the trash generally sold as toilet soaps are still worse ; 
they are made of the coarsest kinds of fat and contain a larger 
proportion of alkali. In proof of this it may be stated that they are 
sold much cheaper, even scented, than pure soap, without the 
addition of such an expensive ingredient, can be procured direct 
from the soap-boiler. All the golden, aniline, red soaps, &c., owe 
their colouring to some noxious or useless ingredient. Most of the 
foreign soaps are still worse than the worst english ones, as, in 
consequence of their being made by what is called the cold process, 
much more alkali is requhred to fix the oil. The soaps sold as 
glycerine, sunflower-oil, &c., are simply in most cases impositions. 
Price's solidified glycerine contains a large amount of pure glycerine ; 
a very excellent glycerine soap is also made by Messrs. Bell, and no 
doubt a pure article of this kind can generally be procured from 
any large chemist; but I have been assured on undoubted au- 
thority that whole tons of soap are sold, bearing, according to the 
demand in the market, the name of glycerine soap, or sunflower- 
oil soap, and coloured according to the taste of the day, which do 
not contain a drop of the liquids from which they take their names. 
Most of the medicated soaps, if strong enough to have any effect at 
all, set up such irritation in some persons that they cannot be borne. 
I have heard in especial several persons complain most bitterly of 
the suffering they endured from the use of juniper-tar soap. 

The one exception I have mentioned is the transparent soap 
made by Messrs. Pears originally for St. John's Hospital, and since 
that time for at least two other hospitals. It is, after boiling, 
thoroughly dissolved in alcohol, precipitated and made up again. 
It consists of pure oil and the lowest necessary amount of alkali. It 
contains no scent and no medical ingredient whatever, and thus 



136 Preparations of Tar ; Baths, 

produces, perhaps, less irritation in the skin than any known 
substance of the kind. 

It is almost time the authorities agreed on some of these points. 
Mr. Startin denounces soap,* substituting paste made of oatmeal, 
or gruel made of bran, oatmeal, linseed-meal, arrow-root, or starch ; 
or he prescribes warm milk-and-water, or yolk of ^gg and water. 
Mr. Wilson, on the other hand, is such an advocate for soap 
that he thinks there can hardly be too much of it : when it sets up 
irritation, the fault lies not with the soap but with the skin ; if the 
skin will not bear soap it must be trained to do so. He recom- 
mends, t almost indiscriminately, the better kinds of glycerine soap, 
Carrick's elder-flower soap and Groux's turtle-oil soap. The latter, 
I believe, is no longer made, not having proved remunerative. 
Glycerine soap is, I believe, useful, in so far as it does no harm ; 
but I have invariably found yellow soap irritate the skin in eczema, 
however useful it may be in health. 

The preparations of tar, such as those from juniper tar, the 
russian birch tar, creosote, &c., form so important a group as to 
merit a notice by themselves. I have had little experience of 
juniper tar, but both the others appeared to me inert. I never saw 
creosote do any good, and I know that others have noticed the 
same thing. Perhaps Mr. Naylefs statement, J that there is a wide 
difference between the ordinary creosote prepared from wood and 
the german creosote obtained from coal tar, which is almost identical 
with carbolic acid, may account for some of the discrepancies in 
the results. The russian tar produced no effect except sometimes 
in the dry stage, whereas in lepra it is often very useful. 

Baths, hot or cold, simple or medicated, saline or chalybeate, 
turkish or russian, are one and all useless or injurious in eczema ; 
more generally the latter.§ Sheridan is said to have remarked 
that man is not altogether an amphibious animal, and certainly 
eczema does not prove him to be one. In fact it is one of the 
complaints in which the human skin will not bear much steaming 
of any kind. Dr. Ross says that in weakly persons suffering from 
lichen, he has seen a fresh crop of pustules break out after each 
warm bath, and I have observed the same thing in eczema; 

» Medical Times, 1858, vol. ii. p. 245. 

t Healthy Skin, sixth edition, p. 162. 

J Treatise on Diseases of the Skin. 

§ Journal of Cutaneous Medicine, vol. i. p. 67. 



Baths in Eczema. 137 

Dr. Lorry has noticed it in prurigo.* Vapour-baths of dry air 
and sulphur-baths proved still more injurious than the others. Still 
there is no denying that baths with linseed, gelatine, quince-seed 
mucilage, glycerine and starch seem to have been very useful in 
the hands of Mr. Startin, some of the physicians at St. Louis and 
other writers. Some of the continental surgeons make great use of 
baths, sometimes employing various kinds in conjunction ; for 
instance, M. Bazint uses starch and sulphur or alkaline baths at the 
same time, prescribing along with them a vapour-bath occasionally. 
M. Hardy also uses baths in eczema,} as does Hebra. 

There is one way in which the sulphur-bath may be occasionally 
very useful, and that is, as a rude means of diagnosis. The papular 
or pruriginous form of eczema is, like impetigo about the hands and 
feet, only to be discriminated with great difficulty from scabies ; there 
is little to rely on except the presence of the insect and the history 
of the infection. The latter is often obscure, and the detection of 
the acarus is difficult enough to those not versed in such vexed 
matters, and not very easy to the most experienced. Eruptions on 
the mammae in women, especially those who are suckling and 
have infected children, on the insides of the thighs, lower part of the 
belly, and the knuckles in adults, and on the breech in infants 
are, of course, suspicious, but they are not pathognomonic signs. 
Now, a few sulphur-baths generally do a great deal of good in 
eczema really resulting from scabies — for this is sometimes a com- 
plication and not a cause — ^whereas in eczema proper, they are 
useless or set up irritation, which, however, disappears promptly 
when they are left off. 

Mr. Alfred PuUar has given § a short but very clear account of a 
mode of treating eczema by means of an impermeable dressing, 
which seems to answer very well in some cases of eczema of the 
limbs in old people. It was first brought into notice at St. Louis 
by M. Hardy, and consists in covering the parts completely with 
vulcanized india-rubber cloth, made of ordinary cotton cloth 
overlaid with a solution of caoutchouc and subsequently vulcanized. 
Hebra, who has tried the plan, had stockings, gloves, caps, &c., 
made of this cloth for his patients, and found it answer very well. 

• Bateman's Synopsis ^ p. i6. 
t Affections cutanies^ p. 31 1. 
X Lemons sur les Maladies de la Peau^ p. 77- 
§ 'journal of Cutaneous Medicine^ vol. iii. p. 41. 

T 



138 Exercise. 

A.fter a covering of this kind has been kept for a few hours on 
a patch of eczema, the surface appears quite wet, and the fluid, 
which collects on the skin in considerable quantity, emits a very 
penetrating odour. The application is not uncomfortable, inducing 
neither heat nor itching, and when sufficiently long continued, seems 
to have the effect of gradually removing all the symptoms. Some 
cases are mentioned by McCall Anderson, in which old-standing 
eczema was promptly and thoroughly relieved by the use of these 
impermeable dressings. 

Exercise, — ^After counselling the patient to protect the skin as 
much as possible from the air, it may seem a contradiction to 
recommend plenty of out-of-door exercise ; but trial will show that 
they are quite compatible. All things that irritate the skin should 
be kept from it, and the air does irritate it. The most successful 
local treatment seems to be that which most effectually wards' off 
the air, and I suspect that the efficacy of the nitrate of mercury 
ointment is due, not to any curative power it possesses, but to the 
fact that the nitric acid combines with the albumen of the serum and 
epidermis so as to form a crust almost impermeable to the atmo- 
sphere. Too much light is almost as injurious, and I have often 
traced relapses to long exposure to the sun, or to the east winds in 
very bright days. Indeed, in some very severe cases, and until a 
certain progress has been made towards recovery, the best plan 
would probably be to shut patients up in a dark room. But cases 
which require such stringent measures are exceptions, and in general 
the patient is all the better for plenty of fresh air and exercise. As 
a rule, I have no faith in 'any system of treatment which compels 
people to stay in the house. M. Rayer says* that he has met 
with " several cases of eczema, in which a vast variety of therapeutic 
agents had been fruitlessly employed whilst the patients went on 
with their usual occupations and took active exercise, but which 
were successfully attacked by the same means from the moment 
these individuals consented to lay themselves up." This may now 
and then happen with patients who are unable to procure a sufficient 
supply of wholesome food ; who sleep in close, overcrowded, stink- 
ing bedrooms ; who have to stand a great deal, and to face all 
weathers, or who lead a very hard, anxious, or wearing life ; but I 
have never seen an instance in which I could fairly trace the in- 
curability of eczema to such causes as exercise only. 

* A Therapeutical and Practical Treatise^ &*c. By P. Rayer, M.D., p. 302. 



Diet 1 39 

Again, great exhaustion may militate against the patient taking 
much exercise, especially in the shape of walking, which is not a 
desirable method when there is any great weakness, or when it is 
carried to the extent of inducing fatigue. Apart from these excep- 
tions, I always advise as much of it as the patient can get, especially 
in the shape of boating, cricketing, riding, &c. 

Diet, — ^As to diet, all that ever I have observed points to one 
conclusion, namely, that eczema is another word for exhaustion. It 
occurs to a great extent among those who work too much and use 
an innutritions diet, or in whom mal-assimilation is going on. In 
some persons it seems to be almost a necessary result of an improper 
mode of living and overtaxed energy. Great anxiety, which is so 
potent and prevalent an agent in the development of this malady, 
almost certainly entails some degree of exhaustion. I have often 
found that patients suffering from eczema, as indeed from many 
other forms of exhaustion, either owing to want of appetite for plain 
wholesome food, or to want of means, go day after day without 
dining; living on tea or coffee and bread and butter, or bacon, 
bloaters, sausages, or something of that kind, "as a relish." One of 
the worst cases of eczema I ever saw was in a gentleman, who 
boasted that he never dined. He took six or seven cups a day of 
strong coffee and the sort of diet I have just mentioned. Long 
before he was rid of his tormentor he was quite satisfied that he had 
been making a mistake. In some few cases this complaint may be 
brought out or kept up by the over free use of stimulants ; but it 
prevails very extensively among temperate persons and total 
abstainers; and in children, among whom it is seen to such an 
extent, stimulants can have nothing to do with its appearance. 
Occasionally it seems to come on from want of fresh vegetables, and 
wears much the appearance of scurvy (for which it is frequently 
mistaken by patients), being marked by great loss of strength, soft, 
spongy state of the gums, indented tongue, foul breath, tendency to 
bleeding from the mucous membranes, costiveness, coldness, and 
coarse muddy look of the face, often with great dejection of the 
spirits. 

I have always found that a good plain diet, containing a fair 
amount of meat, say half a pound a day for an adult, with a large 
proportion of fat, an item only too often omitted or objected to by 
patients, with plenty of well-boiled vegetables, fat ham, or bacon and 
eggs daily for breakfast, and some good red wine, was most suited 



140 Wine; Over-feeding. 

for eczematous persons. The patient should eat only brown or 
household bread, the white bread commonly sold containing 
scarcely any nutrient matter. Fat bacon fried, boiled eggs, and 
brown bread form perhaps the most nourishing and digestible diet 
that can be put upon the table. After numerous trials, in which I 
have been very kindly assisted, I am disposed to say, with very little 
if any qualification, that in eczema red wine is much superior to any 
kind of beer or spirits, and that the best kinds I have tried are 
tarragona and claret. As in pityriasis, the latter answers very well 
in extremely hot weather. A grown person suffering from eczema 
may take at least three to four glasses of tarragona a day ; and even 
children bear a glass daily very well, particularly if made into negus. 
When the weather is neither very hot nor very cold, two glasses of 
tarragona and four of claret mixed together make a very useful and 
pleasant substitute for either separately. In women who are suck- 
ling stout may sometimes be given, but it never answers so well. 
When the scorbutic s)niiptoms just spoken of are prevalent, pure 
lemon-juice becomes invaluable ; and it is a singular fact that no 
remedy which I have tried relieves the sensibility to cold, often 
noticed in eczema, so quickly as lemon-juice ; but only the freshly- 
squeezed juice should be employed ; that sold in the bottle by fruit- 
erers and confectioners cannot be relied on. The same effect from 
lemon-juice has been noticed in the cold stage of ague. 

From starving, bleeding, and purging, men have gone to the other 
extreme. Fat meat, cod-liver oil, bran biscuits, five or six glasses of 
wine daily, stout to dinner, rum-and-milk first thing in the morning, 
hot milk and beaf tea between breakfast atid lunch, and even food 
during the night, are now given to patients who a few years since 
would have been restricted to gruel and tea, dry toast and barley- 
water, with about as much solid food as would just keep a baby 
alive ; a diet much more calculated to hasten the passage of the spirit 
to another world than to support the frame under the devastating 
action of calomel, antimony, and black draught ; bleeding and 
leeches. In skin diseases, at any rate, extremes meet, and at a 
point where they do mischief ; the high feeding of the present day is 
as hurtful as starvation was. It might in rare cases be put in requisi- 
tion for a few days, with the view of relieving great exhaustion, but 
as a system it does not answer. Too much animal food is especially 
injurious in eczema. We do not know very much about the action 
of food, but this much is well known ; for it is an established fact, 



Starvation; Salt Meats. 141 

that however good may be the meat on which soldiers and sailors 
are fed, if they have too much of it and too little vegetables, they 
get into a state of purpura, frequently accompanied by eczema and 
certainly close akin to it ; both blood and tissues being in such a 
state that a slight blow will blacken a whole limb. In training for 
prize-fights the men are put on a diet composed almost exclusively 
of bread and meat, and for a time seem to get into extremely high 
health on it ; but in a very well-informed paper (All the Year Round) 
it was stated, some few years ago, that the health of a great number 
of these men very rapidly breaks down after a few trainings, and that 
an unusual proportion of them are cut off by dropsy and consump- 
tion, to an extent which the supposed looseness of their lives will 
not altogether account for. On the other hand, the better the feed- 
ing, so long as it is well digested, the healthier the skin : starvation 
makes it coarse, flabby, and offensive to the smell. Hufeland 
mentions • that a lunatic, who wanted to starve himself to death, 
exhaled a most noisome smell from his skin so soon as the starva- 
tion began to tell upon his health. To a certain extent I can con- 
firm this. Not only have I observed that the skin is upon the 
whole more offensive in the underfed, even when cleanly, but I have 
notes of six or seven cases where, to my surprise, I had remarked 
that persons whom I had known in better circumstances, and in whom 
I had then never noticed it, had acquired during poverty a very 
unmistakable odour. At the same time, I cannot say that these 
observations are sufficiently complete to warrant me in drawing any 
particular conclusions. They point to some fact, but nothing more. 

In acute eczema, or very sudden and severe relapses,, a light 
diet, such as chicken, rabbit, ham, veal broth, with fish, as soles and 
whiting for instance, and farinaceous diet, is often advisable for a 
few days. Again, I have often seen people worse after indulging 
too freely in pork, curries, or strong soup, and patients themselves 
firequently notice the fact. 

Mr. Wilson does not fear any ill effects from the use of salt 
meats ; he thinks it bad reasoning to argue that, because soldiers 
and sailors suffer from scurvy owing to their being fed so much 
on junk, therefore our salt meats, which are fresh and sweet com- 
pared with junk, are likely to bring on scurvy. A monotonous diet 
he thinks injurious, as does Mr. Hunt, who holds that so long as 

• Hufeland's Art of Prolon^ng Life, edited by Erasmus Wilson, second 
edition, p. 29. 



142 Salt Meats ; Monotonous Diet, 

there is plenty of change it is of little moment what people eat, and 
that half the skin diseases under which children at boarding schools 
suffer, owe their existence to the sickening monotony of the food 
and the restraint. As a change, salt meat occasionally, especially 
such salt meat as good fat bacon or boiled ham, can do no- harm, at 
least I never saw any ; but the frequent use of meat out of which 
the juice has soaked, and the fibre of which has perished and become 
saturated with salt and nitrate of potass, cannot fail to be productive 
of mischief. The patient just spoken of took no meat except of this 
kind. Mr. Wilson also looks with little favour upon salads, pota- 
toes, and watercresses ; salads he thinks are only made tolerable by 
adding the oil to them, and watercresses have merely their pungency 
to redeem them. On the other hand. Dr. Edward Smith * and Sir 
Thomas Watson consider potatoes as a very valuable article of diet 

It must be obvious too that if all substances are to be expunged 
from our diet because they do not evidently contain nutriment, we 
should have to reject salt, which is one of the necessaries of life, 
and tea, coffee, pepper, and many other things which common 
experience has agreed to look upon in the same light. Moreover 
the positive craving felt by sailors for food of this kind, when they 
have been on a long voyage where none could be obtained, shows that 
the almost universal taste for such things as watercresses, salad, 
&c., is founded on a want felt by the system — ^the prompting of an 
instinct likely to be quite as sure a guide as the ponderings of a 
philosopher. 

I am strongly inclined to agree with what Mr. Hunt says in the 
former part of the preceding paragraph, though I quite dissent from 
his view as to diet having no influence over eczema. Boarding schools, 
as a rule, all deteriorate the health ; but I think it is of great con- 
sequence what people eat when suffering from this complaint, and 
that very few can be trusted to exercise their own discretion. There 
is a proverb which says that at thirty every man is a fool or a 
physician. The wide-spread acceptance of this adage shows how 
much men like to be relieved from the trouble of thinking. As 
often happens in such cases, a very thin husk of truth conceals a 
mass of absurdity. It is true that at thirty a great many men are 
fools ; Carlyle says this is the case with most of us. Again, it is 
true that at thirty a few men are physicians, that is to say, in the true 
sense of the word ; but a man has only to cast his eyes about, 

• British and Foreign Medico-Chirurgical Review^ 1865, vol. ii. p. 103. 



Diet as a Cause of Eczema. 143 

and he will see that the majority of mankind are neither the one 
nor the other. The proverb, however, is generally supposed to 
mean that at thirty every man who is not a bom fool knows what is 
best for him in the way of diet, exercise, baths, &c. Admitting that 
a few men, who have contrived to ruin their digestion at that early 
age, or who have naturally a very weak stomach, or are extremely 
fastidious, are aware that certain things will agree or disagree with 
them, it is yet quite certain that they know nothing of what is best 
suited to repair the waste going on in disease. The best authorities 
are so completely at variance here, that anything like certainty 
is quite out of the question, and we have only crude observations 
and convictions to rely upon. As to baths, &c., men have been in 
general so little able to judge rightly, that nearly every improvement 
in this direction, as in ventilation, drainage, &c., has been forced 
upon them by medical men ; and with regard to exercise, the form 
in which it is taken by nine persons out often is absolutely injurious 
in such exhausting diseases as eczema. 

Hebra doubts altogether the power of diet as a cause of eczema ; 
he has seen it amongst the most regular-living people using the 
most rational diet, while others, committing every excess, never 
showed a sign of it. Equally does he object to the idea that the 
seasons, such as the spring time and fall, have any influence in 
causing its outbreak, and that the cold of winter and great heat in 
summer cause more attacks than the times of the equinoxes. The 
first of these views may be met by this question — Do errors of diet 
tend to cause outbreaks of eczema in those predisposed to the 
complaint ? to which I think a decisive answer in the affirmative may 
he given. 

For young children the best kind of food appears to be a 
farinaceous diet, with plenty of milk, and a fair amount of fresh 
meat. Their taste for sherbet and whey, shell-fish, sweets, and 
green fiiiit should be kept in check. Cod-liver oil is an excellent 
article of diet for most children suffering from eczema, especially 
during the winter months. Too much animal food, however, 
especially lean meat, is almost always injurious here, as indeed it 
is generally for young subjects " I have certainly," says Dr. Henry 
Bennett, " throughout my professional career remarked, as already 
observed, that meat-fed children, and great meat-eaters are not 
stronger than other people. With children, indeed, it is the reverse. 
The children whom I have attended, who have lived on meat, 



1 44 Bread, 

eating it three times a day — certainly not by my advice — have not 
proved as strong nor as healthy as those who lived on a more mixed 
dietary;" experience which will, I think, be borne out by every 
observing physician. Pale brandy may be given to children when 
they are suffering greatly from exhaustion ; but to be of any service 
must be administered in tolerably large quantities. 

One thing ought never to be omitted in respect to the diet of 
children, and indeed of adults too, and that is, to supply them with 
good bread ; by which I do not mean fine and white bread, but that 
which contains, in addition to the starch, certain necessary elements 
of nutrition — the gluten, cerealin, and phosphates. A great deal of 
the stuff sold as white bread, especially that made with what is called 
cones flour, is simply a bad kind of starch and yields little more 
nourishment than as much sawdust. Instead of being adequate to 
support life, it is doubtful if it can effect any purpose beyond dis- 
tending the stomach and diluting more concentrated food : in this 
way it may have its use. Pure brown bread, properly made, is much 
superior in nutritive power ; but in order to save trouble, bakers often 
prepare it by throwing so much bran into the " sponge " of the 
ordinary white bread. The consequence is, that when new it lies 
too heavy on the stomach of a delicate child, and if kept for a day 
or two, even in a covered pan, gets so dry and hard that children 
cannot be induced to eat it. Irrespective of this, the coarse particles 
of the bran frequently irritate the bowels in children and even in 
many grown persons. Patients with a strong constitutional ten- 
dency to rosacea are very apt to suffer in this way. Bread, however, 
prepared with the flour made by Messrs. Orlando Jones, the 
proprietors of Chapman's patent, is free from this objection. Mr. 
Squire states that this flour contains a considerable amount of 
phosphates more than can by the same process be obtained from 
ordinary wheat flour, and also more gluten, probably derived from 
the finely ground bran which is mixed with it. Mr. Attfield fixes the 
proportions at i4'i of gluten and 1*62 of phosphates (ash), while the 
same preparation, sold roasted, is even richer ifi these bodies. It also 
contains the cerealin which adheres to the inner surface of the bran 
and is entirely lost in the ordinary process. I have long been in 
the habit of recommending patients to make their own bread, first 
of all boiling the bran for quite twenty minutes in water and then 
using this decoction to make the bread with. The deficiency of 
cerealin, for which this process was intended to compensate, being, 



Bread ; The Phosphates. 145 

however, now supplied by Chapman's invention, I have for some 
time substituted his flour, especially as it is extremely difficult to 
get people to make their own bread at home though they commit a 
great mistake in neglecting to do so. So far it has answered ex- 
tremely well. The bread made from it resembles the " bolted 
bread " used in the north-west of England and the brown bread of 
the north-eastern counties, on which some of the finest and healthiest 
peasantry and farmers in the world are reared. Children generally 
take to it very well. When they do not I find that a mixture of 
equal parts of the flour used for good brown bread and the entire 
wheat flour makes a very good stepping-stone — an intermediate 
stage which reconciles them gradually to the use of the entire wheat 
bread. Grown persons make no objection about beginning, and 
when they have once begun, soon acquire such a taste for it that 
many of them never like any other kind so well. It does not, how- 
ever, find favour with some of the bakers, and naturally enough ; 
as a pound of it contains about as much nourishment as a pound 
and a half to two pounds of common bread, an extensive use of it 
would materially interfere with their profits. 

This flour, as has been shown, contains a large amount of phos- 
phates in a natural form, and to this fact some portion of its value 
may possibly be due. It is not a subject on which I feel at 
liberty to speak with any degree of authority, but from observa- 
tion I am strongly disposed to consider the importance of these 
salts as overrated. Certainly, artificially made and given, they 
appeared to me inert, and I have seen no evidence that their ad- 
ministration benefits the health in any way, unless when combined 
with fneans which often suffice to effect such a change even when phos- 
phates are not given ; while it is certain that some children grow up 
strong enough on diet which is assumed to bring on in others a state 
requiring the use of phosphates. Observation has shown me over 
and over again that there is every reason to think, that to whatever 
extent the material wanting to the system is thrown into the 
stomach, no more is taken up than previously until some improve- 
ment in the health ensues ; whereas, under purgatives, brandy, 
wine, cod-liver oil, et simiiia, which do not contain the wanting 
element, the very object sought to be attained by giving the phos- 
phates ensues to as great an extent as I believe it can under any 
system of medication ; that is to say, children get stouter, stronger, 
and healthier, and this on such various kinds of diet that it seems 

u 



146 Diet of hifants, 

as if any sort of food used in this country yielded sufficient 
phosphates for the restoration and preservation of health, if only 
the digestion and assimilation be first of all set right. To administer 
these salts then, in excess, seems to me a step negatived by reason 
and not sanctioned by experience ; indeed such treatment appears 
to be founded on the theory that certain effects ought to follow, 
not on observation of results which have followed the administration of 
certain substances, the only base on which any system of therapeutics 
can rest. 

The greatest attention should be paid to the diet of infants. In 
the Medical Times and Gazette for 1867 there is a very well-written 
article on this subject, and the different addresses are given where 
the best varieties of infant's food can be procured. The writer's 
bias seems clearly to be towards Liebig's food, prepared, however, in 
a better way than at first recommended. My own experience would 
lead me to look upon it as superior to any other kind of infant's 
food; but it is difficult to prepare, and mothers must be warned 
that remissness on this head will ruin everything. 

But there is one article of diet for these little folks, when suffering 
from bad eczema, syphilis, or severe scabies, which I give to an 
extent that will probably excite scepticism when I announce it. I 
am quite prepared for this, having repeatedly noticed the surprise 
and incredulity which the statement almost always elicits. However, 
it is a question of fact, not of credibility. The article I allude to is 
pale brandy, and the amount given is four, five, and even six table- 
spoonfuls a day to children under a year old. One or two table- 
spoonflils mixed with a little warm water, and a small quantity of 
sugar, may be given the first day, and the quantity be gradually 
increased. The brandy should always be given after a meal, and 
the quantity administered during the day should be divided into 
equal poftions for each dose ; for instance, should six tablespoon- 
fuls be given, and the child have the breast or food eight times 
within the twenty-four hours, about two-thirds of a tablespoonful 
should be given after each time of feeding. 

It is surprising how very well young children thrive upon this 
system. Mothers who were quite horrified at the idea of giving 
even a teaspoonful of brandy to a baby, have become so convinced 
of the benefit the children derived from it that they were only too 
solicitous to continue the treatment. Several have said that under 
its influence the children have recovered, quite against their 



Mr, Star tins Treatment. 147 

expectation. The quantity is large, I admit; but small quan- 
tities, such as a teaspoonful, have never appeared to me of any 
service whatever. It is absolutely necessary to use pure cognac ; 
even a small quantity of grain spirit will often make a child quite 
ill. I therefore wish to be distinctly understood on this point. I 
do not say that brandy is suited to such cases, but that pure pale 
grape brandy is. 

When that cannot be procured, the best beetroot brandy, which is 
now made by some distillers with great skill, being indeed so 
exceedingly well flavoured that it can scarcely be distinguished from 
genuine brandy, may be used instead, but I have no hesitation in 
saying, that good as it is, the superiority of genuine cognac still 
remains established. 

Such are the remarks I have to make with regard to the leading 
forms of eczematous disorders. The varieties offer nothing to detain 
us. Those like eczema solare, I consider to be simply blistering 
from heat, and therefore requiring little beyond a mild febrifuge or 
aperient and cold cream, or a soothing lotion of bismuth or lead. 

The mode in which Mr. Startin's principles of treatment were 
given to the public does not enable one to reproduce his opinions 
upon individual remedies, or even a particular course of treatment, 
so much as it does upon the mode in which certain special cases 
are to be treated. I have, therefore, selected some cases from 
his lectures, published in the Medical Times* and endeavoured to 
give as brief and accurate an analysis of them as I could. It may 
be stated, however, in general terms, that Mr. Startin's treatment 
of eczema is much the same as that for impetigo, and which the 
reader will find in the section devoted to that complaint, and that 
he relies very much on baths, using vapour baths, daily tepid ablu- 
tions with yolk of egg, mucilage or bran water ; he places great 
confidence in the bisulphuret of mercury in ointment, and for 
children, when there is great irritation, a mixture of Goulard's liquor 
and cream. 

Case I. Eczema solare. Purge with calomel. Iodide of potas- 
sium gr. iv., liq. potassae m. xx. ; ter die sum. ; vapour baths, lotion 
of borate of soda used tepid ; ointment of bisulphuret of mercury. 
Cure in less than three weeks. 

Case 2. Eczema rubrum in a man seventy-two years old. Wash 

• Vol. xiii. pp. 449 and 489. 



148 Mr. Star tins Treatment. 

with warm linseed tea, after which an ointment composed of mer- 
curial ointment diluted, and creosote ; mucilaginous bath once; pr 
twice a week ; one-sixth of a grain of bichloride of mercury ii^ter- 
nally. Relapse : iodide of potassium, purge with infusion of seinna, 
opiate at bedtime, lotion of trisnitrate of bismuth warm twice ;a day, 
afterwards a small quantity of liquor arsenicalis. Cure. 

Case 3. Eczema rubrum complicated with hepatic derangement 
in a woman aged forty-four. A quarter of a grain of bichloride of 
mercury with ten drops of laudanum three times a day. Bathe d^y 
with yolk of egg and tepid water ; wash off this, and apply ointment 
of bisulphuret of mercury 5 to Ji. ; after this, trisnitrate of bismuth 
suspended in water by means of glycerine ; aperient chalybeate in 
bitter infusion ; vapour bath once or twice a week. Cure in les§ 
than five weeks. ; 

Case 4. Chronic eczema rubrum in a strumous lad of sixteen. 
Liquor potassae in large doses, with five-minim doses of tincpire of 
iodine, to be taken three times a day ; a twentieth of a grmn of 
arseniate of potash at bedtime ; biniodide of mercury ointment, a 
scruple to an ounce, at night; weak saline bath containing a few 
grains of iodide* once a week. Afterwards, biniodide of mercury in 
solution internally and creosote ointment. Cure in forty-two :flays. 

Case 5. Chronic eczema rubrum in a female aged forty-three ; a 
very aggravated form of the disease, the skin being almost lij:^ the 
shell of a boiled lobster. Daily baths of linseed mucilage, ablutions 
with yolk of tgg in water, trisnitrate of bismuth and bichloride of 
mercury in lotion ; internal use of bichloride of mercury with opium. 
Restoration to perfect health in a month. Chalybeate waters and 
bitters. Remained well. ' 

Case 6. Impetiginous eczema in a woman. An emetic for disorder 
of the stomach caused by overfeeding, followed by iodide of pot^; 
sium in infusion of senna, with weak ointment of bisulphuret «9( 
mercury and creosote ; warm baths. Large doses of liquor potassae^ 
with four-minim doses of liquor arsenicalis. Nearly well in thirty- 
five days 

Case 7.t Eczema in a child two years old. Six-ounce mixture, 
containing one ounce of the iodide of potass mixture of this hospital 
and five ounces of water ; a teaspoonful three times a day ; wash with 
yolk of egg and water, and rub in nitric oxide of mercury ointment 



• I 



presume iodine is meant here. f Medical Times, 1858, vol. ii. p. 245. 



Mr. Wilsons Treatment. 149 

Rapid improvement is said to have ensued in this case, which 
belongs to a much later date than the others, and is selected by the 
reporter as a specimen of the treatment generally adopted at the 
Blackfriars Hospital, but the subsequent progress of it is not men- 
tioned. The iodide of potass mixture consists of a drachm of iodine, 
an ounce of liquor potassae, and a pint of distilled water. The oint- 
ment is made with two ounces of lard, two ounces of olive oil, a 
clrachm of powdered nitric oxide of mercury, half a scruple of oil of 
' bitter almonds, and a drachm of glycerine. 

Mr. Wilson treats eczema with strengthening medicines and 
arsenic. Steel is his principal tonic ; next to it, but subordinate, 
is the nitro-muriatic acid in bitter infusion.* Arsenic he employs 
in all the usual forms, except that of Donovan's solution, against 
which he cautions his readers.f Purging he seems resolutely to 
avoid, especially in the case of children, for whom he only prescribes 
the most gentle aperients, such as magnesia, rhubarb, and manna. 
He considers no external applications necessary beyond the ben- 
^oated oxide of zinc ointment, which is suitable alike to all stages 
qf the complaint. A part affected with eczema should never be 
yvashed. To relieve the itching he orders emulsion of almonds with 
hydrocyanic acid, J or a spirit and borax lotion, § or some preparation 
pf tar ; II but he holds lotions to be objectionable, as, unless they 
^pntain oil or glycerine, they are apt to leave behind them a certain 

* He does not give the fonnula or doses in his last work on these diseases, but 
t believe the following represents one of his favourite prescriptions : — 

R. Acidi nitrici diluti, 

hydrochlorici dil., aa, 5ij. 

Infus. quassiae ^xiss. r\. 
Capiat cochlear, ampl. duo bis terve quotidie. 
* t The formiila for the ferro-arsenical mixture will be found at p. 33. 
'•'^ • ' JR. Acidi hydrocyan. diluti 5ij. 

; Spirit^s rectificati 5xiv. 

Emuls. amygd. amar. 3^'j* ^ ft* lotio. 
§ R. Boracis 5ij. 

Olei benzoat. vel glycerini 5vj. 
Emuls. amygd. amar. Jvij. i»i ft. lotio. 
\\ Asj for instance, Hebra*s : — 

R. Olei picis juniperi 

(Huile de cade, vel oleum cadmium), 
"' ! Saponis mollis, 

' '>■ • Spirit^s rectificati, aa. 5j« 

Aquae Jix. ni ft. lotio. 



150 Dr. Frazers Treatment. 

degree of dr3naess. When there is a good deal of hardness and 
infiltration in the affected part he employs Hebra's plan, that of 
painting, by means of a sponge-brush, a solution of equal parts of 
caustic potass and water over the surface. When there is very 
great irritability he brushes the part with a solution of nitrate of 
silver (two grains up to a drachm in an ounce) in distilled water or 
nitric ether. This treatment, especially in respect to eczema infantile, 
is almost infallible. No relapses or adverse circumstances ever occur 
under his care.* 

One of the most valuable papers I have ever read on this subject 
appeared in the first number of the Journal of Cutaneous Medicine A 
It is by Dr. Frazer, and contains a digest of much original observa- 
tion. Strengthening medicines are his great remedies. He uses 
iron in certain cases, particularly when anaemia is present ; } but his 
chief tonics seem to be yellow cinchona and cetraria ; the syrup and 
tincture of cinchona for children, the decoction and infiision for 
adults. Along with these he gives bichloride of mercury, one-twenty- 
fourth to one-sixteenth of a grain twice a day. . When there is gout 
he prescribes colchicum in small and repeated doses, along with 
bark and mercurials, following it up with daily doses of citrate of 
lithia in some aerated fluid, or with lithia water, with the view, I 
presume, of obviating deposit of urate of soda by forming a soluble 
urate of lithia.§ When the nervous energy is exhausted, dilute 

• "With one exception, all the cases recovered. . . . The only numerical 
evidence that we can offer in support of this statement is, that fourteen cases we 
only saw once, eleven cases twice, . . . and so on. . . . If the case went on 
satisfactorily, the child was not brought back. ... If any adverse change had 
occurred, there can be no doubt that the patient would have been brought again ! " — 
Natural History of Eczema^ by Erasmus Wilson, 'journal of Cutaneous Medicine^ 
vol. iil p. 403. The inference drawn here, then, clearly is, that every patient 
not seen again was cured, 
t Vol. i. p. 63. 
:{: As in the following form : — 

R. Ferri ammon. tart. 5ij. 

et quiniae citratis, 9ij. 

Acidi citrici 9ss. Misce et solve in vini Xerici ^xxiv. 
Capiat cyath. vinar. dimid. bis quotidie. 
§ I would suggest a trial of these formulae : — 

R. Lithiae citratis 9ij. Divide in chart, vj. 
Capiat i. ex aquae selzer vel liquoris sodae effervescent. ^YJ. omni mane. 
Or R. Liquoris lithiae effervesc. ^vj. 

omni mane sumend. 



Dr. Frazers Treatment. 151 

phosphoric acid and strychnia may be ordered ; the latter is espe- 
cially useful when severe pruritus is present ; indeed, Dr. Frazer 
seems to have had great success in the treatment of this troublesome 
sjrmptom. He gives one-fiftieth to one-twenty-fourth of a grain three 
times a day.* Acidity of the stomach and dyspepsia he meets with 
bismuth and soda.+ Sulphur and arsenic he finds useless. 

Dr. Frazer's local treatment consists in the use of bran baths, and 
the application of the yellow nitrate of mercury with glycerine, J 
working the ointment into any fissures by means of a small mop of 
lint tied to a wooden penholder, and the cerate of the red iodide 
of mercury ointment. Lotions he thinks a mistake ; baths, espe- 
cially those containing sulphur, he places in the same category. 
When eczema attacks the scalp, he finds yolk of ^gg^ mixed with an 
equal quantity of water, the best detergent he knows of To fissures 
he applies red iodide of mercury, six to twenty grains in an ounce 
of cerate, sometimes adding a little iodide of potassium ; a method 
which he considers equal to Hebra's application of caustic potass 
and much less dangerous. If the patches be very extensive, and the 
moist secretion from them considerable, he dusts the surface with an 
astringent powder. § Dr. Frazer considers " expatriation to distant 

• His prescription is : — 

R. Strychniae gr. j. 
Tinct. aurant ^ss. 
Acidi phosphor, diluti 5iij. 
Infus. caryophyll. Jxj. m fiat mistura. 
The subjoined formula is, I think, rather an improvement on Dr. Frazer's : — 

R. Strychniae grani partem tertiam. 
Acidi phosphor, diluti ^ss. 
Syrupi aurantii Jss. 
Infus. caryophyll. (vel calumbae) Jxj. m. Capiat 5j. ter quotidie. 
t R. Bismuth, trisnitratis, 

Sodse bicarbon., aa. 5iss. 
Pulv. gum. acaciae, 
Sacchari albi, aa. 5ij. 
Olei cinnamomi gtt. ij. Misce. 
About half a drachm to be taken in water after each principal meal. 
\ R. Ung. hydrarg. nitratis, 

cetacei, aa. 5ij. 

Glycerini Jij. m. 
§ R. Amyli zei maidis 5j* 
Zinci oxydi 5j« 
Pulveris iridis, Jss. 
Olei amygd. essent. gtt. x. Misce ft. pulv. 



152 Dr. Tanners Treatment. 

watering-places uncalled for," a view in which I think every sensible 
person will agree with him. 

Dr. Tanner, in a work * which is an honour to the age that has 
produced it, recommends mild, local applications, such as thin gruel, 
barley-water, linseed-tea, lead lotion, &c. He also finds frequent 
bathing with warm alkaline or starchy water very soothing. Glyce- 
rine, too, mixed with starch or water, is often beneficial. In some 
cases a mixture of soft soap, and the tar ointment of the british 
Pharmacopeia, rubbed in night and morning, has answered better. 
He also uses the linimentum calcis, and the ammoniated mercury oint- 
ment. The latter he finds very useful when there is thickening and 
infiltration of the skin. Cleanliness should be carefully attended to. 

itis general treatment consists in the use of warm and tepid 
baths, plain diet, with fresh meat, and plenty of milk, and daily 
walking exercise. As medicines he orders saline laxatives, or an 
occasional dose of blue pill and colocynth, slightly acidulated drinks, 
opiates to relieve irritation, sarsaparilla, and mineral acids. If the 
kidneys act insufficiently he gives a diuretic like the acid tartrate 
of potass. In severe or chronic cases, steel, quinine, arsenic, 
separately or combined,t and cod-liver oil have proved most 
usefiil. For gout Dr. Tanner prescribes colchicum,J and when 

• The Practice of Medicine^ sixth edition, 1869, vol. ii. p. 396. 

t R. Tinct. quiniae 5 A* j* 

Liquoris arsenicalis m. xviij. 
'■" -. Ferri et ammonise citratis gr. xxx. 
'^'fr 'Aquse aurant. ad 5 A. viij. r\. 
Pars sexta bis tc^ quotidie sumend. 
Dr. Tanner directs this medicine to be taken after mtals. Although the authority 
of so excellent a practitioner is against me, I must adhere to the opinion I have 
elsewhere expressed (an opinion founded not only on experience, but what I 
rate still higher in such instances, observation specially directed to the point in 
question), that steel and quinine should be pven before meals, quinine especially, 
and separately from the arsenic. 

X R. Hydrargyri subchloridi, 
Extracti colch. acet., 

aloes Barbaden., 

Pulverii ipecacuan., aa. gr. j. Misce ft. pil. 
To be taken every four hours till the bowels are well acted on. In gout, with 
congestion of the liver. Or 

R. Extracti colch. acet;, 

aconiti, aa. gr. j. 

Pilulae hydrargyri gr. ij. nt. ft. pil. 
To be taken every night at bedtime. In gout, with deficient action of the liver. 



Dr. Tanner's Treatment ; Dr. M. Wilsons. 153 

Theumatism is present iodide of potassium and bark,* or iodide 
of iron.f In great depression of the nervous system he resorts 
to hypophosphite of soda or lime, and where there is a syphi- 
litic taint to mercurial vapour baths and the red iodide of mercury. 
In one very obstinate case of eczema he gave the patient, a lady, 
two tar capsules:]: three times a day, with excellent results. 

In infantile eczema Dr. Tanner gives aperients of magnesia, 
rhubarb, and calomel, and directs that great care should be 
taken to secure a supply of pure milk. The scabs are to be 
softened with olive oil and bread poultices, zinc ointment, 
acetate of lead ointment, or elder-flower-water lotion being sub- 
sequently employed. He also gives arsenic with steel wine, and 
cod-liver oil with a little sweetened orange juice. 

Dr. Marris Wilson recommends § a trial of sedatives when there 
is much nervous excitement In one case which he mentions, that 
of a female patient who had suffered long and severely from eczema, 
the benefit was very marked, and possibly the plan might succeed ; 
but in two or three cases where I gave these medicines I noticed no 
particular effect either from large or small doses. In one there was 
considerable improvement. The patient, a man in the prime of 
life, took four successive nights a scruple dose of hydrate of chloral 
to relieve the pain of rheumatism. He had at the same time several 
irritable patches of eczema in the dry stage and of long standing. 
The use of the remedy was followed by great sleepiness the two first 
nights, and still greater excitement the two succeeding. Profuse 
sweating occurred each morning. At the end of six days the patches 



* R. Potassii iodidi gr. xxx. 

Potassse bicarbonatis gr. Ix. 
Tincturee hyoscyam. 5 fl. iij. 
Infus. cinchonae flav. ad 5 fJ. viij. ni. 
Stunat partem sextam ter quotidie. 

t R. Potassii iodidi gr. xij. 

Ferri et quiniae citratis gr. xxx. 
Tincturae aconiti m. xxv. 
Infus. chiratse 5 f^- YJ. tn.. 
Capiat partem sextam ter quotidie, 
Or, R. Syrupi ferri iodidi, 

Extract, sarsae liquidae, aa. 5 AJ- ""l- 
Capiat coch. min. i. ter quotidie ex aquae cochlear, amp. ij. 
J These tar capsules each contain about six grains of tar. 
§ Journal of Cutaneous Medicine, vol. ii. p. 45. 

X 



i 



154 Dr. Hillier's Treatment ; Mr. Naylers. 

had improved so much that only the stains remained, and he has 
been, on the whole, better since that time. 

I am inclined, therefore, to think the plan might be useful in the 
dry stage. When eczema is secreting freely, and especially in the 
ulcerating form, the only sedatives I have tried, opium and morphia, 
have, I confess, disappointed me as regards the cure of the disease. 
I have frequently kept the pain under by the free use of these means 
for weeks, without bringing on any change for the better in the 
eczema. I have then given the acid solution of iron, and have 
seen a rapid improvement both in the pain and the disease of 
the skin. 

Dr. Hillier,* in a case of general eczema of twenty years* 
duration, accompanied by chronic bronchitis, gave five-minim 
doses of liquor arsenicalis and ten grains of sulphate of zinc, 
three times a day, applying zinc ointment at the same time. 
The patient recovered rapidly. In acute eczema he used to give 
a puige such as colocynth and calomel, following it up with 
salts and senna. If the pulse were full and bounding a quarter 
of a grain of tartar emetic was added to the draught After 
this salines were given. To less robust subjects he gave a milder 
purge, such as sulphate of magnesia with bicarbonate of potass 
and tartaric acid with lemon juice. Externally he employed a 
powder of starch, oxide of zinc, and camphor. Later on he 
prescribed arsenic. When there was any suspicion of a syphilitic 
taint he ordered Donovan's solution. Alkalies, such as liquor 
potassae, he thought decidedly useful. Dr. Hillier held that the 
diet should be very simple, pork, cheese, highly-spiced food, pastry, 
and all indigestible things being prohibited. Locally he preferred 
mild preparations of mercury, and for severe itching, cyanide of 
potassium ointment, four to eight grains of the salt to an ounce. 

Mr. Nayler has great faith in antimony in the acute stage. In 
the summer months he gives alkalies, such as the acetate or 
chlorate of potass, to children. In the pyogenetic form of eczema 
he finds an ointment of fifteen to thirty grains of sulphur and 
the same quantity of blue ointment to an ounce of lard, very, 
efficacious. As a lotion he praises the carbolate of glycerine 
made by Calvert, and in chronic eczema recommends a solution 
of sulphate of copper as very useful in allaying irritation. 

* Handbook of Skin Diseases, 1865, p. 116. 



Dr. M^Call Andersons Treatment. 155 

Dr. M'Call Anderson gives, when there is any tendency to gout 
or rheumatism, acidity of the stomach and deposit of lithates, 
sesquicarbonate of ammonia in doses gradually increasing up to 
forty grains twice a day. He recommends a suitable diet, but 
after all seems to place more reliance on local than on constitu- 
tional means. He removes the crusts by softening them with oil, then 
bathing with warm water, poulticing, &c. The surface beneath is 
then dusted with some mild astringent powder, such as starch, over 
which a cold starch poultice may be laid. He also uses occasionally 
an ointment, such as that of the oxide of zinc, or cucumber, or cold 
cream. When there is much infiltration he employs the solution of 
potass recommended by Hebra,* and in troublesome chronic eczema 
solution of chloride of zinc, a scruple to an ounce.f He recom- 
mends as a lotion, free from both staining and smell, carbolic 
add, four grains to an ounce. Against pruritus he employs hydro- 
cyanic acid and chloroform ;J he also makes free use of prepara- 
tions of tar.§ 

• R. Potassse causticoe gr. ij. ad gr. xx. 
Aquse 5j» i*l ft* solutio. 

Or, R. Potassse causticse, 

Aquse, aa. 5j. m ft. solatia 

t As the addition of gum acacia is useful, I give a formula which, I think, 
represents Dr. Anderson's views : — 

R. Zinci chloridi 5j. 

Mucilaginis acacise 3^* 

Glycerini 5iij. 

Aquse rosse ^ij. n\ ft. lotio pro eczem. manuum. 

J R. Acidi hydrocyan. dil. (Pharm. Brit.) 5ij. 
Aquse rosse ^viij. 1U ft. lotio. 

R. Chloroformi 5ij. 

Linim. camphorse 5vj. in, ft. liniment. 

Neither of these should be applied too freely at first : the chloroform liniment 
because it acts on some skins with great rapidity, setting up considerable irrita- 
tion ; the acid lotion, because absorption of it by an abraded surface is not free 
from danger. Should the reader wish to combine chloroform with hydrocyanic 
acid in a lotion, he should bear in mind that the first of these two fluids, when 
mixed with water, glycerine, or weak spirituous solutions, immediately separates 
from them. 

§ R. Olei rusci, 

Spiritils rectificati, 

Eau de cologne, aa 5j. 

Potassse causticae gr. xv. x\ ft. linimentum. 



1 56 Dr, Swift's Treatment ; Dr. Spender^ s. 

Dr. Swift considers* the external treatment of infinitely more 
importance than the internal, and relies on baths, and fluid and 
oleaginous preparations ; using in this form nervous sedatives, as 
opium, camphor, or hydrocyanic acid. He also makes use of cold 
in the shape of lotions, and sheaths the part attacked in some mild 
oleaginous preparation, such as benzoated zinc ointment, cucum- 
ber ointment, or carron oil. In the second stage he employs 
astringents, such as acetate of lead, in tiie form of ointments, oil of 
cade or carbolic acid. Absorption of the thickened state of the 
derma is to be effected by blisters, tincture of iodine, strong solution 
of potass, or rubbing in green soap as suggested by Hebra. 

Dr. Spender thinks black wash very useful in eczema rubrum. He 
applies it by means of strips of lint, over which is placed a thin 
calico bandage. In some bad cases where this treatment has failed, 
he has used nitrate of siver with great benefit Dr. Durkce finds 
carbonate of lead ointment (5ij.), mixed with prepared chalk (5iv.), 
and simple ointment (Jij.)) very useful when the eruption is limited 
and the discharge active. For eczema of the lips he uses a cerate 
of oil, yellow beeswax, new honey, and oxide of zinc. 

Holding such views as Hebra does about the entire independence 
of eczema on any internal disorder, we can scarcely wonder that he 
entertains no very high opinion of the action of internal means of 
cure. All these medicines, he says, are useless and wasteful. They 
are injurious except when eczema is called into play by previous 
disorder of the organism, or when it is complicated by another 
disorder. Antimony, iodine, sarsaparilla, and purgatives are equally 
bad ; arsenic itself is only useful in a few refractory cases ; cod-liver 
oil internally is useless. 

What, then, are the almost omnipotent means destined to outvie 
mercury and arsenic, iodine and steel, sulphur and cantharides, and 

R. Picis mineralis, 

Spiritiis rectificati, aa. ^j* 
Liquor, ammonise m. iv. 
Glycerini 5iij. 
Aquae ^iijss. m ft. linim. 
Or, R. Hydrarg. nitr. oxid. 9j. 

Ung. hydrargyri nitratis 5j. 
Olei betulae albae 5iss. 
Adipis benzoat. 5iv. m. 
I should have thought that even a small quantity of benzoin in the lard would 
reduce the mercury. 
• Anurkan Journal of Syphilography, &c., 1S70, p. 103. 



Hebrds Treatment. 157 

dismiss them to the limbo of forgotten horrors ; which are to degrade 
them to the rank now held by the old sweating tub and rolled clout 
of the quicksilver doctors ? They are certainly a most formidable 
phalanx. I cannot spare space for them in extensOy and am not 
sure that I clearly understand to what particular class of cases 
or exactly in what order Herr Hebra applies his means of treat- 
ment 'y but I believe the following condensed account may be relied 
on as representing his system fairly. Free use is made of water 
which has been boiled so as to throw down its salts, rain water, 
distilled water, or water in which almond bran or wheat bran has 
been boiled, or decoction of marsh mallow, common mallow, or 
marsh violet (pansy, viola tricolor). By constant use of these we 
soften and relieve the itching, possibly quell it, and even cure many 
cases of eczema. Then come vapour and shower baths, particularly 
useful in eczema of the head or hairy parts of the body. The 
shower baths are to be taken three or four times a day, with half an 
hour's walk after each. Bv these means we can, in the course of a 
few months (im Zeitraume von mehreren Monaten), cure eczema or 
aid other means of cure. After tlie shower baths comes the con- 
sideration of the value of fatty matters. So long as we can secure a 
due consistence, the nature of the material is unimportant, and a 
long list including such materials as cream, nut oil, linseed oil, &c., 
is given, which may be used at discretion. The grand object is to 
keep the oily substance constantly on the part and prevent its being 
rubbed off. For the latter purpose wool may be used without any 
fear of its irritating. In eczema of the hairy scalp, Hebra rubs in at 
least twice a day about an ounce of oil, and covers the head with 
flannel. He seems to be partly of M. Rayer's opinion, that it is 
as well for the sake of the moral effect to have at command a number 
of ointments, even if some of them only differ in colour. With this 
object in view, he gives a list of those which may be employed \ they 
are very numerous, and comprise lead, quicksilver, and zinc, and 
ointments of various kinds, which may also be combined with spirit 
of wine and camphor, glycerine, peruvian balsam, &c. His favourite 
preparation seems to be one of lead or diachylon. Then come the 
caustic ointments, such as those of white and red precipitate, and 
yellow ioduret of mercury, to be employed in the papular and 
squamous forms. Next we have the substances to be used in 
watery or spirituous solution, such as sulphate of zinc, corrosive 
sublimate, borax, and caustic potass. These are adapted for red 



A 



158 Hebrds Treatment 

eczema of small extent. A strong solution of caustic potass (one 
part of the salt to two of distilled water) is our last refuge in 
obstinate cases, as it heals them infallibly (indem es allerdings jedes 
Eczem ohne Ausnahme heilt), but occasions great pain. All crusts 
and scabs having been first removed, the solution is quickly rubbed 
over the part with a dossil or brush of lint (Charpiepinsel), and 
directly after the hand or a piece of flannel soaked in water is 
passed rapidly over the part Compresses dipped in cold water are 
then applied and covered with wax-cloth or gutta-percha tissue. 
The cauterization may be repeated every eight days, and on an 
average not more than twelve cauterizations are needfiil. In general, 
however, Hebra prefers to this friction with potass soap (Schmierseife, 
savon mou) or spirit of soap. For partial frictions a piece of this 
soap, the size of a walnut, is laid upon a cloth and rubbed hard 
upon the eczematous patch for several minutes, the cloth being 
repeatedly dipped in water. After this either water is applied or 
one of the ointments or oils spoken of. This is done twice a day 
till no more excoriations are seen. For more extensive outbreaks it 
is simply smeared upon a cloth and laid upon the part for several 
days together. For eczema of the hairy scalp the spirit of soap 
(spirit, saponatus kalinus). Tar is very useful when there is not 
much infiltration and weeping, but it should be used with great 
scruple at first, only a small patch being selected for experiment, as 
it sometimes increases the itching to an intolerable degree. It is 
not to be used in acute eczema, or where there is great serous 
infiltration of the skin. When it can be borne it is to be painted on 
the part twice daily till the secretion no longer washes it away. 
Carbolic acid he considers a valuable preparation in eczema of the 
hands, face, or^any part^that cannot be covered. To sulphur he 
ascribes very little^virtue ; indeed ''in acute[eczema and red eczema 
when discharging fireely, in the impetiginous and vesicular forms, it 
is injurious. The diffierent forms of eczema also require means 
which form a protecting surface, *as collodion, or absorb the exuda- 
tions, as do the seed of the club moss (witch-meal), powder of starch, 
orris root, alum, zinc, &c. &c. In acute eczema the two last are 
useful, but if there be much burning and itching,J[cold lotions with 
acetate of lead or Goulard's water may be applied, but they are to 
be employed sparingly till we see if the patient can support them. 

Herr Hebra then goes'fully into details as to the treatment of 
eczema fixed in any particular part. I would gladly enter here 



Bazins Treatment; Ulcer. 159 

more fully into these, but it is not practicable. It must suffice to 
say that he treats eczema of the head and face with local applica- 
tions of cod-liver oil, tar soap, carbolic acid, &c. ; adding, in grown 
persons, the cold dash, painting with spirit of tar, and the oils 
spoken of. For eczema of the face he employs solution of sulphate 
of zinc, caustic potass, &c. ; of the ear, compresses smeared with 
some of the ointments given above ; of the nipple, solution of 
sublimate, five grains to an ounce, or the solution of caustic potass, 
one drachm to two of water ; for eczema marginatum, preparations 
of sulphur, as sulphuret of potassium in water ; for eczema of the 
lower extremities, of the armpit, bend of the arm, thigh, &c., the 
diachylon ointment, &c. 

Bazin's treatment of eczema in the acute stage consists in the 
frequent use of light purgatives, baths, and small doses of alkalies ; 
externally, cataplasms of flour or rice, powder of rice or flour, &c. 
Later, pomade of glycerine, or calomel, sulphate of iron, or carbonate 
of soda. In the acute herpetic form he follows up the antiphlo- 
gistic treatment with acid drinks, as of lemon or dilute sulphuric 
acid. For the dry and scaly stage, oil of cade, pure or mixed with 
an equal quantity of sweet almond oil ; also alkaline, sulphur 
and vapour baths ; for red eczema he advises rest, bleeding, light 
diet, diluents, dusting with starch, and afterwards emollient and 
sulphur baths. 

B. Ulcer. 

To my thinking all divisions of ulcer into painful, irritable, 
indolent, &c., however valuable they may be from a pathological 
point of view, are useless in practice. The only division I would 
recognize is that into specific ulcers, such as those from s)rphilis, 
and common ulcer. The former I leave aside; the latter I 
propose to treat as one and the same disease, under whatever form 
it may appear, and however it may be complicated; as after all 
ulceration, , whether slow or rapid, whether painful or indolent, 
is essentially the same process so far as the effects of treatment are 
concerned. All other questions are merely matters of extent, 
degree, complication, &c. ; they do not in any way touch the fiinda- 
mental part of the subject. 

The only means of treatment which I have seen useful in 
ulcer are : 

I, Raising the position of the foot at night, and, if possible, 



i6o Treatme7it of Ulcer. 

by day also. Putting a stool or pillow under the foot is useless ; it 
only increases the pressure of the bedclothes on the aifected part, 
especially in winter, and even when this is averted by means of a 
cradle,' the limb gets wearied and aches, and the patient is kept 
awake and distressed by. the irksome posture and want of support 
for the back of the leg. To secure a proper position, the foot of the 
mattress must be raised, so that there is a regular slope from the hip 
to the far end of the bed, the patient's foot being raised quite eight 
or ten inches above the hip. The best plan that I know of for 
attaining this end is to procure two pieces of board, A^ B, long 
enough to reach from the hip to the end of the bedstead, and quite 
eighteen inches broad. These meet at C, and are there firmly fixed 
together, the edges being planed off so that they run to a sharp 
line, thus securing an even, unbroken slope. A third piece, Z>, of 




D 



the requisite depth, that is to say, six, eight, or ten inches, as the 
size of the patient may require, is placed between the other two, and 
the whole nailed together. The rest is now simply placed under 
the mattress of the bed (Z> resting against the foot of the bed) or 
the squab of the sofa. This done, the surgeon may confidently 
assure the patient that the pain, weariness and engorgement of 
the part under which he has been suffering, will speedily begin 
to yield. 

2. A sedative every night. Taking all things into consideration, 
opium is perhaps the best, and the best suited to hospital practice 
because it is the cheapest. I am inclined, however, to think that so 
long as two or three indispensable conditions are attended to, it is of 
very little consequence what sedative the surgeon uses ; extract of 
poppy, lettuce, henbane or hemlock, nepenthe, chlorodyne and 
morphia are possibly all equally good. Some of them I have never 
tried, and, therefore, cannot give any reliable opinion as to their 
powers. I have, however, made numerous observations with respect 
to hyoscyamus, lettuce, poppy, opium, and acetate of morphia, and 
am disposed to put as much faith in pure opium as in anything 



Sedatives in Ulcer. i6i 

Morphia is, however, a very valuable remedy, particularly in 
conjunction with ammonia.* 

But there are certain conditions necessary for success, what- 
ever ingredient be selected. The first is that the drug employed 
should be pure and fresh, a great deal of what is sold as opium, 
extract of hyoscyamus, &c., being so adulterated and stale, as 
to be well-nigh useless. The second, that however high we may 
carry the dose, we must subdue the pain. Accordingly, though the 
patient need scarcely begin with more than a grain of opium, 
or a third of a grain of morphia at bedtime, yet I have never any 
hesitation about giving three times this amount if necessary. The 
third requisite is to take care that the liver does not get too sluggish, 
and the bowels too confined, complications which are apt to follow 
the prolonged use of sedatives. Hence an aperient is often very 
useful here.f 

When the appetite is bad and the tongue foul, the surgeon may 
give an acid and bitter, or the acid of solution of iron of St. 
John's Hospital, previously mentioned, which often relieve these 
symptoms though they possess little if any control over the ulcer. 
I have repeatedly seen a sore which was progressing very well under 
their use, aided by proper local treatment, begin to relapse so soon 
as ever the latter was remitted, although the medicines were 
continued ; I observed this happen three times in the same patient. 
Indeed, I have never been able to satisfy myself that any medicine 
possesses the slightest power of making a common ulcer heal up. 
In sluggish ulcers, I have sometimes given a long course of small 
doses of biniodide of mercury, with a view of inducing absorption of 

• A grown person may begin with any of these preparations : — 

R. Liquoris morphiae acetatis 5ss. 

ammoniae acetatis 5iij. 

Syrupi rosse 3ij. 
Mist, camph. ad ^iss. m- 
Fiat haustus hord decubit. sumend. 

R. Tinct. opii crocatse m. x. 

camphorse compos. 5ss. 

cardam. comp. 5j. 

Mist, camphorse ad ^iss. 
Misce et fiat haustus omni nocte sumendus. 

R. Opii purificat. gr. xij. 
Divide in pil. xij. Sumat unam omni noct^ 
J* As^ for instance, the pill at p. 12. 

Y 



1 62 Local Applications in Ulcer. 

the hard, thickened welt surrounding the sore, which is supposed to 
prevent healing (though I believe that this view is erroneous, and 
that a coincident symptom has been here confounded with a cause), 
and have now and then fancied it did some little good in this way, 
but it was very slight if not altogether an illusion. 

3. The avoiding of all irritating applications. Generally speaking, 
all ointments, lotions, poultices, concretes, plasms, operations, irri- 
tating and expensive contrivances like elastic stockings, are, with a 
few exceptions, one and all utterly unnecessary in every kind of ulcer. 

The exceptions, then, are these : — Should there be much inflam- 
mation round the ulcer, a weak lead or bismuth lotion * may be 
applied to any extent thought proper. Such occupation as this 
sometimes amuses an anxious patient, and that is something \ but 
I should very much question whether the lotion possesses the least 
influence over the sore. When an ulcer is healing, that is to say 
when the bottom of it is level with the surrounding skin, and the 
edges begin to draw near each other, the use of benzoated zinc 
ointment will often expedite the healing process ; it acts, I think, 
solely by soothing the surface and warding off the irritating action 
of the air. A turnip poultice may be used to remove any foul 
smell, particularly in close weather, or when there is a very free dis- 
charge of serum with very dark colour of the adjacent skin. When 
turnips cannot be procured, a weak solution of chloride of zinc or 
carbolic acid, used warm, proves a very good substitute. Strong 
decoction of poppies, applied hot, possibly has the power of reliev- 
ing pain and may be tried when this symptom is very troublesome. 
Indolent ulcers should be freely blistered. I always employ this 
remedy at least once a month in such cases, but I consider it a 
mistake to restrict it to this form of sore. Any ulcer may be blis- 
tered. I have repeatedly tried the experiment with very painful 
sores, and can assure the reader that there is nothing to dread. 
Should the patient be very timid, or the surgeon very nervous, about 
doing this, the ulcerated surface may, first of all, be covered with 
lint, and the blister applied over this and the surrounding skin ; but 

* R. Liq. plumbi subacetatis 5iij. 
Glyceringe 5iv. 

Mist, camph. ad ^viij. *n. ft. lotio. 
R. Bismuth! suhnitratis 5ss. 
GlycerinjE 5iv. 
Aq. flor. sambuci ad Jviij. m ft. lotio. 



Bandaging. 1 6 3 

the precaution is scarcely called for. Except, however, in indolent 
ulcer, blistering is not absolutely demanded unless other means have 
failed. The only dressing the blistered surface, or indeed the ulcer 
itself, requires, is soft cotton wool or lint, and, generally speaking, 
the best fomentation or lotion for the ulcer is simple hot water poured 
from a moderate height upon it. 

4. Proper bandaging. This is the grand thing, the one really 
indispensable feature in the treatment. In the first place . a good 
bandage must be selected, and to my thinking there is no material 
equal to flannel. When the sore is small and superficial, or when 
the weather is very hot, a thin, cheap variety, such as is used at 
St. John's Hospital, may be employed ; but when the weather is 
cold, or even temperate, and when the ulcer is deep or indolent, so 
that a good strain is required to bring the edges together, there is 
nothing like the best welsh flannel. It should be all in one piece ; 
the system pursued by poor patients at hospitals, of tearing a yard 
into strips and felling those one on another, is bad : the pieces are 
rarely of the same breadth, so that the bandage does not lie flat 
at the folds, and the ridges, where it is joined, fret the skin. The 
selvage should be rejected. A width of from two inches to two and a 
half is quite sufficient, and the bandage should not be less than seven 
or more than eight yards long. When taken off", it should be care- 
fully sponged with lukewarm or cold water, ironed with a flat-iron 
at as low a heat as will allow of the creases being taken out, and 
then rolled very firmly up ; one person holding it while the other 
winds it. If hot water be thought necessary to secure cleanliness, 
it may be washed in hot soap-suds and then wrung out, without 
putting it into any other water, so as to avoid shrinking. A pad of 
lint being now laid upon the ulcer, the bandage is passed twice 
firmly roimd the instep, and then the heel, ankle, and leg are care- 
fiilly and uniformly bandaged up to the knee. When the ulcer is 
indolent, considerable pressure may be applied almost from the 
outset ; when very painful, too much gentleness cannot be exercised. 
As the bandaging cannot always be borne at first, tjie patient should 
be told to take it off" so soon as ever he finds that it is occasioning 
more pain, and then to have it put on again as soon as possible. 
Mr. Hunt, when bandaging, fills out the hollows of the ankles 
with tow or cotton wadding; I have not found this necessary. If 
possible, the surgeon should bandage the ulcer two or three times 
a week. 



164 Bandaging ; Rest. 

But all the advantages likely to be gained by the most careful 
attention to these points will be thrown away, unless the surgeon 
is quite au fait at putting on the bandage itself. I do not know 
whether this little operation is now taught in our medical schools or 
not. Judging from what I hear, I should not expect it. An age 
which has pretty generjdly expelled from its curriculum vaccination, 
spermatorrhoea, almost everything connected with skin diseases and 
the surgical part of dentistry, diseases of the eye and deformities ; 
which quietly proposes to destroy the special institutions in which 
these great branches of surgery are studied and taught, because it is 
found that they prove dangerous attractions to students and patients ; 
which reserves its honours for useless and cruel experiments in 
physiology, and its censures for those who strive to improve treat- 
ment ; is scarcely likely to recognize such a very elementary subject 
as bandaging. Indeed, among the leaders of the medical world we 
should be sure to find a good many who would not even try to hide 
their contempt for persons so far behind the age as to think it of 
more consequence to show how a few thousand ulcers may be healed, 
than to demonstrate how the process of ulceration takes place — the 
one promotes the march of science, the other only relieves misery. 
One is therefore not surprised to find Mr. Gay, in his truly admirable 
Lettsomian lectures on ulcers, after devoting a hundred and sixty- 
seven pages to pathology, dissections, &c., giving us, at the very 
ciose,y2?«r pages of treatment, heralded in by something which sounds 
very like an apology for broaching such a topic. 

Rest is often a most important part of the treatment. In slight 
cases the patient may continue his ordinary work, and generally a 
certain amount of exercise, such as a moderate walk, will do no 
harm ; long sitting or standing almost certainly retards the cure. In 
severe ulcers the patient should, if possible, lie up. I know it is very 
difficult to carry out this rule, but it is sometimes the only means 
of insuring success. A short time ago I had under my care a most 
severe case. The patient was a very tall, meagre, underfed and over- 
worked man, seventy-four years of age, with a large deep ulcer on 
the lower and inner part of the left leg ; on the right leg was a large 
sore over the tendo Achillis, and a deep one on each side of this, 
while on the front of the leg, reaching from the middle of the tibia to 
the middle of the dorsum of the foot, was an immense, ragged, deep 
ulcer. Three times I had succeeded in reducing this large ulcer to 
one-third of its original dimensions, and bringing the skin and granu- 



Varicose Veins. 165 

lations to a level, and each time a relapse took p^ace in cooscquence 
of his havii^ to go to work again. 

Some suigeons conEider that in varicose ulcer we cannot rely on 
effecting a cure, or at any rate a lasting one, unless the state of the 
vdns be remedied, for which I need not say that several different 
(^erations and forms of treatment are recommended, I believe this 
to be a mistake. I was at one time under the same impression, but 
experience has taught me that this kind of sore may be cured quite 
as fast as any other without doing anything for the veins, and that 
the treatment of these can be more conveniently carried out after- 
wards, I am quite of Mr. Gay's opinion ; • the varicose stale is here ■ 
simply a compUcation and not a cause. 

Of all the modes of treat- 
ment I have seen put in force, 
I prefer that of tying the 
veins by simply passing a 
needle underneath them, with- 
out any cutting, and then 
winding a thread over the two 
projecting ends, like a figure 8, 
the sharp end of the needle 
being subsequently cut off with 
pliers. When the patient ob- 
jects to this, a very simple and 
efficacious plan is to wear the 
flannel spiral bandage made by 
Messrs. Walters and Co., the 
extreme cheapness of which 

renders it peculiarly adapted to hospital practice. It consists of 
a narrow slip of flannel, not more than an inch in width, and 
bound at the edges with white silk. It should be quite eight 
yards long. The part intended for the foot should be made like a 
stirrup, and drawn well up on the instep. The rest of the bandage 

• " It is impossible, I thinlt, to avoid the further inference that ulceration is not 
a direct consequence of varicosity, but of other conditions of the venous system, 
with which varicosity is not unfrequently a complication. ... I infer, therefore, 
that pathologically, this doctrine of the varicose ulcer does not appeu' to ' hold 
water;' that, to rdterale my conclusions, ulceration, when it exists with vari- 
cosity, but without other complication, is a coincidence and not a consequence." 
—On Varicatt Disaisi. By John Gay, F.R.C.S. 1868, p. 99. 




1 66 Results of Treatmerit. 

is then wound pretty tightly in a spiral line round the leg up to the 
knee, where it is tied in a bow by means of the tapes, as shown in 
the engraving. This bandage gives the patient great comfort, and 
relieves the aching, weariness, and sense of weakness about which 
patients suffering from varicose veins often complain. It is very 
cleanly, does not confine the perspiration like elastic stockings, and 
being very inexpensive, is easily renewed. Moreover, the adjust- 
ment of it is a very simple matter. I need scarcely say, that though 
it may relieve, it is not very well adapted to the cure of varicose 
veins.* Elastic stockings, being based on an unsound principle, 
that of trying to compress a whole vein instead of a part^ should, in 
my opinion, never be resorted to. I believe them to be perfectly 
useless, while they are at the same time dirty, uncomfortable, and 
expensive. 

The quickness with which ulcers of every kind, except the 
indolent, heal up under this treatment, must be seen to be 
realized, and even the most sluggish ulcers yield to it much more 
quickly than to anything else I have seen put to the test. Ulcers 
which had gone on getting worse for months and years have begun 
to narrow and fill up almost directly. Among other cases I may 
mention that of an immensely stout old woman, a patient at 
St. John's Hospital; she was so corpulent that she could not 
stoop to touch her foot, and had two enormous ulcers, one on 
each leg. They had been open for nearly seven years, and for 
some time past the pain had been so great as to deprive her, 
to a great extent, both of sleep and appetite; she had not, she 
said, been able to taste plain food for weeks ; yet both these 
large ulcers closed up rapidly and healthily, under bandaging, 
aided by a sedative every night. In another case, an ulcer of 
the leg in a patient at the same institution, a delicate underfed 
woman, which had lasted more than twenty years, healed in a few 
weeks when properly bandaged. I treated a girl who had been 
nine months under the care of a very skilful surgeon with a bad 
ulcer of the leg. The gentleman in question seemed to have taken 
all possible pains with the case, except that he did not resort to 
bandaging, and the patient to have faithfully carried out his 
instructions, using a perfect host of lotions, poultices, ointments, 

. * I believe Mr. Startin was the first to employ a bandage of this kind, but I 
am not sure. 



TJie Arterial Ulcer. 167 

mixtures, &c. Notwithstanding all this the sore had got per- 
sistently worse, yet, under bandaging, it had diminished to less 
than half its size, within a fortnight, and in less than a month 
had cicatrized, though no dressing was applied beyond a piece of 
dry lint. There is a patient now attending at St. John's Hospital, 
whose disease, when he first came under my care, was of the most 
unpromising nature. The patient was an elderly man, of most 
unwieldy frame, being almost as stout as the woman referred to. 
Being a watchman, he was greatly exposed to inclement weather, 
and could get no rest. He had a very large, deep, indolent 
ulcer on the lower and outer part of the leg; the surrounding 
tissues were so infiltrated as to feel like brawn, and the ulcerated 
surface was covered with a tenacious, adherent, greenish slough. 
When I last heard of him this sore had considerably diminished 
under bandaging, bUstering, and opiates. These are only a few, 
out of many instances — sufficient however, I hope, for the purpose 
aimed at. 

I believe most cases of ulcer will yield to this treatment when it 
has fair play. I should not expect to have any success with one 
which had encircled the leg or nearly so. What is more, I believe 
it would be useless trying any method of treatment with persons 
in this condition, as they either could not, or what is more pro- 
bable, would not, carry out any instructions. A patient, with an 
ulcer in this state, has in general systematically neglected it and 
will most likely continue to do so. Mr. Gay mentions a form of 
ulcer which he calls the "arterial" and considers utterly in- 
curable. I have not seen this variety, but, judging from my own 
observations, I should have said that the only thing likely to make 
an ulcer incurable was its having extended over the whole, or 
nearly the whole, circumference of the limb. My readers, how- 
ever, I doubt not, know that Mr. Gay has studied ulcers with 
great care, and that he has written two excellent works on the 
subject. I therefore do not for a moment expect them to 
prefer my opinion to his, nor do I indeed seek to controvert 
Mr. Gay*s views. I merely state the result of my own ex- 
perience. 

Mr. Gay recommends,* in all cases, rest, with the foot elevated 
above the pelvis in the simple and venous ulcer, and on a level 

* On Varicose Disease^ p. 167. 



1 68 Gays Treatment of Ulcer. 

with it, or inclined in another direction in the arterial ulcer.* 
The simple sore, if acutely inflamed, is to be treated with leeches, 
scarification across the edges of the ulcer, hot applications, con- 
stitutional remedies, purgatives, calomel when the biliary system is 
deranged, and opiates if the sore be painful. When the inflamma- 
tion is subacute, when the tissues are thickened and the edge 
welted, he blisters. Irritability is to be subdued by opium, 
quinine, and iron, applying, at the same time, a strong solution 
of nitrate of silver to the surface. For (constitutional weakness 
tonics and change of air with generous diet. When, after all this 
has been done, the ulcer still refuses to heal, the surface should be 
destroyed by some powerful escharotic, as the solution of the per- 
nitrate of mercury. In tedious and doubtful cases of simple 
chronic ulcer he has seen the best results from the administration 
of the liquor hydrargyri bichloridi with iodide of potassium. For 
venous ulcers he still prefers incisions at the edges.t When great 
pain accompanies an ulcer, especially at night, it arises from 
periosteal complication and requires opium, iodide of potassium, 
and occasionally free subcutaneous division of the periosteum. 
The arterial ulcer is incurable. In conclusion he again adverts to 
the value of incisions, and tells us that sores of from one to 
twenty years' standing have been made to heal under this treat- 
ment. Without wishing in the least to detract from the justness 
of Mr. Gay's estimate respecting the value of this measure, I may 
still remark that at one time I tried incisions very extensively, and 
that I found many patients refuse to submit to them the first time, 
while few would endure a repetition. Yet he tells us that " it 
may be necessary to repeat the incisions, even to two or three, on 
either side of the ulcer." That ulcers of twenty years' duration 
heal under it, I firmly believe, but so they do under bandaging. 
Some authors recommend yeast poultices ; Mr. Wilson holds that 

• ** Ulcers of the leg are, in relation to their pathological genesis, divisible into 
three species : — 

** I. The simple ulcer ; that in which the morbid processes are limited to the 
confines of the tissues directly engaged therein. 2. The venous ulcer ; most fre- 
quently with * bronzing * and induration of the skin ; dependent upon obstructive 
disease of the trunk veins, superficial or deep. And 3. The arterial ulcer; 
generally vdthout bronzing, but with induration of the tegument, and due to 
incompetency of the arteries through disease of their coats." — Ibid, 

t On Indolent Ulcers, By John Gay, F.R.C.S. 1855, p. 94, 



Treatment of Ulcer. 169 

if we can keep a layer of carbonic acid between the ulcer and the 
air, the healing of the former is only a question of time ; the 
explanation, I suppose, being, that the irritating action of the air is 
thus effectually warded off. The simplest way to do this would be 
to place the whole limb, up to the knee, in an oiled-silk bag filled 
with the gas, taking care that there was no escape at the place 
where it was in contact with the skin. Galvanism has been very 
successfully employed by some surgeons ; it may be applied by 
means of a piece of thin silver, the size of the ulcer, laid upon it ; 
over the silver is laid a piece of flannel, which is kept wet by 
sprinkling it with a solution of salt and water (one part of the salt 
to twenty of water) or weak dilute sulphuric acid (half the dilute 
acid of the pharmacopoeia and half water). Over the flannel a plate 
of zinc, three times as large as the ulcer, is laid, and then the 
whole is fastened with a bandage. I have seen granulation take 
place at a wonderful rate under this treatment, but it requires 
more rest than most patients can get. I need scarcely repeat, that 
where there is a varicose state of the veins, some surgeons prelude 
all treatment of the ulcer by endeavouring to obliterate some of 
the veins. When there is a thick hard welt Mr. Startin gives 
mercury, and, I believe, prefers calomel. M. Velpeau employed* 
a kind of cement to remove the smell. It was composed of a 
hundred parts of chloride of lime and one to five of dry tar, 
rubbed down to powder, and either laid upon the ulcer in that 
fonn, or first made into an ointment with olive oil. Qn the same 
principle it has been recommended to fill the ulcer up with 
chalk, or precipitate of iron.t For very painful and irritable 
ulcers Mr. Hunt recommends applying a dossil of lint dipped 
in chloric ether. 

Skin grafting seems to have succeeded in the hands of so many 
surgeons, in indolent ulcers, that it ought to have a fair trial. I 
need scarcely say that it is effected by transplanting minute portions 
of sound skin to one or more points in the surface of the ulcer. 
Mr. Goldie recommendsj that these should be kept in situ 
by means of soap plaster. Chlorate of potash, in ten-grain doses, 
twice a day, internally, with solution of the same salt in glycerine, 

* Medical Times, 1859, vol. ii. p. 237. 
t Braithwaite's Retrospect, vol. xlv. p. 260. 
% Lancet, 187 1, vol. i. p. 46. 

Z 



170 Treatment of Ulcer, 

a drachm to an ounce, has been favourably spoken of. As an 
outward application it seems to have been useful * 

Professor Fischer, of Breslau, considers that chronic ulcer 
invariably leads in time to amyloid degeneration of the kidney. 
Supposing, in the first place, a coincidence to be established, it 
will be, I think, a question as to which is the cause and which the 
effect. 

• yonrnal of Cutaneous Medicine^ vol. iv. p. 10. 



( 171 ) 



CHAPTER V.—ERYTHEMATA. 

A, Erythetna. B, Erysipelas, C, Urticaria, D, Parpura, 

E, Pernio, 

A. Erythema (a, atisy neut.) ; from ipvOpog, red. 

Definition, — A superficial, vivid redness, appearing in spots or 
patches, sometimes attended with swelling and itching. Redness 
sometimes migratory, occasionally of a purplish hue ; fades into 
a blue and yellow stain like that of a bruise. Followed by throwing 
oflf of the cuticle. 

Divisions, — i. E. simplex, marked by the above-mentioned S)rmp- 
toms. 2. E. fiigax, in which the patches form and fade with great 
rapidity ; are of irregular or circular shape. Common on face ; may 
also appear on arms, neck and breast. 3. E. laeve, a red, glazed 
state of the skin, often accompanied by tenderness and itching. 
4. E. papulatum, in which the patches are raised almost like those 
of nettle rash. 5. E. nodosum, in which the patches are very large, 
roundish or oval, much raised and very tender. Recurrent Often 
accompanied by great pain. Patches may run together. 

Dr. Purdon proposes* to group together erythema, herpes, pem- 
phigus, and urticaria, as being all neuroses of the skin. Erythema 
nodosum, in young chlorotic girls, he looks upon as a reflex neurosis 
arising from uterine derangement. Acrodynia, as an erythema, 
ushered in by pains, loss of appetite, blood-shot conjunctiva, and 

* On Neurotic Cutaneous Diseases, By Henry Samuel Purdon, M.D. 1869, 
p. 18. 



172 Prognosis of Erythema ; TreatmenL 

development of erythematous patches on the legs and arms. From 
purpura to pemphigus again there is, he considers, only one step. 
The latter will appear while the fonder still Ungers. 

Prognosis. — Erythema, even in its mildest fonn, is often trouble- 
some, as it so frequently appears when the health has long been 
giving way, or when the patient is constitutionally weak, or lias a 
marked tendency to nervous irritability, dyspepsia, rheumatism, and 
chlorosis, llie prognosis of K Iseve, when connected with anasarca, 
will, of course, depend oil the condition of the latter, its cause and 
so on. The papular form, passing into the tuberculated, is serious 
at all times. Dr. Durkee has seen four fatal instances of this 
variety. 

Treatment. — When mild, erythema scarcely demands anything 
beyond very simple remedies, such as lead lotion, or any mild 
ointment, and an occasional aperient. In more severe cases, as for 
instance, in E. nodosum and papulatum, the patient for the most 
part requires a pretty long course of iron and quinine, often 
accompanied by colchicum.* Should the appetite be bad, I would 
suggest a course of acid and bark in preference to anything, + sub- 
sequently following it up with iron, or iron and quinine. Aloes 



* R. Ferri et quinise citratis 5J. 

Liquoris ammoniae citratis Sj* 
Syrupi 5iv. 
Aquae ad Jvj. in.- 
Capiat coch. ampl. j. ter quotidie. Or 

Vini citratis ferri et ammonise ^iij. 
Capiat cochlear, min. duo ter quotidie. 
The former of these may be preferred when there is loss of appetite as well as 
of strength. The following suits nervous women very well : — 

R. Mist, ferri aromat. Sviij. 
Capiat cochlear, duo bis quotidie. 
Should rheumatic symptoms be present, I would add — 

R. Sodse carbon, exsicc, 
Extracti colchici, 
Pilulae hydrargyri, 
Ext. rher, aa. gr. vij. r\ ft. pih v]. 
Capiat unam omni nocte. 

t R. Acidi nitrici diluti 5ij. 
Syrupi aurantii, 
Tinct. cinnam. c, aa. 5iv. 
Dec. cmchonae flavse, ad Jxij. wi. 
Capiat cochlear, amp. duo bis terve quotidie. 



Treatment of Erythema, 173 

should, I think, especially in the cases of girls, be given along with 
these remedies,* and when the patient is hysterical, assafoetida 
requires to be added ; or a full dose of the compound decoction of 
aloes may be given daily, when they will take it, which is not always 
the case. A combination of this with Griffiths' mixture answers 
very well with some persons.f In some elderly persons, when the 
colon is torpid, a dose of the compound gamboge or scammony pill 
answers very well. I cured a case which had resisted treatment 
for a long time, by giving the latter until I had brought away a 
quantity of faeces almost like sheep-dung, which had evidently been 
adhering to the sides of the colon and caecum. The patient, who 
had been perpetually tormented with griping and flatulence, began 
to improve almost directly and made a rapid recovery. When 
heartburn (pyrosis) is present, I would recommend a trial of the 
prescription given below. J With the addition of some simple syrup, 
this medicine answers very well for children, especially if aided by 
the exhibition of small doses of hydrargyrum c. creta, two or three 
times a week. A short course of iodide of potassium is requisite 
when rheumatic symptoms linger, but unless I have deceived myself, 
it is rarely requisite to give more than two or three grains twice or 
thrice a day. 

But when erythema is refractory, and especially when it is so in 
adults, when it settles on the face, about the nose and cheeks, 
retuming and persisting when there is no complication to account 
for its obstinacy, then I would suggest giving a course of arsenic as 

• R. Pil. aloes et myrrhae 5j. 
divide in pil. xij. Sumat j. vel ij. omni nocte. 
Or, R. Pilulse aloes et assafoetid. 3j. 

divide in pil. xij. Capiat j. vel ij. omni nocte. 
t R. Mist, ferri co. Jvjss. 

Decoct, aloes comp. ^iss. r\. 
Capiat cochlear, amp. duo bis quotidie. 

% R. Radicis rhei concis. 3j. 

calumbse 3ij. 

zingib. Bj. 

Coriandri fruct., 
Cardamom, semin., aa. Bj. 
Sodae carbonatis 3j. 

Aquae buUient. ^YJ. tn. Post horas duas cola et adde 
Syrupi aurant. ad ^vj. 
Capiat cochlear, amp. j. bis quotidie. 
In hot weather, only half this quantity should be made at a time. 



1 74 Treatment of Erythema, 

for lichen. I believe, however, this remedy is never called for in 
young persons. 

For external use in erythema, a weak Goulard lotion, of two or 
three drachms of liquor plumbi in eight ounces of strong camphor 
mixture, may be prescribed, or a scruple or two of oxide of bismuth 
may be mixed with eight ounces of elder-flower water, to which a 
little glycerine is added. These lotions are simply poured upon a 
fold of linen rag laid upon the inflamed part Arrowroot jelly may 
be used instead. It is made by mixing a drachm of arrowroot with 
a little water and two ounces of glycerine, and gently warming, the 
whole till it becomes a soft clear jelly. This jelly is then simply 
applied in linen or a soft handkerchief the same way as a poultice. 

When erythema nodosum is extremely painful, a strong sedative 
may be applied directly to the part. Veratrin in ointment answers, 
in the proportion of two or three grains to the half-ounce, or ten 
grains of well-powdered opium may be added to the same quantity 
of lard. The ointment should be laid on pretty thickly. In girls, 
bandaging with flannel has answered very well in my hands. Dr. 
Spender employs this remedy in nearly every case, using Domette 
flannel. For the treatment of erythema laeve I must refer the 
reader to works on general medicine. I may, however, suggest 
acupuncture. 

Dr. Purdon treats* simple erythema externally with a mixture of 
five parts of glycerine and four of yolk of egg. In E. papulatum, 
tuberculatum, fugax, and marginatum, he gives aperients and 
alteratives, such as mercury and chalk, dried carbonate of soda 
and rhubarb. When acidity is present he prescribes the liquor 
calcis saccharatus in drachm doses, or calcined magnesia or bismuth. 
If mucous diarrhoea, exist, chlorate of potash, syrup of iodide of iron, 
cod-liver oil, or pancreatic emulsion ; in E. nodosum, steel, aloes and 
boraxf are his principal aids. In one case J of this variety, in a 
lady sixty years old, which had resisted every remedy, the peroxide 
of hydrogen was given with complete success. 

Dr. Cheadle, in his " Report on Hospital Practice," gives the 

* On Neurotic Cutaneous Diseases^ p. 37. 
t R. Dec. aloes compos., 

Mist ferri compos., aa. ^iij. 
Boracis 5iss. 

Tinct. hyoscyam. 5ss. in.. Capiat Jss. ter die. 
Published in the Glasgow Medical Journal^ September, 1867. 



+ 



Definition of Erysipelas. 1 75 

case of a woman in whom papular erythema was accompanied by 
acid dyspepsia, and in which bicarbonate of soda, with hydrocyanic 
acid, effected great benefit. 

Dr. Thomson, in E. nodosum, used to give bark in preference to 
quinine.* In E. laeve, when there is ground to suspect that gout 
is the cause of any obstinacy, Mr. Wilson says we may give a warm 
antacid purgative, such as Gregory's powder, or a powder composed 
of rhubarb, soda, and calumba, with or without colchicum, or 
iodide of potassium, two or three times a day, and the juice of two 
or three lemons as a cooling drink. Dr. Gregory's powder is such 
an unpalatable jumble that I wonder how people can take it at all. 
I have more than once seen it expelled immediately from the 
stomach, after a child had been compelled to swallow it, and on one 
occasion I saw a man of great resolution nearly suffocated by 
an attempt to get down a dose. As all the materials of which it is 
composed can be given in a much more palatable form,t I think 
some change for the better might be effected in this direction. 



B. Erysipelas (as^ atis^ neut.), from fpuw, to draw, drag, &c., 

and TreXac, near, surrounding. 

Definition, — Redness and swelling of a portion of skin, accom- 
panied by pungent burning, tingling and heat, sense of stiffness and 
weight in the part affected. Redness disappears under pressure ; 
returns when this is removed ; vesications, containing a pale, clear, 
yellow serum, often supervene and burst quickly. Fluid albuminous, 
with a neutral or alkaline reaction. Usually ends in resolution, but 
suppuration or mortification may supervene : latter very rare. Often 
migratory ; most frequently met with in head or face. Commonly 
preceded by disorder of health and pyrexia! symptoms. In acute 
cases resolution may be accompanied by free discharge of brick-red 
or fawn-coloured urates. Quantity of urea normal or less than 
usual; proportions of other constituents unchanged. The trau- 
matic form is omitted here as belonging more exclusively to 
surgery. 

Treatmmt, — To judge by the number of remedies advised for this 

* Medical Times and Gazette, 1857, vol. i. p. 133. 

t For instance, magnesia may be given in milk, as already mentioned ; rhubarb 
in the form of tincture, syrup, or pill, and ginger in the shaplle of syrup or tincture. 



1 76 Treatment of Erysipelas. 

complaint, there ought to be no difficulty in curing it, whatever form 
it may put on ; in the storerooms of surgery there seems to be a 
salve for every wound of this kind at least. Long ago I tried to 
draw attention to this fact, and remarked that here was a disease of 
almost uniform course and symptoms, a pure inflammation, treated 
by surgeons of great eminence on the most opposite principles and 
yet with much the same success ; proving that, on one side or the 
other, there must be something strangely and radically wrong in the 
theory of the disease ; for, if six men found each a different system 
upon the same symptoms — ^if it be considered by one an excess of 
strength and another a loss of strength, by one a spasm, and another 
a plethora ; and if such opposite means as the knife and lancet in 
the hands of one man, black draught, calomel, antimony, and 
starvation under the care of another, lead yet to the same goal as 
wine, bark, and ammonia, when given by those who hold the heat, 
pain, and throbbing to be only so many signs of prostration, the 
irregular action of weakness — then I think it is pretty clear that at 
least five theories out of six must be wrong. How are we to decide 
here, and by what mysterious process of induction are we to evolve 
some stable theory of treatment out of positions and statements so 
conflicting? or has internal treatment, as Hebra saw reason to 
believe, no control over the course of erysipelas ? I confess that I 
see no solution of the problem except that disorder arises from 
misdirected flow of vital power to the affected part, and that a 
remedy acts by attracting it back to its natural seat. Therefore, 
the most opposite things may be equally good remedies, when 
they possess a power in common of attracting abnormally directed 
vital power to the nearest, or most attainable, natural seat of such 
power. 

Some years ago Dr. Balfour, called attention to the great power 
tincture of sesqui-chloride of iron exerts over erysipelas.* I believe 
Mr. Hamilton Bell first recommended it, but about this I am not 
confident. Dr. Balfour gives first of all a sharp purgative, such as 
ten grains of calomel with a drachm of jalap, or two drachms of 
sulphate of potash, and then twenty drops of the tincture every two 
hours till the disease is quelled. It may be given at any stage ; it 
never brings on any headache, and it would not matter much if it 
did ; it checks suppuration, and cures in less than a week. Dr. 

• Monthly Jburnal of Medical Science, vol. xvi. (1853), p. 426. 



Treatment of Erysipelas. 1 7 7 

Balfour gives the tincture even to infants at the breast. To an 
infant four months old he gives two minims at a dose. 

All I can say of this treatment is, that, with the exception of the 
powder, I consider it admirable, and by far the best ever introduced. 
I have used it for years, and have never seen a case do badly under 
it. It will not always check suppuration, but it will limit this process, 
and support the patient's strength. It has always appeared to me 
greatly superior to antiphlogistic treatment, and to have a decidedly 
more powerful control over erysipelas than either bark or ammonia. 
I have never seen any harm arise from the tincture, though I use 
it in larger doses than Dr. Balfour, generally giving quite thirty 
minims every two or three hours. But I altogether object to the 
purge ; patients get refractory about powders, and pronounce them 
disgusting messes. Besides, I think the purging simply lowers the 
patient, and valuable time is lost in waiting for its action being set 
up before giving the iron. I therefore always begin with this at 
once. 

Of the treatment with ammonia and bark, or quinine, I have of 
late years had very little experience, and that with wine, recom- 
mended by Dr. Williams, I have never tried, but I understand it 
has not proved so successful in the hands of others. The anti- 
phlogistic treatment always appeared to me useless except for 
mischief. 

Hebra seems to think there is nothing like cold dressings for 
erysipelas. He uses ice very freely, continuing it at times till the 
part gets quite numb. The plan introduced by Mr. Grantham * I 
have tried in a great number of cases, and found it most useful. 
The inflamed part is thoroughly bathed with hot water, dried, satu- 
rated with hot lard, and covered with cotton wool. Any similar 
substance, as melted flare, beef or mutton suet, zinc ointment, &c., 
would, if I am to judge firom my own observations, answer especially 
well ; the object being to secure immediate contact of the skin with 
a thick layer of some material which is a bad conductor of heat, not 
irritating, or rather sedative if possible, and impermeable to air. The 
application of white paint seems to have been successful, t Dr. Walter 
Curran has witnessed % great benefit from the iodide of ammonium 
ointment, the same strength as the iodide of potassium ointment of 

* On Diseases of the Skin. By Erasmus Wilson. 1863, p. 129. 
+ Lancet^ 1856, vol. i. p. 610. 
X yournal of Cutaneous Medicine^ vol. iv. p. 35. 

2 A 



178 Definition of Urticaria; Divisions. 

the Pharmacopeia. The application was uniformly successful* in 
sixteen cases. 

C. Urticaria («, a^ fem.), from urtica^ a nettle. 

Definition, — A rapid formation of white or pink, usually evanescent, 
flattened swellings ; generally from the size of a sixpence to that of 
a shilling, but may be much larger ; sometimes in long irregular 
wheals, like those made by a whip ; generally with marginal redness. 
Accompanied by burning, aching, or tingling. Usually attended, 
when acute, with very considerable disturbance, such as headache, 
coated tongue, weariness, sickness, &c. ; occasionally by symptoms 
of poisoning, such as giddiness, severe oppression at the stomach, 
anxiety, with sense of burning of the throat, constriction of this part. 
When attacking face, mamma or scrotum may be followed by 
oedema. 

Divisions, — i. U. acuta, arising from some substance used as 
food or medicine in having acted as a poison : eruption in such 
cases preceded by the more severe symptoms just mentioned. 2. 
U. communis, in which there is little if anything more than the 
sudden swelling and itching. 3. U. evanida, in which the burning, 
itching, and swelling continue to recur for years, not unfrequently 
with symptoms of dyspepsia and exhaustion. In a variety of this, 
described by some writers as U. perstans, the wheals remain some- 
times for days.* 4. U. tuberosa, in which the swellings are much 
larger in size, and often accompanied by considerable and serious 
disturbance of the health. The connection between urticaria and 
disease of the liver, sexual organs and acne, has veen adverted to by 
some authors ; t I have not been able to verify the fact except as a 
mere coincidence. Dr. Gull considers % that the wheal is due to 
" contraction of the muscular tissue of the skin." 

In a paper read before the British Medical Association,§ Mr. Bal- 
manno Squire stated that many cases considered as urticaria are 
really dependent on the irritation of the acarus scabiei, or, in other 
words, are cases of itch. I am not aware that this view has been 
confirmed by any other observer, and I cannot understand how such 
a mistake, as that of confounding urticaria with either scabies or 

* Hillier, Op. cit.y p. 48. + Id., Op, cit.^ p. 23. 

X Gu^s Hospital Reports^ Third Series, vol. v. p. 191. 
§ Medical Times and Gazette^ 1865, vol. ii. p. 210. 



Treatment of Urticaria, 179 

phthlriasis, could be committed by any one versed in those dis- 
orders. The rapidity with which the swellings of urticaria form is 
so much greater than that seen in either of the latter complaints, 
and the swelling itself is so much more extensive as alone to consti- 
tute a decided line of separation. Besides, in even mild cases of 
scabies, pustules, fissures or vesicles rarely fail to appear, while in 
the most severe cases of genuine urticaria they are absent, or very 
rare. 

Treatment — Simple or febrile urticaria requires in general little 
beyond the use of a mild effervescent aperient, such as citrate of 
magnesia, or some remedy to allay the thirst and act upon the bowels 
at the same time, such as sulphate of magnesia in infusion of roses ;* 
that from taking any noxious substance, an emetic or purgative. 
In the treatment of the chronic forms (the urticaria evanida, tube- 
rosa, &c.) the first step is to simplify our means, as so many remedies 
have been recommended. 

These are then — i. Saline aperients containing magnesia, which 
should form the staple of treatment so long as the tongue is foul and 
there is much feverishness, dryness of the mouth and lips, thirst, and 
heat 2. These may be followed, when there is much anaemia, by 
small doses of aloin or strychnia in a pill,+ and a steady course of 
steeL 3. The state of the digestion must be sedulously inquired 
into, and if anything transpire which leads to the suspicion that it is 
at fault, every effort must be made to set it right. Alkaline remedies, 
and those suited to painful digestion or gastralgia, seem most adapted 
to the case. Mr. Wilson speaks very highly of bismuth and oxide of 

• Patients who have reached puberty, and adults, may take the foUowing : — 

R. Pil. hydrargyri gr. xij. 

Sodse carbon, exsicc. gr. vj. 
Extract! hyoscyam. vel conii 9ss. tn. ft. pil. vj. 
Sumat unam hor^ decubitiis. 

R. Magnesiae sulphatis 3vj. 
Acidi sulphuric, dil. m. xv. 
Infus. rosse acid., ad 5vj. in.* 
Capiat coch. ampl. duo bis terve quotidie. 

t R. Extracti colocjmth. compos, gr. xij. 

rhei gr. vj. 

hyoscyami gr. x. 

Strychnise grani quartam partem. r\ ft. pil. vj. 
Sumat unam hora decubitiis. To this may be joined the saline mixture 
prescribed at p. 37. 

For formulae for steel see p. 172-3. 



i8o Treatment of Urticaria. 

silver ; he gives as much as a grain of the latter at a dose, a quarter 
of an hour before meals. The reader will see in the section on 
" silver staining *' an objection to the use of oxide of silver. Sir 
Benjamin Brodie told me that nothing answered so well in his hands 
as the " caustic alkali." Mr. Startin, in obstinate cases, bleeds and 
gives iodide of potassium and colchicum. 4. If there be any tendency 
to gout colchicum may be given, and here I may say, that at the 
first outbreak of this complication I have found no plan answer so 
well as that of Sir Everard Home. He used to keep the colchicum 
wine in large bottles, so that all the mucilage fell to the bottom, and 
of the clear fluid above he gave drachm doses in an ounce of water.* 
This plan I have followed for many years, and have never seen these 
large doses bring on either vomiting or purging, except now and then 
to a very trifling extent. If rheumatism be present iodide of potas- 
sium and biniodide of mercury may be given along with colchicum. t 
5. When urticaria assumes an intermittent form, quinine or bark is 
called for. J Many practitioners indeed give quinine in all cases. 
Dr. Frazer prescribes quinine before meals and trisnitrate of bismuth 
after. § He also administers an ipecacuanha emetic and a brisk 
purgative. 6. In obstinate cases no remedy appears to answer like 
ars nic. Mr. Wilson gives it, and Cazenave, who like Bazin takes a 
very gloomy view of inveterate urticaria, mentions a case of tuberose 
nettle-rash, which had lasted four years and was cured by the use of 
Fowler's solution. Mr. Startin uses it along with large doses of 
liquor potass9e,|| and Mr. Hunt turns to it in obstinate cases. My 
own opinion is decidedly in its favour, and I invariably recommend 
a course of it in all cases, on the plan laid down at page 6 for lichen, 
raising the dose till a decided effect is produced. Quinine in large 

* See Philosophical Transactions (1817), p. 267. 
t For formulae see pp. 127 and 128. 
X The formula given at p. 12 may be tried here. 

§ Dr. Frazer does not give the dose or formula 5 I therefore append a pre- 
scription : — 

R. Bismuth, carbonatis gr. v. 

Sodae carbonatis exsicc. gr. ij. 
Confect. aromat. q. s. ft. pil. ij. 

To be taken at meals two or three times a day. The subnitrate of bismuth 
may be substituted for the carbonate, or a drachm of the liquor bismuthi et 
ammonise citratis may be taken three times a day. 

II A very pleasant way of taking potass is in the form of the citrate, flavoured 
with syrup of roses or orange. 



Local Treatment of Urticaria ; Diet. 1 8 1 

doses appears to be useful in some cases where die disorder returns 
periodically. When urticaria occurs in a gouty habit of body — for 
such I imderstand the cnidosis arthritique of Dr. Bazin to be, — this 
gendeman, in obstinate cases, recommends a course of mineral 
waters, such as those of Vichy, Ems, and Wiesbaden. 

Dr. Neligan does not take by any means a gloomy view of even 
the most obstinate forms — the evanida and tuberosa. Chalybeates and 
opiates combined will always overcome the former. The tubercular 
form may require a course of arsenic as well. Dr. Neligan's favourite 
formula was the- compound iron mixture in doses of two ounces 
eviery morning, or twenty minims of the tincture of the sesqui- 
chloride in infusion of quassia three times a day, or two ounces of 
Bewle/s aqua chalybeata twice a day ; he also gave eight to twelve 
grains of Dover's powder every night* Dr. McCall Anderson says 
the bromide of potassium is very beneficial in urdcaria perstans 
when not caused by constitutional vice. 

Mr. Wilson speaks favourably of the power of chloroform and 
laudanum, and soap liniment, in quelling the itching and tingling 
which so harass many of these patients, but his chief reliance is upon 
a lotion of bichloride of mercury, nearly a grain to an ounce. Dr. 
Gull remarked that " afler dropping chloroform on the skin, however 
susceptible it might have been before, no wheal could be brought 
out by friction, and when chloroform was applied to a wheal already 
risen it quickly reduced it." Dr. Neligan employed with good effect 
an alkaline spirituous wash, containing half a drachm of carbonate 
of potass and half an ounce of spirit in eleven ounces and a half of 
elder-flower water; another favourite remedy was the chloroform 
ointment recommended at page 22 for prurigo. Dr. Frazer says + 
great relief is given by the use of a lotion made of equal parts of 
glycerine and liquor plumbi, or of these with the same amount of 
laurel-water. During winter the hot bath should be used once or 
twice every week, and very frequently during summer warm sponging 
affords more relief than any form of cold bathing, though, occa- 
sionally, strong persons find benefit in very hot relaxing weather 
from the use of the shower-bath. 

Diet is considered to play a great part in urticaria. Some writers 
believe that if we are vigilant enough we may always trace it to some 
noxious article of food. Mr. Wilson mentions a case where even 

* Practical Treatise on Diseases of the Skin ^ p. 60. 

t Treatment 0/ Diseases of the Skin. By Dr. William Frazer. 1 864. 



1 82 Diet in Urticaria; Exercise. 

sugar was banished with advantage to the patient.* Dr* HiUier says 
that in some cases a milk or vegetable diet has been found to cure 
the disease. But I apprehend these cases are very rare, and that in 
by far the greater number of instances the influence of diet is not 
greater than in other diseases of the skin. Dr. Willan was obliged to 
admit t that " in some cases a total alteration of diet did not produce 
the least alleviation of the complaint," and Mr. Hunt says that dis- 
order of the digestive organs is seldom the cause of this aflfection. 
Often, too, where some particular agent brings on nettle-rash, as nuts 
do, for instance, with some persons, abstinence alone will only do 
with those who have an inborn inability to support them ; where this 
tendency has been suddenly acquired, it is the disordered state of the 
health that we must look to. I was consulted in the case of a gen- 
tleman who suffered most severely from urticaria, principally in the 
face, and who attributed it to eating walnuts. On cross-examination 
it came out that he had previously eaten nuts enough with impunity, 
and that lately he had fallen into bad health, chiefly from great con- 
finement to business, and anxiety ; I therefore gave it as my opinion 
that the nuts had nothing to do with the matter, and that, though it 
would be prudent to abstain, yet that it was not really of much con- 
sequence, and that if he took plenty of fresh meat and good vegetables, 
and went out for a ride every day, he might eat as many nuts as he 
liked. The result proved that this view was right, for he got quite 
well though he had no particular restraint upon himself. 

Exercise in the open air — not mere walking, but active exercise, 
particularly in company, — is of much more consequence. Many of 
these patients lead very monotonous lives, and it is very difficult to 
get them to shake off their habits ; but they must do so, or see the 
complaint endure. 

The following very unusual case J seems to me more nearly con- 
nected with urticaria than any other disease of the skin. That it 
was a neurosis I think admits of little doubt. The singular features 
in it were the extraordinary size of the swellings, and the total 

* I had under my care a strong-looking man in whom a minute dose of opium, 
henbane, mercury, or antimony at once produced the most violent urticaria I ever 
saw; he was always quite imfit to work for eight or ten days. 

t A Practical Synopsis of Cutaneous Diseases, By Thomas Bateman. 1819, 

P- 93- 

t From a paper read by the author before the Medico-Chirurgical Society, 
June loth, 1856. 



Unusual Form of Urticaria. 183 

absence of all itching. I showed it to several surgeons, but no one 
recognized the disease except Sir Benjamin Brodie, who had seen 
one or two instances of it in a very mild form, but confessed himself 
so entirely puzzled as to its nature that he had not ventured to give 
it a name. I believe no published account of the disorder is to be 
found, at any rate I found none after a long search in the Library 
of the College of Surgeons. The patient was a gentleman in his 
thirty-fifth year, usually enjoying very good health, though rather 
below par, owing to overwork. The account is taken almost word 
for word from the paper read before the Society : — 

" After having long suffered from a slight touch of eczema of the 
scalp I was attacked in June, 1855, with colicky pains and neuralgia. 
Soon after this I noticed a large swelling,* extending from the inner 
to the outer side of the left thigh, running just below Pouparfs liga- 
ment It was of the colour of the skin, firm and painless ; of a 
pyriform shape, the broad end being at the inner side of the thigh, 
over which it extended full three inches. I was alarmed, but on 
undressing at night found that it had disappeared. The next morn- 
ing an unusual stiffness was felt along the upper part of the left hip. 
Remembering the phenomenon of the previous day, I examined in 
the glass, and was astonished to see a large swelling stretching back- 
wards just below the crest of the ilium. This time it was red, but 
painless as before. It was five or six inches in length, about two in 
breadth, and raised a full half-inch above the surrounding skin, the 
margin being dearly defined. This was quite a new state of things 
to me, and I watched its progress with no little anxiety and 
interest . 

" The third day, the left extremity of this swelling had become 
indistinct, and the other end began to stretch down the left side of 
the sacrum ; but after a short interval it took another direction, and 
on the fourth day there was a fully-formed lump creeping along 
the crest of the right ilium ; it extended but little more than half- 
way round, when it began to lessen, and passed gradually away. 
Meantime a smaller swelling formed on the middle and upper 
part of the left thigh, which disappeared in the same way as the 
others. 

" For upwards of three weeks one or two of these swellings formed 
every day about the hips, crest of the ilium, and upper part of the 
left thigh, the right thigh not being attacked. Sometimes two 
occurred almost simultaneously ; on one day there were three. In 



i 



184 Unusual Form of Urticaria. 

every instance they appeared in the same manner and over the 
same tract as those first described, being only more isolated. 
From this time they diminished in frequency, and became more 
dispersed. 

" Towards the end of October the face was attacked. A hard 
swelling passed slowly over both eyes, beginning outside the external 
angle of the right eye, and subsiding considerably there before it 
reached the corresponding point of the left eye. It ran its course 
in about eight hours and then slowly subsided, but considerable 
puffiness remained for several days. Each eye in succession was so 
firmly closed at the height of the attack, that not a ray of light could 
be perceived, even when an attempt was made to open the eyelid 
forcibly with the fingers. A few days after the mouth was assailed, the 
swelling being much more prominent One or two swellings also 
showed themselves on the legs, and one or two small ones on the 
arms. There was now generally an interval of a day or two between 
them, and after a few irregular outbreaks, the disorder almost entirely 
quitted the lower part of the firame to appear with concentrated 
violence in the face. 

" Here, after three attacks, the disorder fairly reached its climax 
on the nth of December. About 4 a.m. a swelling commenced with 
a peculiar sensation of tension and uneasiness in the left cheek, which 
soon roused me, and prevented further sleep. On grasping it with 
the hand, it felt like a large walnut. It spread with the most sur- 
prising rapidity, and by eight o'clock had reached right across the 
lower part of the face, which was so swollen as to be visible, like a 
dark projecting shadow, on casting down the eyes. The anterior 
surface of the upper lip was protruded horizontally outwards, and 
firmly pressed against the nostrils ; the mucous membrane of the 
lips was shining, and so tense as to feel as if it would crack. All 
attempts at articulation were very imperfect, and though the mouth 
was not firmly closed, yet nothing could be swallowed, owing to its 
rigidity and the total loss of control over the movements of the 
lips. The swelling was quite defined, ceasing above on a level with 
the nostrils and inferiorly about an inch below the mouth. The 
margin rose abruptly from the surrounding skin, and it lay like an 
oblong tumour across the face. Thus it remained till early the next 
morning, when both eyes were for the first time attacked at once ; 
in a short time I became totally blind and remained so for some 
hours. 




Unusual Form of Urticaria. 185 

"The engraving represents the last and smallest of the swellings 
on the face ; it was taken an hour and forty minutes after I first 
noticed the peculiar sensation of 
stiffness. This time the swelling 
was confined to the lower lip. I 
regret much that the figure of some 
of the larger ones was not preserved, 
bnt the blindness and difficulty of 
speaking rendered me averse to 
leaving my room. 

"Three times the throat was 
affected, and here the swelling 
reached its maximum in half an 
hour. A medical friend, whose aid 
I requested in one of these atucks, S£ud that the posterior fauces 
presented much the same appearance as in a bad case of cynanche ; 
the uvula, soft palate and tonsils being greatly swollen. Saliva was 
poured oiit in large quantities, and for some hours the sense of 
suffocation was almost unbearable, owing, probably, to the epiglottis 
being involved. 

" From the i ith of December the number and severity of the 
attacks steadily declined, and they finally disappeared on the 14th 
of March (1856). 

"At no time were these swellings painful, even on firm pressure, 
to which I may here obsen'e they did not yield. Some of them 
conveyed a feeling of heat to the hand, but in general the only 
sensation remarked was an extreme stiffness and distension. The 
skin was, for the most part, unaltered in colour, though some of the 
lumps on the arms and legs were of a pale pink, and one or two 
on the hip of a bright red. The subsidence of the swelling was 
never followed by any desquamation or itching, but on two occa- 
sions the skin of the lower part of the (ace became slightly yellow, 
and there was a free secretion of sebaceous matter, which for some 
days after could be peeled off in flakes. 

" No constiturional disturbance of any kind accompanied either 
the outbreak or decline of these singular phenomena, nor did 
they seem to bear any relation to such aggravation or improvement 
as occasionally took place in the eczema. I never succeeded in 
tracing them to the use of any particular article of food. When 
once the swellings had begun to form, no local application, such as 



1 86 Unusual Form of Urticaria. 

vapour-baths, hot fomentations, poultices, cold spirituous lotions, 
and pressure, exerted the slightest influence in checking their 
progress. Mr. Gay and Mr. Skey were consulted; both recom- 
mended tonics, and these certainly improved the general health, 
and possibly also controlled the severity of the symptoms. Mr. 
Robert Taylor kindly examined the urine, but found it quite 
normal ; he moreover advised colchicum and bichloride of mercury, 
which seemed to hasten the disappearance of the disorder, thils 
suggesting an analogy with chronic urticaria. Sir Benjamin Brodie 
considered the affection dependent on disorder of the stomach, 
remediable by the use of liquor potassae. Diaphoretics were tried, 
as the skin was always dry, but I cannot say that I ever noticed any 
appreciable effect from their employment. 

" None of these swellings ever formed in the afternoon or even- 
ing. All those of which I noticed the commencement began between 
four and ten a.m., and with one exception, always reached their 
utmost height in four hours. Those on the face were generally 
about a week in subsiding completely; the others disappeared 
almost as rapidly as they came. 

"I have thus endeavoured to give a faithful description of the 
case while it was yet fresh in my memory, and would gladly learn 
if any light can be thrown on the pathology and history of the 
complaint. 

" In the beginning of January, 1857, these swellings again made 
their appearance in as severe a form as ever, but this time confined 
entirely to the trunk. Iodide of potassium, in doses of seven 
grains, three times a day ; a grain and a half of the acetic extract 
of colchicum every night, followed by one-eighth of a grain of. 
bichloride of mercury, also at night, removed them. This time also 
they supervened upon the use of dilute nitric acid taken in 
moderate quantities for about a month previous to the last attack. 
Some years later one of these swellings formed on the right wrist. 
With that exception there has been no return.*' 

Dr. Oppenheim describes* a very similar disease as occurring in 
Turkey. The patient, he tells us, goes to bed weU, but wakes in 
the morning with one or more of the tumours 01. •f'^'iio..''^js. They 
are generally seated at some distance from the joint, and at the 
inner or flexor side of the limb. They are globular, but not very 
sharply circumscribed, hard, scarcely movable, dr«// very painful to 

* Ueber den Zustand der IleUkunde. 1833. 



Definition of Purpura ; Divisions, 187 

the touch. They are not discoloured or red, neither are they 
hotter than other parts. They vary in size from the bigness of a 
filbert to that of the fist, and acquire their full size in a few hours. 
They are qftener met with on the upper than the lower limbs, and on 
the leg and forearm than on the thigh and arm. Dr. Oppenheim 
speaks also of their appearing on the palm of the hand and the 
sole of the foot, situations in which they never occurred in the 
foregoing case. When neglected, the disease is apt to continue 
for life. Dr. Graves, from whose essay on Oppenheim's work I 
extract this account, saw* one case of this disorder in the Meath 
Hospital, but he gives no further account of it. 

It will be observed that the affection described by Oppenheim, 
though perhaps closely allied to that which I have recorded, still 
differs from it notably, especially in the characteristics in the lines 
which I have italicized. 

D. Purpura {a, cb, fem.), from 7rop(i>vpay the shell-fish used for 
dyeing purple. The accentuation has been corrupted. 

Definition, — ^An eruption of livid, purple, often rounded spots, vary- 
ing in size from a line to an inch, bright red when they first appear, 
principally seated on the limbs, especially the lower ones ; do not 
disappear or fade on pressure ; margins of spots abrupt at first. 
Several successive eruptions of spots. Gradually changing, as they 
decline, to a green, brown, or yellow hue ; often accompanied by 
languor, weariness, loss of spirits, and other signs of exhaustion. 
Not attended by desquamation. Seat of disease in papillary layer. 
Outbreak often preceded by slight febrile symptoms ; may compli- 
cate iichen, ecthyma, and scabies, and be complicated by eczema. 

Divisions, — i. P. simplex (the purples), attended chiefly by the 
S)rmptoms mentioned. P. haemorrhagica, marked by the same 
phenomena in a more severe form, accompanied by bleeding from 
one or more of the mucous membranes. 3. P. senilis, more a 
dark brown or yellowish staining of the skin than disease. 4. P. 
urticans, in which -the patches are at first elevated like those of 
urticaria (to ^^^ . .i/lnight, I think, be referred with advantage), 
and are followed by livid, brownish-yellow stains. t 

* Studies in Physiology and Me4icine, 1863, p. 296. 

t A tendency to purpura sometimes runs through several members of a family. 
I had three sisters, Jewesses, under my care for it at the same time. 



1 88 Treatment of Purpura. 

Treatment, — Simple purpura and purpura senilis alone belong to 
our subject ; the haemorrhagic form pertaining to general surgery, 
and purpura urticans being removed to urticaria, the usual treat- 
ment for which seems best adapted to it. Purpura senilis is 
soon disposed of, as unless there be any particular disorder of 
the health which requires setting right, it demands nothing more 
than the use of some simple unirritating ointment, such as that of 
zinc, elder, or spermaceti. For simple purpura I would recom- 
mend the unsparing use of purgatives, such as mercury and chalk, 
in five-grain doses every night, and the acid mixture, with sul- 
phate of magnesia, prescribed at page 179, until free action of the 
bowels takes place. At the same time I think meat in every form 
should be forbidden, and the patient should be restricted to 
vegetables, farinaceous food, milk, red wine, and light fish. When 
the first symptoms are subdued mineral acids may be given, but 
I think that in general bitters should be avoided, especially those 
possessing a tonic action.* Quinine and iron have always in my 
hands proved, at the outset, either useless or downright hurtful. I have 
seen the tincture of the muriate useful in the form often observed 
in sailors after a long voyage, from a blow, but I am disposed to 
think it was the acid that did the good. Mr. Wilson however gives 
them, as also sulphuric acid with bark, and nitro-muriatic acid with 
bitters, combining all treatment with generous diet, as meat, wine, 
and so forth. Locally he recommends tepid baths with juniper 
tar soap, lotions containing the sesquicarbonate of ammonia, or 
the bichloride of mercury, with emulsion of bitter almonds. 
Dr. Joseph Lindsay has employed the tincture of ergot of rye, 
in half-drachm doses every two hours, very successftiUy in the 
haemorrhaghic form. Mr. Startin not having published his treat- 
ment of this affection, I am unable to state what his views are. 
Mr. Hunt, I believe, employs purgatives, such as ca,lomel and 
compound jalap powder, very freely. I do not envy the sensations 
of the man who has to swallow the latter. Dr. Neligan considered 
no remedy equal to turpentine.t He used to give an ounce once 

* R. Acidi nitro-hydrochlorici dil. 5iss. 
Synipi rosae gallicse 5iij. 
Infusi dulcamane ad 5vj. tn.. 
Capiat cochlear, ampl. duo bis die. 
Along with this the patient may take a grain of calomel at bedtime, and ^ 
scniple of confection of scammony in the morning. 

+ Practical Treatise on Diseases of the Skin. 1 85 2, p. 305. 



Definition of Pernio. 1 89 

or twice daily;* when there was much haemorrhage from the 

intestinal canal, or when the stomach rejected the medicine, he 

prescribed it in the form of an enema. I should fancy any 

ordinary stomach would frequently reject such a dose. Some 

years ago I tried half-ounce doses for s)rphilitic iritis, and since 

then have repeatedly treated the complaint in the same . way, but 

have often found it impossible to make patients continue the use 

of the remedy, as even this quantity sometimes induced nausea 

lasting for hours, and excessive sickness. In extreme debility 

Neligan recommends astringent preparations of iron, and in cases 

complicated with bleeding from the mucous surfaces, acetate of 

lead and opium, or gallic acid. Sponging the surface with cooling 

lotions he consideredf a valuable adjunct. He allowed the free 

use of acidulated drinksj and light diet, taken cool rather than 

warm. Lime-juice has been recommended in purpura. 



E. PERNIO (^, onis^ masc), said to be derived from wifyxpQ or 
vepxyoc, black-spotted; just as probably from wipvay a 
gammon of bacon, the colour of which it quite as nearly 
resembles; but derivations are often incomprehensible. 

Definition, — ^A red swollen state of a portion of skin, fol- 
lowed by a deep ham-colour, or livid hue. Patch of scarf-skin 
aflfected becomes contracted, shrivelled, and drops off. Sometimes 

* R. Olei terebinthinae fluid. 5j- 
Mucilaginis 5j« 

Aquae menth. piperitae ^iss. r\. 
ft. haustus semel vel bis quotidie sumendus. 
R. Olei terebinth. 5j« 
Ovi unius vitellum. 
Decocti hordei 5vj. m ft. enema, 
t R. Spiritils rectificati 5x. 
Acidi acetici"5iij. 
Aquae ad S^iij. m ft. lotio. 
1 think the following will be found equal to this in every form of purpura which 
requires a lotion :— 

R. Liquoris ammoniae acetatis ^iss. 
Spiritils aetheris 5yj. 
Aquae camphorae ad 5viij. n ft- lotio. 

♦ Cold tea, flavoured with rum, very slightly sweetened and acidulated with 
**°Wtt-juice, may be recommended. 






1 90 Treatment of Pernio, 

followed by painful, tedious, superficial ulceration. Possibly chil- 
blain is really an undeveloped vesicle, the effusion of serum being 
checked by the constriction of the vessels in consequence of 
cold. 

Treatment — I need scarcely say that the remedies for chilblains 
are almost countless. Probably any application which can be 
made to combine a balsamic principle, such as turpentine or 
camphor, with alcohol in some form ; or which is naturally a 
strong stimulant to absorption, as for instance tincture of iodine 
or solution of nitrate of silver, is equally good so long as the 
skin is unbroken. When this has been removed, or when sup- 
puration has begun, the benzoated zinc ointment, thinned down 
with spirit of camphor, say in the proportion of seven parts of the 
ointment to one of spirit, is a very useful application. It should 
be laid thinly upon the part (any pus being first removed) and 
covered with lint, which is to be kept in its proper place by a strip 
of linen. In many cases it is highly advisable to attend to the 
state of the health, as most patients suffering from chilblain, at 
least those who habitually suffer, are in an unsatisfactory state in 
this respect. Tonics are generally called for in such cases. 



( 191 ) 



CHAPTER VI.— EXANTHEMATA. 
A. Scarlatina, B. Rubeola. C, Roseola, D, Variola. 

A. Scarlatina (ti, ^, fern.), from scarlatto^ deep red. 

Definition, — ^An eruption of very minute, bright-red papulae and 
stains, preceded by heaviness, languor and drowsiness, pains in limbs 
and head, shivering, nausea and rise in the pulse, followed by swell- 
ing of the face. Fauces red ; tongue white, except at edges, and 
moist ; soreness of throat ; skin hot and dry. Early appearance of 
throat affection. Eruption appears on second day. 

Divisions. — i. S. simplex, or sine angina, corresponding to the 
account given above. 2. S. anginosa, in which both constitutional 
and throat symptoms acquire greater severity, especially the latter ; 
marked by great heat of skin (temp. 105°), foul deep ulcers in ton- 
sils, great stiffness of neck, and hoarseness ; retarded appearance of 
eruption, which comes out on third or fourth day in scattered patches 
on chest and arms, and recedes day after with partial reappearance. 
3. S. maligna, marked by a typhoid charactier, great delirium, often 
diarrhoea, feeble pulse, brown dry tongue, dusky hue of throat ; dark 
incrustations on tonsils and uvula. 

Treatment, — If I were asked to name a disease which would show 
the discrepancy between facts and teaching, between the stem irre- 
futable evidence in the returns of the Registrar-General, and the 
inferences which flow from reading the settled deliberate opinions 
of those who ought to know most about the matter, I would name 
scarlatina. For many years, plans of .treatment have been before the 
world which, so far as we can judge, ought to have almost as effectually 



192 Frictions with Fat, 

defeated the inroads of this malady as vaccination has defeated small- 
pox ; yet week after week and year by year this relentless scourge 
sweeps away its victims, not by hundreds but by thousands. There 
must be something strangely wrong in a system which presents such 
a sad and startling contradiction as this. 

Long ago I endeavoured to bring under the notice of the profession 
a mode of treatment which had proved very successful in Germany, 
but the attempt met with no response except from Mr. Erasmus 
Wilson, Dr. Routh, the late Dr. Snow, and one or two others. It 
consists in daily rubbing with hot fat or lard, and the manner in which 
it checks and quells the violence of the disorder is, if the accounts 
given be true, most extraordinary. Death is a rare result ; the patient 
never takes cold \ dropsical symptoms are almost unknown ; no infec- 
tion is given, because the sources of it are mechanically closed ; the 
distressing heat and irritation of the skin are abated, and, according 
to a statement made at the Medical Society by Dr. Routh, the pulse 
will fall thirty beats in three hours when the patient is subjected to 
this treatment I have never noticed such a result myself, but I 
have seen it sink fifty beats, or from 130 to 80, in three days. 

All that needs to be done is to rub the patient over from head to 
foot with fat ; lard or fat bacon is the best material, and the salt 
should be removed as far as possible. The rubbing is to be done 
once at least, twice if thought proper, in the twenty-four hours. 
No harm can come from rubbing in too much ; a great deal may 
ensue from rubbing in too little. The patient wants no washing, 
may wear the same clothes all the time, and requires little medicine 
and no precautions beyond those which common observation would 
direct 

I have great pleasure in giving my unequivocal testimony in favour 
of this excellent plan of treatment. Although I have not had any 
opportunity of trying it in large numbers of cases, and not at all 
among the poorer classes, yet I have observed enough of its work- 
ings to satisfy me of its vast superiority over any other method I 
have seen put in force. Dr. Schneemann merits the gratitude of 
mankind for his discovery, and it is not very creditable to the state 
of medicine in this country, that a plan, so widely known and justly 
esteemed on the continent, should have been so utterly neglected 
here, and that thousands of children should be swept off every year 
by this fell disease, while a cheap and simple remedy lies untried 
and almost unknown. 



Frictions with Fat ; Cold Affusion. 193 

Not long ago I was called in to see two children, girls, who had 
just had this disease, and had been treated, so far as I could make 
out, antiphlogistically. One was clearly dying of anaemia ; the other 
was in a very critical state, being anasarcous, very weak, and having 
eczematous crusts forming about the mouth and nose. Within two 
days another child, a son, was seized with the disorder in a very 
severe form, the temperature of the skin being extremely high, and 
the throat affection very marked : pulse also rapid, 136. He was 
nibbed all over twice daily with lard, and had the sesquicarbonate 
of ammonia freely, and though his parents tried rather hard to neu- 
tralize the effects of any treatment by the most absurd indulgence, 
the boy had not a single bad symptom, and made a rapid and 
steady recovery, getting well long before his surviving sister, for the 
other had died in three days from my first visit. 

Mr. Edward Richardson, of Mount Street, London Hospital, 
having tried this treatment pretty extensively, was kind enough to 
favour me with the following communication : — 

" I can testify to the great success of the treatment, as within the 
last three years I have attended upwards of one hundred cases, and 
have only had one death, and this was caused by a secondary affec- 
tion. The patients express themselves as greatly relieved by the 
unguent friction, which I always direct to be used twice a day. 

" I have followed this plan of treatment in private, workhouse and 
district union practice, and with equally beneficial results in each. 
I should say that I administer carbonate of ammonia internally every 
three hours, and give a purge of pulv. jalap, co.*' 

The next best plan, yet seemingly far behind it in efficacy, is 
that of cold affusion. Bateman dwells with fervid energy upon the 
wonderful soothing powers of cold affusion, the great febrifuge as it 
has been justly called. For ten years he says he had used Dr. 
Currie's plan without once seeing inconvenience, much less injury, 
from it* It is, however, more than questionable if it could ever be 
introduced again. There is no getting parents now to allow chil- 
dren, burning with fever and oppressed with bedclothes, to have 
even a breath of fresh air, much less to come in contact with cold 
water. The habit of using their senses is not one of the things 
taught to children at schools, and ladies assume the duties of wives 

* Practical Synopsis of Cutaneous Diseases. By Thomas Bateman. 1819, 
p. S2. 

2 c 



194 Necessity for Fresh Air. 

and mothers, as ignorant of the simplest facts of hygiene as the 
savage who bu3rs a charm from the medicine-man. Every now and 
then, in a lecture on the exanthemata, the speaker touches with 
complacent pity on the ignorance and prejudice which Sydenham, 
RadclifFe, and Mead had to overcome about keeping patients with 
fever stewing in close, superheated rooms, as though those great men 
had for ever banished such mischievous practices, whereas they 
flourish as vigorously as ever. 

In my opinion, the medical attendant should either insist upon 
the free admission of air into the sick-room, or give up the case at 
once. Unless medical men set themselves vigorously against this 
mania for keeping doors and windows closed, there is no hope of a 
more rational system being introduced. When a surgeon or phy- 
sician finds a patient with scarlet fever, lying, even in mild weather, 
under aheap of clothes, with a fire burning night and day, and doors 
and windows closed so as jealously to exclude every breath of fresh 
air, he may make up his mind that he has got to do with obstinate 
lunatics, who may be fiightened, but who cannot be reasoned into 
doing anything. If he can succeed in getting in fresh air by means 
of an open window both day and night during the sunmier, and aU 
day in the winter, except in very inclement weather ; if he can reso- 
lutely shut his ears to all nonsense about driving in the eruption ; 
cut down fires to what is simply necessary in order to give the sick- 
room a cheerful look; stop everything in the way of "stuffing," 
especially with rich, fat soups ; keep the temperature at a rational 
standard, instead of a heat which will make a strong man feel faint 
and sick ; then he may stand some chance of doing good. If not, 
he is only doing mischief by sanctioning such destructive folly and 
is better ^away. 

Mr. Wilson considers sesquicarbonate of ammonia to be a remedy 
which, in its power over scarlet fever and rubeola, may be ranked 
with quinine in ague, iron in erysipelas, arsenic in eczema, and 
sulphur in scabies. I think myself that the success recorded to have 
followed the use of this remedy is among the most striking triumphs 
that discovery can boast, and its beneficial results in small-pox are 
equally cheering. Dr. Witt says " It is the only remedy yet known 
which appears to have any decided effect upon this terrible malady" 
( variola ) ; and Mr. Wilson adds, " My own experience of the 
sesquicarbonate of ammonia fully corroborates the value of Dr. 



Ammonia; Acids. 195 

Witt's suggestion, and I feel that the adoption of this method cannot 
be too forcibly pressed upon medical men."* In scarlatina the 
success has been marvellous. Out of several hundred cases one 
gentleman did not lose more than one in a hundred. Mr. Henry 
Jackson, of Sheffield, with his father, treated patients in this way for 
fifty years, in which time they did not lose more than four patients, 
and these died from typhus following the scarlatina. Another gen- 
tleman reports that ne rarely lost a patient during twenty years' use 
of the remedy, whereas his successor, who rejected the treatment by 
ammonia, lost seventy-four out of a hundred and six cases in a single 
epidemic. These results contrast strongly with the havoc this dreadful 
complaint used to make under the treatment with antiphlogistics, 
two, three, and even four or five deaths in a single family, and which 
I am much inclined to believe, from what I saw of it in my younger 
days, never saved a single bad case, if it even did not hasten the 
progress of thousands to the grave. 

It does not seem necessary to prescribe anything with the am- 
monia. From three to six or seven grains, according to the age of 
the patient, may be given at first every hour or two till a decided 
effect is produced upon the disease, after which it may be taken less 
fi"equently. Simple or cinnamon water seems to be the favourite 
vehicle, but nothing can answer better than camphor mixture. In 
some slight cases, where there is not much difficulty in swallowing, 
ammonia may be given in the form of an effervescing drink, the 
carbonate in solution being mixed with lemon-juice. I believe, 
however, that it is of little use to employ this medicine if the reader 
be going to restrict himself to the doses sanctioned by the British 
Pharmacopeia. 

Dr. Sisson considers t that when scarlet fever is complicated with 
acute catarrh of the stomach, a very likely contingency if east winds 
prevail at the time, we must have recourse to mineral acids in pre- 
ference to ammonia, as the tenacious alkaline mucus with which the 
stomach is lined is not acted on by alkalies. Milk should be avoided 
in such a state of matters, as there is reason to believe that it is not 
digested. 

Belladonna has obtained a high reputation on the Continent, not 

* Diseases of the Skin, 1863, p. 521. 

t yournal of Cutaneous Medicine^ vol. i. p. 376. 



1 96 Belladonna ; Gargles. 

only for its curative but its preventive powers in scarlatina. Some 
of the gennan physicians seem to think it is the best remedy in use ; 
one of them goes so far as to say that it may be considered as 
eflfective against scarlatina as vaccinia is against small-pox. Even 
supposing this view to be overdrawn, enough still remains to show 
that belladonna does exert control over scarlatina, and that there is 
every reason to believe, if it were freely and judiciously used at the 
outbreak of an epidemic, the number of fatal or even serious cases 
would be materially diminished. 

It may be given in the form of extract dissolved in water, sweet- 
ened and flavoured with orange, cinnamon, or nutmeg ; about three 
grains of the extract to an ounce of fluid are perhaps the best pro- 
portions. Of this solution two or three drops may be given to an 
infant under a year old twice a day, three or four drops to a child 
between one and two years old, and from this time of life a drop may 
be added for each succeeding year. 

These, then, are the remedies which the experience of very suc- 
cessful practitioners warrants us in selecting as the most reliable — 
cold bathing, rubbing with fat, ammonia, and belladonna. They are 
few, but potent, and all the more valuable because they are few. 
The peroxide of hydrogen has been recently eulogized* by a 
gentleman quite capable of forming a true estimate of its value. It 
is given in drachm doses with a few minims of tincture of perchloride 
of iron every three or four hours. All the other means, such as 
gargles, aperients, &c., are only auxiliaries, for the use of which no 
general rule can be laid down, but which the experience of every one 
capable of profiting by experience will teach him how to use. We 
have the high authority of Sir Thomas Watson, that a weak solution 
of common salt is a great improvement upon the old capsicum 
gargle ; it may also in suitable cases be injected by the nostrils, and 
its effects, when used in this w^y, are said to be most efficacious. I 
have often employed it, a teaspoonful or two of salt in three or four 
tablespoonfuls of hot, not warm, water, not only in the sore throat 
of scarlatina but in other painftil ulcerated states of this membrane, 
and am disposed to believe it is decidedly useful. Carbolic acid, 
two grains to an ounce, has been recommended by Dr. Kempster 
of Utica. 

* yournal of Cutaneous Medicine^ vol. iv. p. 66. 



k 



Rubeola; Roseola. 197 

B. RuBi^OLA («, «, fem.), from rubeo^ to become red. 

Definition. — An eruption of dull-red spots accompanied by more 
or less diffuse redness ; sometimes forming patches of a horseshoe 
shape ; preceded by headache, weariness, feverishness, and general 
disturbance. Eruption appears on fourth day on forehead and face ; 
accompanied by white tongue, suffusion of mucous membrane of 
eyes and nostrils, intolerance of light, frequent and hard pulse. 
Eruption declines on seventh day. Followed by desquamation, 
itching, and some albuminaria. 

Treatment. — Same as that for scarlatina, especially with respect to 
rubbing in fat, which has succeeded in my hands better than any- 
thing else. 

C. Rosi^OLA («, <^, fem.), from rosa^ a rose. 

Definition. — ^An eruption of vivid red, small patches of dots, little 
or not at all elevated, generally in clusters (corymbs), occasionally 
circular or annular ; preceded by some feverishness and congestion 
of the fauces, and accompanied by tenderness of the submaxillary 
glands ; occasionally ending with greenish discoloration of the parts 
where the rash has appeared. Often accompanied by itching. Occa- 
sionally epidemic. 

Divisions.- — i. R. simplex or idiopathica, embracing the varieties 
known as the corymbose, annulated, autumnal, &c. ; and 2. R. sym- 
ptomatica, in which it appears as a complication of rheumatism, 
continued fever, variola, teething, leucorrhcea, surgical operations, 
&c. Some authors also discriminate such forms as R. infantilis, 
R. autumnalis, and R. annulata, &c. 

Treatment. — The simple form of this complaint does not generally 
call for active interference ; its treatment is that of any mild attack 
of feverishness, a febrifuge, containing some liquor ammoniae acetatis 
and spirit of nitric ether, with a brisk aperient, being generally suffi- 
cient.* Often the best febrifuge is simple unsweetened lemonade 
drunk ad libitum. The aperient for an adult may consist of a mild 

• R. Liquoris ammon. acet. Jiss. 
Spir. oetheris nitros. 5iv. 
Vini antimonii 5ij. 
Mist, carnph. ad Sviij- m- 
Capiat coch. ampl. duo bis terve quotidie. 



vrf Definition of Variola. 

MJI^ :^ilht tswQ Qt tdturee teaspoonfuls of granulated citrate of magnesia.* 
It i$^:$iaUfoift oeccssary to continue the use of such remedies more 
cJMtt tj«Q or three days, immediately after which a vegetable tonic 
UMi)i l>ti given with some mineral acid, such as the dilute nitric or 
;MPii)ffia^ sulphuric acid ; or a grain of quinine, with five minims of 
i^tu^ sulphuric acid and half a drachm of compound tincture of 
v^'QdKJiaiDoms, may be taken three times a day. A favourite prescrip- 
UQ& of Mr. Wilson's seems to be sulphate of magnesia with quinine 
^(od infusion of roses. In some instances I think it would be an 
io^provement to prescribe the magnesia separately, in the form of 
citrate or heavy calcined magnesia, and the quinine and infusion of 
loses together. In severe chronic cases of roseola Mr. Startin gives 
calomel and opium at bedtime, and brisk saline aperients, containing 
tartar emetic and liquor potassae and colchicum. The treatment of the 
sympathetic form will of course depend on the parent disorder. In 
children suffering from their teeth the gums may at once be lanced, 
and rheumatism may be assailed with iodide of potassium and col- 
chicum ; when the functions of the womb are disturbed it is as well, 
perhaps, to subdue the roseola first, and then give undivided attention 
to the uterine disorder. 

To relieve the uneasiness of the skin, the itching and tingling, 
the surface may be freely bathed with a lotion containing equal 
parts of liquor ammonias acetatis and camphor mixture. Emulsion 
of bitter almonds has been recommended by Mr. Wilson, as also 
sponging with tepid water containing a little vinegar, which he says 
answers every purpose. Mr. Startin uses lotions containing a little 
borax or distilled vinegar, and eau de Cologne diluted with water. 
Perhaps inunction with hot lard acts as well as anything. 



D. VARfoLA (tf, «, fem.), from vdrius, spotted, speckled. 

Definition, — An eruption of umbilicated vesicles, preceded b 
red papules. Contents of vesicle subsequently become ser 
purulent. Preceded by languor, headache, muscular pains in t' 
back, chills, drowsiness, nausea, and often vomiting. Erupt? 
appears on third day : generally breaks out first on upper par 
face and mouth. Mucous membrane of nose, mouth, and thr 
sometimes similarly affected. Unhealthy suppuration in ves 

• Or those at pages 12 and 37. 



Divisions of Variola ; Treatment, 199 

completed by ninth day. Accompanied by peculiar and disagree- 
able smell from skin. 

Divisions, — i. V. discreta, in which the vesicles remain separate, 
and the disorder runs a mild course. 2. V. confluens, in which 
they run together. Accompanied by swelling and closing of the 
eyelids, severe affection of tonsils and parotid glands ; salivation in 
adults, diarrhoea in children, rapid pulse, great debility. Frequently 
fatal. 

Judging from the preparations mentioned* in the catalogue of the 
United States Army Medical Museum, the following pathological 
changes ensue in small-pox. i. Thickening of the rete mucosum by 
cell-multiplication; hypertrophy of papillae near margin. 2. Separation 
of homy from mucous layer of epidermis ; cavity filled with the 
contents of the pustule. 3. Appearance of a lining membrane to 
this cavity, similar in structure to that of the free surface of the 
epidermis ; papillse shorter than natural, and blunted ; active cell- 
multiplication in connective tissue of corium. 4. " Centre of pustule, 
under portion of lining wall of cavity, gives way ; " rete mucosum 
degenerates into a mass of ill-defined cells and granules ; corium 
ulcerates superficially ; all signs of papillae gone. 5. Thinning and 
rupture of superficial homy layer at apex of pustule. 

Treatment, — Intemally the same as for scarlatina. Dr. C. Black 
recommends,t extemally, to prevent pitting, absolute exclusion of 
light, and guarding the face from the action of the air by keeping 
it constantly covered with fresh hog's lard. Another author calls 
attention J to the value of darkness in preventing pitting in this 
disease. He prescribes Fowler's solution intemally at the same 
time. Ample testimony has already been bome § to the utility of 
Dr. Black's suggestion. It is, however, to be remembered, that not 
only did Dir. Benjamin Ridge recommend || total exclusion of light 
as far back as 1859, but that the idea has every now and then been 
mooted ever since the days of John of Gaddesden. In addition to 
this, an immense number of ectrotic remedies has been recommended ; 
among them nitrate of silver, collodion, mercurial ointment, 
emplastrum vigo, the best of all being, perhaps, the nitrate and the 
ethereal solution of mastic and iodine suggested by Dr. T. Smith 

* yournal of Cutaneous Medicine^ vol. ii. p. 64. 

t Lancet^ 1867, vol. i. p. 792. t Ibid.^ vol. ii. p. 88. 

§ Ibid.^ vol. ii. p. 284. || Ibid.^ p. 19 1. 



200 Treatment of Variola. 

Rowe, of Margate.* To my thinking there is nothing like punctur-r 
ing each vesicle so soon as ever it contains fluid, wiping the fluid 
gently away with lint, and covering the part with thick lard. When 
practicable, I would advise, in severe cases, touching each vesicle^ 
as it is punctured, with nitrate of silver. I say this in ignorance, 
however, of the practical effects of Dr. Rowers treatment, which I 
have had no opportunity of trying. The room should, I think, be 
kept as dark as possible. In a case of confluent small-pox lately 
under my care, this method almost entirely averted all pitting. A case 
in which pitting was prevented by the use of carbolic acid is men- 
tioned in the Lancet^ i868.t Two drachms of carbolic acid were 
mixed with two ounces of suet ; the mass was coloured with lamp- 
black and applied, spread thickly, on black cotton wadding. It was 
changed every second day, when the face was washed with soap and 
water, and then with carbolic acid and water. One arm, to which the 
ointment was applied, did much better than the other, which was not 
treated with it. 

Dr. HewanJ says that at Old Calabar the natives suffer very little 
from pitting, the reason why they escape being that they cover the 
parts with burnt clay mixed up into a stiff" thick paste with water. 
Their houses are very dark, and when sick they get into the most 
obscure part, in fact, they are in almost total darkness. The dyed 
amadou made by Mr. Ewen of Jermyn-street, has been strongly 
recommended. 

The Sarracenia purpurea, at one time very strongly recommended 
in America for internal use, seems to have answered indifferently 
in this country. § Mr. Ch. Miles says|| that if a large wine glassful 
of the infusion be given to a person suspected to be labouring under 
the influence of small-pox, the effect of the first dose is to bring out 
the eruption, and that after a second or third dose, given at 
intervals of from four to six hours, the pustules subside and 
apparently lose their vitality. In a person covered with the eruption, 

• R. Spirit^s rectificati 5v. 

iEtheris sulphuric! 5iij. misce et adde 
Gummi mastiches gr. xxv. solve et adde 
lodinii 9ij. -n\. ft. solutio. 

t Vol. i. p. 151. 

J yournal of Cutaneous Medicine^ vol. ii. p. 35. 

§ Edinburgh Medical yournal, 1862-3, P- 671. 

II Lancet^ 1862, vol. ii. p. 430. 



Treatment of Variola. 201 

the prominent S3rmptoms of the disorder subside in three or four 
days, the urine becomes pale and abundant, and no marks are left 
when recovery takes place. It speedily quells delirium, clears the 
tongue,, makes the urine clear. No other medicine is required. 
The root is used, and the firm solid part should be chosen. Two 
ounces, sliced, are put into a quart of cold water, and allowed to 
simmer down to a pint and a half. As Mr. Miles is such a pains- 
taking and truthful observer, the matter ought not, in my opinion, 
to be lost sight of. It is, however, possible, that the dried root may 
lose its virtue before its can reach England. 



2 D 



( 202 ) 



CHAPTER VII.— VESICULiE. 

A, Herpes, B, Pemphigus, C, Rupia, D. Miliaria. 

A. Her'pes (es^ is, masc), fpTnyc, from epTrw, to creep. Derivation 
entirely corrupted, or rather, word quite misapplied. 

Definition, — ^An eruption of vesicles in clusters, generally seated 
on inflamed patches. Vesicles vary in size from a coriander-seed to 
a split pea ; gradually becoming milky but not truly purulent ; end 
by rupture and desquamation ; sometimes followed by pitting, occa- 
sionally, in bad, cachectic subjects, by ulceration ; often accom- 
panied or followed by severe neuralgic pain. Occasionally attacks 
eye, mouth, &c. 

Divisions, — i. H. zoster (zona) or shingles, in which the vesicles 
extend in groups, principally seen round one side, or part of it, but 
may form on back of neck, and many other places ; 2. H. circi- 
natus, in which the eruption takes the form of rings ; 3. H. c. bul- 
losus seu gestationis, a rare affection accompanying pregnancy, of 
great severity, the vesicles appearing nearly all over the body; 
4. H. perstans, in which the vesicles return, scattered, with great 
obstinacy for months or years, followed by pitting and often super- 
ficial ulceration, seen in face, leg, &c. ; 5. H. iris, a still rarer form, 
occurring chiefly on the backs of the hands of elderly persons. It 
seems to be admitted that the seat of the vesicle is between the 
mucous and horny layers of the cuticle. 

Dr. Grimshaw mentions* a case of herpes which proved fatal; 

• yournal of Cutaneous Medicine^ vol. ii. p. 38. 



Herpes epizooticus. 203 

each vesicle was surrounded by a black areola, " as if a line of ink 
had been drawn round the vesicle and smudged over the surrounding 
skin." The hips, nates, and sacral regTon were so closely covered 
with the eruption, that they presented a continuous black surface. 

Transient hemiplegia has been known to accompany herpes in 
the aged.* Dr. Duncan, who tells the story, seems inclined to 
believe that the herpes was the original disease and exciting cause, 
and the hemiplegia the effect, just as paralysis may be the effect 
of teething. It seems pretty certain, from the fact of the vesicles 
following the distribution of only a branch of a nerve, that the 
irritation can hardly start from the ganglion, as mentioned by some 
authors. 

Several cases are recorded in which a peculiar form of herpes 
seems to have been communicated by horses^ cows, &c. Mr. 
Curgenven has related some.t The disorder attacked the tonsils, 
uvula, nostrils, eyelids, each side of the neck, left side of the 
scrotum and prepuce. Vesicles were also seen, on the thighs, 
forehead, and backs of the hands. The constitutional symptoms 
were very severe. The first patient was a coachman. A week after 
his attack began his wife was seized in the same way, and his 
mother, who had sat up to nurse him, was also attacked, but less 
severely. His brother, who came to see him, had an eruption on 
the tonsils a week later. In another case, a servant had an eruption 
of these vesicles on the tonsils, and the day following her mistress 
was taken ill ; but in her, though the tonsils were red and swollen, 
no vesicles appeared. The servant seemed to have caught it from 
a fellow-servant with whom she slept. Dr. Burrows described % two 
cases of this disease, complicated by bullae, apparently contracted 
from sheep. Both the patients were butchers. 

I was consulted last autumn (1870) by a patient for an affection of 
this kind. A great number of aphthous spots had formed on the ton- 
sils and insides of the cheeks. They were yellowish and aphthous- 
looking.§ I could however detect no vesicles, though I saw some 

• On Herpes Zoster, By John Duncan, M.A. Journal of Cutaneous Medicine^ 
vol. ii. p. 242. 

t British Medical Journal ^ 1869, vol. ii. p. 488. 

X Medical Times and Gazette^ 1856, vol. i. p. 589. 

§ Dr. Hillier states that the development of herpes in the mouth is due to a 
parasite which can be readily seen on microscopic examination. — Op» cit , p. 130. 
It seems to be distinctly epidemic at times. — Journal of Cutaneous Medicine^ 



204 Treatment of Herpes zoster. 

slfght elevations on the mucous membrane of the tonsils which a 
superficial examination might have passed as such. There were no 
vesicles elsewhere. The patient complained of weariness, dejec- 
tion, and general feeling of indisposition. As I knew him to be a 
strong, healthy, temperate man, I felt indisposed to assign any 
great share in his indisposition to the mere appearance of the 
aphthae. Having heard a good deal of this epizootic form, I 
inquired of him, but the only approximation to a cause of this 
kind was that the patient lived five doors from a dairy which had 
been recently shut up. 

Treatment, — H. perstans and h. c. buUosus excepted, zoster is the 
only variety of this affection which requires more than a mere passing 
notice, and all that is really required for it is generally to be summed 
up in a few words ; a mild aperient or febrifuge may be prescribed, 
and every vesicle should be pricked with a needle so soon as it begins to 
fill with serum ; the fluid should then be removed by sponging gently 
with warm water. The surface may next be bathed with a Goulard 
lotion containing three or four drachms of the liquor plumbi to the 
eight ounces, and at night a mild ointment, like elder-flower ointment, 
or cold cream, may be applied. Dr. Hillier recommends, if there be 
any sloughing, that a nitric acid and opium lotion should be applied. 
Dr. Frazer has found great benefit firom the internal use of tincture 
of muriate of iron. When the pain is severe, arsenic may be pre- 
scribed. Mr. Wilson here recommends colchicum and iodide of 
potassium followed by quinine, and has seen tincture of aconite 
rubbed into the part relieve the pain, while in other cases it has 
failed. Sir W. Jenner* recommends belladonna for the pain 
remaining after the herpes, and Barensprung blisters near the spine 
and prescribes the endermic use of morphia. I have never found it 
requisite to use any of these medicines. If arsenic be given, the 
pain will always, I believe, yield immediately. I have never yet 
found this remedy fail. I treated, not long ago, an old lady nearly 
eighty years of age, who suffered so much from the pain after zoster, 
that she maintained it was killing her. Sedatives had been tried 
without effect, whereas the action of the arsenic produced immediate 
relief. This statement is borne out by the experience of Bazin, who 

vol. iv. p. 29. On Herpetic Eruptions^ by Dr. W. Frazer. According to this 
careful observer there was a diagnostic offensive odour of the breath in the cases 
observed in Dublin during the year 1869. 
* Medical Times, 1857. 




Herpes gestattonis, 205 

gives* two cases promptly cured by arsenic, in one of which the 
pain had resisted all treatment for three months, and in another had 
lasted six years. When this remedy is withheld, it may endure an 
indefinite time. Dr. Duncan speaks of the pain lasting a whole 
year after. 

In the da)rs when humoral pathology was in the ascendant, men 
looked upon the vesicles as an effort of nature to relieve the system 
of some poison, and to further this purpose the older surgeons, who 
of course could do better than nature, used to cut the loose skin of 
the vesicles away and cover the raw surface with red nitrate of 
mercury. This caused no slight amount of torture, but then it was 
secundum artem; it was supported by theory, without which the 
world could not go straight, and though it did not promote the 
patient's recovery, it established a principle, which was of more 
consequence. 

Herpes of the prepuce rarely demands more than water dressing, 
and herpes of the lip generally only requires to be let alone or treated 
with camphor cake or cold cream. Dr. Frazer advises for herpes 
attacking the eyeball, rest of the organ, small leechings, blisters, 
mercurial alteratives, and full doses of bark and quinine. 

Herpes gestationis was first described, under the title of herpes 
circinatus buUosus, by Mr. Wilson, who has seen and recorded t two 
cases of this extraordinary affection. Almost directly after I con- 
tributed to Xht Journal of Cutafieous Medicine % a. third case, which I 
now append, and a fourth case occurred in the practice of Dr. Klein 
of Jicin, which I recorded in the same joumal.§ What little I have 
to say about treatment is to be found in the narrative of the case 
which now follows. Intimately connected as the disease is with 
pregnancy, all treatment must to a certain extent be merely pal- 
liative. • 

Jane S., 45 years of age, a well-made, healthy-looking woman, 
applied, March 15, 1867, as out-patient at St. John's Hospital, 
suffering under the following symptoms : — Nearly the whole surface 
of the inner part of the right arm and forearm, and a somewhat less, 
but still very considerable extent of the left arm and forearm were 
covered with vivid red, very slightly elevated patches, varying in 
size from that of a bean to that of the base of a split walnut. On 

* Lemons ThSoriqueSy p. 127. 

t Diseases of the Skin^ sixth edition, p. 294. 

X Vol. i. p. 311. § Vol. ii. p. 203. 



2o6 Case of Herpes gestationis. 

most of these patches were vesicles about the size of a small pea, 
very rarely solitary, and generally in groups of two to four. They 
were mostly prominent and pointed in shape, but some were oblong, 
with the ends apparently communicating. They were in all stages ; 
some quite tense from accumulation of limpid serum ; others just 
rising. She tells me that she noticed none of the vesicles before 
the previous day, though the patches had formed a day or two 
prior to this. Her face had a peculiarly distressed look, and she 
complained of utter sleeplessness, occasioned by intense itching, 
smarting, and heat She has been pregnant about four months. 

As she also complained of being very constipated and feverish, 
a saline aperient was ordered, with an aperient and sedative pill, so 
as to procure her some rest if possible ; a lotion containing liquor 
plumbi diacetatis and camphor mixture was directed to be freely 
applied. She was enjoined to puncture each vesicle as soon as 
possible, to keep very quiet, have a light, warm diet, with a glass of 
wine daily, and to leave oflf beer. 

When seen on the 19th, there were rather fewer vesicles, 
otherwise there was no particular change : the patches had some- 
what increased in size, and new ones were coming out. She felt no 
better, and was still very constipated. The dose of the aperient 
was accordingly augmented a little. 

But a week later, the 26th, the complaint had gained ground in 
a very decided manner. There were now at least fifty patches on 
the right arm, all bearing vesicles, varying in size from a pea to a 
haricot bean ; some were also coming out on the outside of the arm 
which had hitherto remained free. On the inside of this arm, about 
halfway between the axilla and elbow, were two parallel lines of 
tolerably large bullae and vesicles, mixed together, and sixteen in 
number, and between these again and the elbow there was a patch 
as large as the palm of the hand, containing between fifty and 
sixty vesicles. On the left arm also there were now large numbers 
of vesicles, some of them assuming a whiter look than on the 
opposite side. 

At her next visit, 29th, there were fewer vesicles, but the number 
of bullae had increased, there being now quite fifteen to twenty on 
each arm, fully formed, and great numbers rising ; in fact, it seemed 
as if every part on which vesicles had not yet formed would be 
invaded. The fluid was no longer limpid, as at first, but white 
in some and yellow in others. The front part and sides of the 




PHOTOGRAPH OF HERPES aN ARM). 



Case of Herpes gestationis. 207 

abdomen and the inside of the thighs were by this time almost 
covered with the same red patches, but no vesicles had as yet 
formed upon them. Her bowels had been freely acted upon, and 
she now complained of being so cold that she shivered all day, 
and felt as if nothing would make her warm. She was therefore 
ordered eight minims three times a day of the acid solution of iron, 
and the free use of zinc ointment to the affected parts, as she 
thought the lotion rather irritated them. 

From this time she got worse, and the day after, a visit to a 
photographer, to have a portrait taken of the eruption, so com- 
pletely prostrated her that she was obliged to take to her bed. I 
visited her on the ist of April, and found the tongue red and 
chapped, pulse 120, great prostration both of mind and body, total 
loss of appetite, utter sleeplessness, and the most distressing irrita- 
bility of the parts affected ; that is to say, of almost all the surface 
of the frame except the back, face, and hairy scalp. She was 
ordered a quart bottie of stout daily, with at least one or two 
glasses of port wine, rum and milk at night, and beef-tea ad libitum^ 
as she could not touch solid food now. The steel, having obviously 
done no good, was given up, and sesquicarbonate of ammonia 
prescribed instead, ten grains every three hours in one ounce of 
infusion of cascarilla. She could not bear even zinc ointment^ and I 
therefore directed that she should be covered from head to foot 
with linen rags dipped in fresh-melted suet. 

Two days later the pulse had fallen to 108, the tongue was less 
red, and there were fewer vesicles ; the prostration was still ex- 
cessive, her bowels were obstinately confined, and she thought 
the ammonia gave her pain. The aromatic spirit was accordingly 
substituted for the sesquicarbonate, and a stronger aperient pill 
prescribed, to be followed by the citrate of magnesia. By the 8th 
vesication had pretty well ceased, and she was so much better 
that I advised her to go into the country for a week, which she 
did shortly afterwards with considerable benefit. Her pulse had 
already fallen to 96, her appetite was somewhat restored, she had 
been able to get a little sleep, and the irritation in the skin had 
greatly lessened. On her return to town I carefully re-examined 
her. She was covered from head to foot with the erythematous 
patches, but the vesication had ceased some time. She was again 
ordered steel, and for some time seemed to improve under it ; but 
this was of very short duration, the feeling of languor and irritability 



208 



Case of Herpes gestationis. 



again assailed her, and from this time up to the date of her con- 
finement never left her. No more vesicles formed, and onlv a few 
very small pustules, but the patches continued to increase in size and 
number from the beginning of May onwards. 

About the end of the first week in June she noticed a slight show, 
which gradually increased, and on the Saturday following premature 
labour took place. The foetus, which was more than six months 
old, had, according to the statement of the medical gentleman who 
attended her, been dead some time. Directiy after her confinement 
the eruption began to relapse, and by the third day she had a 
tolerable crop of large vesicles on each arm, while many of the 
spots on the legs and trunk became speedily covered with dry 
yellow crusts. But these soon abated again ; by the 25th of June 
she was almost entirely free from them, and at the beginning of July 
she had had no relapse. 

Though a very intelligent woman, she committed the singular 
mistake of repeatedly telling me that this was the fourth time she 
had suffered in this manner, and always during pregnancy.; but 
when she came to put the dates on paper she found there were only 
two previous attacks ; the first having occurred in 1853, the second 
in i860 ; there being thus an interval of seven years between eacL 
There were three confinements between the eruption in 1853 and 
that in i860, and two between the latter and the present attack, so 
that the entries stand thus : — 



WiUiamS.... 
Still-bom child 
Johns. 
Henry S. 
Still-bom 
Louisa S. 
Anne S. 
Still-bom 



First eraption (i) 
No eraption 
No eruption 
No eruption 
Second eruption (2) 
No eruption 
No eruption 
Third eruption (3) 



... 1853. 

... 1854. 

... 1855. 

... 1858. 

... i860. 

... 1861. 

... 1863. 

... 1867. 



All three, she asserts, began about the same time after im- 
pregnation, ran the same course, and invaded the same parts in 
succession. The second attack, however, was more severe than the 
first, and the present one is more severe than the second. Like the 
present, the previous outbreaks scarcely seemed to be in any degree 
influenced by treatment. They both disappeared spontaneously 
after parturition. I questioned the patient about ever3rthing that 



Case of Herpes per s tans. 209 

seemed in the least degree likely to throw any light upon the 
subject, but could make nothing out. 

In both Mr. Wilson's cases the disorder was associated with 
pregnancy, as also in Dr. Klein's. In one of Mr. Wilson's cases 
the disorder had accompanied this state four or five times, in the 
other six times. The disease proved very serious in the first case, 
as it did in mine. In l^oth there was intense itching ; the bullae 
were flat, and accompanied by thin crusts, moist excoriations, and 
papulae ; and in both there was sympathetic disturbance of the 
stomach, with duskiness and cachexia of the skin. I did not notice 
the two latter symptoms : indeed the patient, a comely woman, 
looked as if, but for the eruption, she would have been a model of 
good health ; and in the notes taken at the time I find it expressly 
stated that there were no moist crusts and no weeping from the 
surface at any stage of the complaint, — perhaps in some degree, 
results of the very free use of the liquor plumbi. 

From the very outset I had expressed a decided opinion as to the 
inefficacy of any treatment whatever, and certainly I never observed 
that the medicines prescribed exerted the least real control over the 
progress of the complaint. The sedatives, relieved the pain and 
sleeplessness to a certain extent, and she appeared to be benefited 
both bodily and mentally by the employment of purgatives, but these 
remedies exerted no visible influence, at least, over the course of 
any stage of the eruption. She expressed herself as very grateful 
for the comfort afforded by the use of the suet, which she believes 
carried her through her illness. Possibly some of the numerous 
prescriptions in vogue for itching might have quelled this trouble- 
some symptom, but my experience of them has been so unsatisfactory 
that I did not make the attempt. 

Out of the few instances of herpes perstans which I have seen I 
select the following : — 

George A., an intelligent young lad, a cabin-boy in a river steamer, 
came under my care for an obstinate vesicular disease of the face, 
which gave him a most singular, and at times rather revolting 
appearance, though but for this he would have been healthy-looking. 
On the ears were several hard, brown, tenacious scabs, while from 
ear to ear stretched a broad irregular band of scattered vesicles and 
cicatrices. This band was only about an inch broad where it crossed 
the bridge of the nose, but further back it extended down to the 
angle of the jaw ; the upper margin lay just below the eye. The 

2 E 



2IO Case of Herpes per s tans. 

pits were superficial, and might, on a cursory inspection, haVe been 
taken for those of small-pox. There were not very many vesicles, 
and they were tolerably uniform as to size, being generally as large 
as split peas. They were in all stages, some perfectly clear ; some 
having concreted into the firm brown scabs just spoken of. 

The history of the case, as given by the lad's mother, is, that 
about six years and three months previous to this he suffered from 
typhus fever, and very soon after the vesicles began to appear on 
his cheeks ; from which time to the present he has never been free 
from them. Not long after they also showed themselves on the 
lips, and he was then taken to a surgeon, who seems to have applied 
the nitrate of silver very freely to them. The remedy, whatever it 
was, did its work effectually ; it gave great pain> but the disease has 
never reappeared in the part. It, however, soon after began to 
attack the ears, and there it. has abode to the present date — quite 
six years and a quarter, one year and a half of which hd passed at 
school, and the remainder in his present occupation. 

The attacks are always preceded by stiffness, burning, and itching 
of the skin, and then the vesicles break out. The vesicles vary in 
number from eight or ten to twenty or thirty ; except in respect to 
the pitting, they run the usual course of vesicles^ becoming opraquCj 
rupturing, or drying up, but always forming hard scabs. Thfey are 
all fiat, and some are umbilicated. They are not followed by any 
weeping surface, nor do any soft crusts form. There are nopusr 
tules, in the proper sense of the term. During the six months that 
I have watched the case, a fortnight has never elapsed without some 
vesicles appearing, and generally a distinct relapse. The boar's health 
is, with this exception, excellent ; he has no bad habits that I can 
make out, seems well fed and cleanly, and as he suffered from the 
affection for quite a year and a half before he left school, it cannot 
be laid at the door of his occupation. 

He was treated with salines and mild aperients, with the free use 
of fresh-made oxide of zinc ointment to the spots, a lotion of liquor 
plumbi and camphor mixture being substituted in the daytime when 
the heat and itching come on. After this the nitric acid was given 
in infusion of quassia, but as no good resulted from a fair trial of 
this medicine, arsenic was prescribed instead. But at the end of 
several weeks no ground whatever had been gained, and the acid 
splution of iron was substituted. He took it for a month, and during 
this time he had two bad relapses. It was therefore given up, and 



Definition of Pemphigus ; Divisions. 211 

the sulphate of iron in mixture ordered. This he has now taken for 
four weeks, along with an eighth of a grain of bichloride of mercury 
daily, and upon the whole he is better. The disease is confined to 
the ears, and for three weeks he has not had a fresh attack — the first 
time he can ever recollect having had so long an immunity, 

I never saw but one case approaching this in obstinacy. The 
patient, was a chemist, was of a most irritable temperament, and had 
suffered firom herpes of the face for eighteen months. Here, how- 
ever, the disease speedily yielded to moderately large doses of tincture 
of steel.* 

B. Pem'phigus {us^ /, masc), from Trc/u^ef, a bubble, a drop. 

Definition, — ^An eruption of one or more bullse on slightly in- 
flamed surfaces. Bullae spring up in a few days, and may vary 
in size from a small haricot bean to a walnut ; outbreak of them 
sometimes attended by severe tingling. Maybe solitary or very 
numerous. Burst in a day or two. Surface beneath left excoriated 
and tender; subsequently covered by a thin brownish or blackish 
scab. Contents of bullae stated by Dr. Hillier to be usually 
alkaline, though said by many writers to be acid. Found by Simon 
to contain albumen,. cholesterin, fat, lactate of soda, free acetic acid, 
mucous .corpuscules, chloride of sodium, and potassium. Uric acid is 
occasionally found in it.t Sometimes accompanied by great itching. 

Divisions, — i. P. vulgaris, answering, except in the bullse being 
never solitary, to the above description. 2. P. solitarius (Pom- 
pholyx), distinguished by the appearance of one very large solitary 
vesicle at a time. 3. P. gangraenosus, the same complaint as 
P. vulgaris, but occurring in poor irish children, among whom it 
appears as an epidemic : the bullse purplish, livid, and with a 
sloughing base. 4. P. foliaceus, in which the bullse are very im- 
perfectly developed and produced with great rapidity ; attended with 
extreme prostration; generally fatal. P. syphiliticus, generally 
seen only in children and on the soles of the feet ; may attack 
neck, face, and upper extremities ;J also palms, palmar surfaces 
of fingers, and soles of feet in adults.§ 

• See also Medical Circular^ 1864, Sept. 7. 

t Hiller, Op. cti., p. 141. 

J American Journal of Syphilography^ vol. i. p. 205. 

§ Lancet^ 1870, vol. i. p. 65. 



2 1 2 Treatment of Pemphigus. 

Acute pemphigus is sometimes ushered in by a certain amount of 
heaviness, symptoms of nausea, pyrexia, &c. ; but considering that 
sometimes fifty or sixty bullae will make their appearance in twenty- 
four hours, the amount of constitutional disturbance must be 
looked upon as remarkably small. When it occurs in children, it 
proves occasionally a very serious matter. In an outbreak in the 
Children's Hospital, at Stettin, where eight young persons were 
attacked, six died* In newly-born children it is commonly 
fatal. This form of pemphigus is usually considered to be 
syphilitic, but it appears in cases where no syphilitic history can 
be traced. 

Dr. Edward Ballard published in the Medical Times and Gazetted 
a case of pemphigus occurring in a man, which seemed beyond 
all doubt to have been communicated to him by the cow. He 
had given a horse a ball, and on withdrawing his hand had been 
slightly bitten on the back of it ; he afterwards milked four cows 
suffering from a vesicular eruption on their udders and teats. A 
bleb soon formed at the bitten spot, which was followed by a large 
number of others. Dr. Ballard says there must have been in all 
quite a hundred blebs. In this case also the mouth and throat 
showed bullae. The tongue was swollen, and " bloody matter '* 
flowed from the nose. The general symptoms were very severe, 
there being vomiting, haemorrhage from the bowels, and apparently 
also blood in the urine. Mr. Ceely, of Aylesbury, who has paid 
great attention to the subject, has no doubt that the disease in the 
cows was that known as the white or blister pock, which often in^ 
oculates the hands of milkers but does not afford immunity against 
smallpox. 

Treatment, — I believe it is pretty generally admitted that the 
treatment of pemphigus should be tonic. For the complaint, when 
it occurs in children, I have found steel answer very well. Mr. 
Wilson considers iodide of potassium a valuable remedy in pemphigus. 
Mr. Startin employs quinine, bark, mineral acids, and vegetable 
bitters. Chlorate of potass often proves very serviceable, especially 
in the gangrenous form. The state of the bowels, particularly in 
elderly persons, must be very closely inquired into. Restlessness 
and pain require to be met at once by opiates. Mr. Startin seems 
to consider the chronic form (pemphigus diutinus) as incurable. 

• Joiirnal of Cutaneous Medicine^ vol. i. p. 432. 
t 1871, vol. i. p. 45. 



Definition of Rupia. 213 

Mr. Nayler mentions one case in which pompholyx seemed to 
decline spontaneously. Dr. Hillier speaks very favourably of 
arsenic^ as does Dr. Spender, and I invariably have recourse to it 
when the case proves obstinate. Dr. Spender also tells us that in 
some cases arsenic and bichloride of mercury together succeeded 
where the former alone has failed ; but the prognosis is always 
grave when the patient is old.* 

For external use most writers have advised the warm bath. 
Mr. Wilson recommends spermaceti ointment with peruvian balsam, 
diluted tar ointment, or ointment of nitrate of silver; excoriated 
surfaces to be dusted with oxide of zinc or starch powder. In the 
epidemic gangrenous form, Dr. Stokes speaks very favourably of the 
scrofularia nodosa ; the ointment is to be as strongly impregnated 
with green matter as it is possible to make it. It is laid on with a 
brush every six hours. Dr. Stokes also recommends carrot poultices 
when there is swelling of the surrounding parts. 

My experience is that the warm bath in the early stages of the 
disease either does no good or a great deal of harm ; it is as 
useless or hurtful here as in eczema. When the disease declines, it 
is sometimes serviceable in restoring the skin to a healthy state. 
I would advise that every bulla should be pricked as soon as 
possible, and that no other dressing should be employed beyond 
zinc ointment, laid on while warm, and oyer this soft cotton wool 
secured with strips of linen. 



C. Ru'piA {a, (By fem.), from pviroQ, filth, stains. 

Definition, — An eruption of sero-purulent scattered bullae, with a 
narrow reddish ring round the base. Fluid speedily becoming 
sanguinolent ; followed by formation of thick, more or less conical, 
dark green, grey, or blackish crusts. After removal of these an 
obstinate ulcer is left, secreting an ichorous, purulent, foetid fluid. 

* The examination of the urine in this form (pompholyx) does not give us any 
clue to treatment Heller found it a little below the normal specific gravity, 
urea rather increased, as also the sulphates. Hillier observed normal quantity of 
urea, excess of uric acid, and abnormally small quantity of chlorine. As the results 
of autopsy, Bamberger met with great deficiency of albumen in the blood. Biett, 
who was not always so accurate as he might have been, says fatty liver was almost 
constantly found in patients who had died of chronic pemphigus. Hirtz found 
amyloid degeneration of the liver and spleen. 



214 Treatment of Rupia ; Miliaria. 

S3rphilitic. Rupia simplez, it is said,* may follow measles or scar- 
latina in children. 

TrecUffunt. — ^The best remedy, where it has not yet been given, 
is, so far as I have seen, the iodide of potassium in five-grain 
doses two or three times a day, accompanied by the use of iron 
in some form or other. The cerate of the yellow resin, which 
should be applied gently warmed to the base of the vesicle or 
ulcer, all secretion being first carefiilly removed, is a very useful 
dressing. Dr. Hillier recommends sulphate of magnesia aperients, 
accompanied, when there is much debility, by sulphate of iron or 
quinine. The diet should be strengthening. 



D. Milia'ria (^, a, fern.), from milium^ a millet-seed. 

Definition, — ^An eruption of . minute vesicles about neck and 
breast, sides of trunk, inner and upper sides of arms and back, 
often preceded by sensation of pricking and accompanied ,by signs 
of great exhaustion, strong and peculiar odour in perspiration. 
Contents of vesicles generally acid. Vesicles speedily become 
white and desquamate, while fresh ones appear. Often seen in 
delicate females, especially after childbirth. 

Treatment — ^The first step is to reduce the excessive temperature 
to which the part affected has been exposed, for miliaria means 
heaping up too many clothes on the bed and letting in too little 
fresh air. The next is to give a mild diffusible stimulant, such as a 
teaspoonful of the valerianate and tinctiure of ammonia, or five 
grains of the chloride of ammonia, every three hours in an ounce of 
infusion of cascarilla; but indeed almost any preparation of this 
kind will do. A tonic draught containing a grain of quinine, or some 
mineral acid, may be given at least once a day, just before dinner. 
Under such treatment a favourable result may be quite anticipated. 

• Hillier, Op. cii. The cases of this kind that I have seen, generally on the 
face, scarcely merited the name of rupia. 



( 215 ) 



CHAPTER VIII — PUSTULE. 

A, Impetigo. B, Ecthyma, C, Acne, D, Sycosis. • 

A. Impeti'go (Oj iginis^ fem.), from impeto^ to infest ; ab impdu 
agens ; acting suddenly and .fiercely. About as sensible a 
derivation as many others. 

Definition,— -Trxxe inflammation of patches of the surface of the 
cutis, accompanied by the formation of pustules, and frequently by 
some degree of swelling ; followed by greyish or yellow crusts,^ which 
fall off mostly without leaving any scars. 

Divisions, — i. I. communis, in which the above symptoms are 
found. 2. I. contagiosa, in which the secretion is more unhealthy- 
looking, the* crusts of a dirty yellow, the edges more welted and 
irregul^, with a peculiar sodden look. 3. I. rodens, marked by great 
pain, much thickening of the base of the pustules, unusual size of 
the latter, and permanent disfiguring cicatrices. ' 

In addition to these, certain forms of what is called impetigo have 
attracted attention on account of their supposed contagious nature. 
One of these is that complaint described as a form of favus, begin- 
ning with an eruption of straw-coloured pustules, and ending in the 
formation of favous crusts ; a complaint I have never seen, and 
about which the accounts are not quite clear. If it run the course 
just described, I fancy its place is with impetigo. Another is the 
porrigo scutulata or true pustular ringworm of the scalp, beginning 
with clusters of small light-yellow pustules, which break and form 
thin scabs over each patch, the skin underneath being red and 
shining. This form is thought by Bateman * and many others to be 

* Practical Synopsis, fifth edition, 1819, p. 170. Bateman describes it (p. 169) 
as beginning with '* clusters of small light-yellow pustules." 



2i6 Impetigo contagiosa. 

decidedly contagious ; I have not been able to see any proof of its 
real nature, and I confess myself unable to make out from Bateman's 
description whether it was kerion, favus, or true impetigo. 

Another form has been described as eminently contagious, the 
impetigo contagiosa mentioned above. The first account of this 
disease was published in the British Medical Journal by my friend 
Mr. R. W. Dunn, whose attention had been directed to its nature by 
Mr. Startin. The disease in question occurs mostly on the face, but 
may appear on the trunk and limbs. It begins with small pustules, 
which enlarge, umbilicate, and then dry up, leaving a dark scab with 
a little matter oozing out, or the spot spreads till it reaches the size 
of a shilling, and then looks like a flattened bleb sunk in the middle, 
having a ring like soddened white leather round it. Thick crusts 
then form, and when these are picked off, a sticky puriform fluid is 
found covering the ulcerated surface beneath. The disease lasts six 
or eight weeks. There may be only one solitary spot, and then it 
is generally on the face or head, rarely on the trunk, except from a 
direct inoculation. This spot is sometimes as large as a florin. On 
the face several may run together and form a thick crust, like a 
patch of impetiginoid eczema. The microscopical characters are 
at the beginning a few pus-cells, but chiefly homogeneous blastema, 
fat and epithelial debris; later on the pus-cells predominate. In 
the crusts are found vegetable parasites ; the steatozoon has been 
discovered, but is supposed to be an accidental appearance. The 
small hairs in the centre of the crust are split up by the fungus. 

The disease attacks pale, flabby children ; dirt, darkness, and low 
living favour its development. It may, however, attack any person, 
as it seems to be highly contagious. Cases are mentioned which 
are supposed to have been communicated by a bite or scratch, &c. 
The forearm of a woman was inoculated, and in twelve hours the 
edges of the wound had become red, swollen, and itching. The day 
after a slight blush was seen and the centre rose to a little red 
point ; in forty-eight hours it had the appearance of a small yellowish 
head. On the third and fourth days there was a well-marked areola ; 
then'it began to dry, and the centre, previously sunk in, puckered 
together, a little oozing taking place from beneath one edge. The 
spot was between the size of a shilling and a sixpence ; the parts 
around felt hot and stiif. The rest of the course run by the 
disease was the same as in other cases. The disease is not 
parasitic. 



Impetigo contagiosa, 217 

Thinking it desirable to test the accuracy of these views, I per- 
formed the following experiment : — 

On the 23rd of October, 1866, I inoculated myself with the fluid 
from one of the pustules on a patient suffering under this disease. 
The patient was a strong and otherwise healthy young man, the 
lower part of whose face was almost covered with this kind of 
impetigo, the greater part of the affected surface being in the healing 
stage. The part selected for the experiment was the lower and fore- 
part of the left wrist At the end of about forty hours there was 
distinct evidence that inflammatory action had begun, and on the 
following day, although there were no signs of a pustule, a hard, irre- 
gular crust, the size of a small split pea, of a yellowish-green colour, 
and firmly adherent, had formed at the inoculated part, in the centre 
of a red patch quite a quarter of an inch across, and raised slightly 
up in the form of a dome-like swelling, if such a term can be justly 
applied to an elevation which at the most prominent part did not 
rise more than a hne above the surface. There was a little stiffness 
and at times a feeling of heat during the whole of this day and the 
day following. By the 28th the swelling had shrunk, and the red- 
ness had faded. There was now no prominence except that of the 
crust itself. 

In the mean time I again (October 27 th) inoculated on the inner 
side of the palmar surface of the same wrist. At the end of about 
twenty-four hours I noticed that the cicatrix from the puncture 
seemed broader and more defined than I should have expected to 
see it firom a similar wound made with a clean instrument \ and I 
may here remark that the instrument used for inoculation was an 
exceedingly sharp, clean bistoury. 

When the crust was lifted up from the first sore for the purpose of 
inoculating, a distinct discharge of very pale serum took place. On 
the 29th there was a good deal of uneasiness at the radial side, and 
on looking at it I observed that a small ragged pustule had formed 
at this point. I pierced the pustule with a bistoury and put by 
some of the fluid for examination, but it was accidentally spoiled. 
On the following morning (October 30th) there was some uneasiness 
at the same site, and I again pierced the pustule, which now yielded 
a dirty reddish-colomred pus. A drop of this, well diluted with dis- 
tilled water, was placed under the microscope, the field of which was 
at once filled with a mass of very small, irregularly-shaped and almost 
angular corpuscules. I noticed several which, small as they were, 

2 F 



i 



2i8 Impetigo contagiosa; rodeiis, 

had a smaller one attached in this manner, oo, as was clearly seen 
when they moved across the field. A few of these corpuscules were 
transparent, \iith a clear outline, but the most of them seemed filled 
with several dense nuclei. 

On the I St of November the second inoculations seemed to have 
abated. On lifting up the crusts there was only ^een an almost dry, 
red surface without any matter, whereas this was still present under 
the crust of the spot first operated on. The day following, however, 
pustules had clearly formed at both the more recently inoculated 
spots, and there was distinct heat and uneasiness in both. That 
(the pustule) at the radial spot was on the outer side of it, and was 
like an irregular, bisected circle. Unfortunately, in the course of the 
day both of these got broken, and the only source firom which any 
fluid could be procured for fiirther experiments was that which had 
dried on the rag tied round the spots. The surfaces of the pustules 
were now cleaned and painted over with solution of nitrate of silver, 
ten grains to an ounce. A small portion of one of the crusts, 
removed at this time and treated with liquor potassae, showed swarms 
of light-coloured, transparent, irregular-sized inflammation corpus- 
cules floating in the field of the microscope. 

On the 4th of November the crust of the outer spot of the second 
inoculation was removed. There was scarcely any matter whatever 
under it. The surface was again painted with solution of nitrate of 
silver. The inner spot, however, yielded a dirty-coloured pus ; it 
was also painted with the solution. On examining a little of this 
pus, it presented to view a large number of globules, mostly joined 
in twos, threes, and fours ; a few groups contained as many as 
five or six. When treated with liquor potassae the globules 
rapidly lessened in size, and small specks of dAris of tissue 
appeared. 

I need scarcely say that these few observations do not prove any- 
thing. We are not yet sufficiently familiar with inoculation firom 

9 

pustules to say how much may have been due to general proper- 
ties, how much to the specific nature of the fluid inoculated. Taking 
into account the results of the second inoculation, I think it must 
be admitted that the balance of evidence is rather in favour of the 
action being specific. 

Impetigo rodens, though its characteristics are chiefly due to 
suppuration arising in a mass so hard as rather to resemble a boil 
than the base of a pustule, may, I think, be fairly classed with the 



Treatment of Impetigo, 219 

foregoing. While in some cases it is clearly syphilitic, others occur 
in which there is no evidence to connect it with such a cause ; and 
occasionally I have seen, in what were almost certainly non-syphilitic 
cases, a chain of pustules running across a tract of skin, as, for 
instance, over the breast, which at once resembled this and common 
impetigo. 

Treaimmt — The treatment of the milder forms of this complaint 
need not differ from that of any simple inflammation of the skin, 
such as zoster for example ; mild febrifuge medicines and aperients, 
such as those already prescribed in earlier parts of this work (e.g, 
page 12), followed by mineral acids,* iron with an aperient, t or 
quinine. J The lead lotion recommended at page 130, and the zinc 
ointment,' are generally all the external applications called for ; the 
lotion being freely applied by means of a linen rag during the day, 
and the ointment, which should be applied hot, being substituted at 
night. Over the ointment should be laid a single thickness of linen. 
I would most strongly advise that every pustule be pricked as soon 
as possible, especially in children. When the inflammation is severe, 
the application of a linen rag dipped in melted suet often affords 
great relief Bateman says § it can be borne when no other greasy 
substance is tolerated, and I quite concur in what he says. It is much 
more soothing than zinc ointment. If, however, the irritation be very 
great, sedatives may be given ; for instance, half a drachm of the 
ammoniated tincture of opium, or fifteen drops of the liquor of the 
acetate of morphia, can be added to each dose of the febrifuge ; or 
twenty minims of Squire's solution of bimeconate of morphia can 
be given every night. Mr. Wilson says that if the surface be too 
sensitive to bear even the zinc ointment, it may be pencilled with 
solution of nitrate of silver, two grains up to six grains to an ounce ; 
he recommends for the same purpose the use of a liniment of olive- 
oil and lime-water, alone or with liquor plumbi or sedative solution 
of opium ; after using it the surface should be covered with cotton 

* See formula at page 119. 

+ R. Magnes. sulph. 5iv. 

Mist, ferri compos. Jvj. *»n.. 
Capiat cochlear, ampl. duo bis quotidie. 

R. Pil. aloes c. myrrha gr. xv. 
divide in pil. iij. i. omni nocte sumend. 

t For formula see page 5. 

§ Practical Synopsis ^ p. 155* 




220 Startifis Treatment of Impetigo. 

wool Dr. McCall Anderson uses the soothing lotion given below,^ 
as he also does for acute eczema. 

Mr. Startin separates impetigo from porrigo on the ground that 
impetigo tends to ulcerate while porrigo does not. I cannot say 
that I see any valid ground for the distinction. I know of no form, 
of impetigo except L rodens which necessarily tends to ulcerate. 
As to the term porrigo I see no justification for retaining.it, as I am 
ignorant of any disease which can be referred to this head. Mr. 
Startin's treatment of impetigo figurata is simple ablution with gruel, 
mucilage, yolk of t%% thinned down with water, or decoction of 
Jinseed; after this biniodide of mercury ointment, and, later on, 
creosote ointment are used as dressings. Internally he gives arse- 
niate of potass, and where there is great acidity of the stomach, 
liquor potassae. For impetigo sparsa, iodide of potassium with 
colchicum wine and arseniate of potass, followed by a course of 
liquor potassae and mild mercurial alteratives. When there is much 
irritation he gives laudanum, and for great weakness vegetable bitters 
and aromatics, persulphate of iron and dilute sulphuric acid, following 
them up also with arseniate of potass and liquor potassae. His ex- 
ternal treatment of this variety is hot baths, creosote ointment, and 
biniodide of mercury ointment In a case of impetigo rodens 
Mr. Startin gave persulphate of iron and hydriodic acid ; the most 
benefit however seemed to arise from applying a solution of nitrate 
of mercury in water ; equal parts of salt and fluid being used. 

The variety called porrigo scutulata, or true pustular ringworm, a 
disease quite unknown to me, has been considered to approach so 
closely to favus and those obstinate forms of eczema, &c, which in 
children are often accompanied by great disturbance of the nutrition, 
sour breath, eructations, wasting, diarrhoea, and other signs of cachexia 
being at hand, as to require some special remedies. These are — t. 
Cod-liver oil ; 2. Mercury in conjunction with some antacid, as soda 
or chalk ; 3. Sulphur, which often proves peculiarly beneficial in this 
complaint. 4. To follow these, a long course of arsenic. For any 
of these to do good it must be taken for a considerable time ; say 
six or eight weeks at least. Sulphur, internally and in the form of 
baths, has been often recommended in obstinate cases of impetigo. 

* R. Acidi hydrocyan. dilut. 3ij. 
Sodse bicarbonatis 5j. 
Glycerini 3iv. 
Aquae rosse Jvss. ni. Lancet^ 1869, vol. ii. p. 698. 



Case of Impetigo rodens. 221 

Dr. Hillier advises tlfat when the stomach is out of order it should 
be given in ten-grain doses, with ten or fifteen grains of nitrate of 
potass, every morning for a week. I cannot say that I have observed 
any particular benefit from it. An ointment of a scruple of sulphur 
and fifteen grains of white precipitate to an ounce of lard, is said to 
answer very well with the contagious form of impetigo. Dr. Durkee 
frequently uses in impetigo the ointment given below.* 

Impetigo rodens is, I believe, generally benefited by iodide of 
potassium and iodide of iron, aided by aperients, which seem to 
subdue it with tolerable certainty if properly taken. I give a case 
which will perhaps illustrate the course of the disorder and the 
action of medicine better than anything I could say in another form. 
It is taken almost word for word from the patient's own account. 

E. M., Esq., a healthy man, aged 51, who had not been confined 
to bed a single day for thirty-four years, after suffering from bad 
headache, colds, &c., observed, July i6th, 1867, four pimples on the 
breast and one on the thigh, which he compared to mosquito-bites, 
and which gradually became very sore. Five days after this he 
consulted a gentleman, who prescribed blue pill and Pullna water. 
Under this treatment the stools became very foetid and the sores 
worse. Being at a distance from home he consulted another surgeon, 
who prescribed iodide of potassium in moderate doses. 

By the 27th the sores on his chest were much worse. He described 
them as "hard, purple, rocky lumps '*; that on the thigh looked like 
an angry boil. His surgeon now ordered him quinine and gentian. 
He then returned home, the journey being very painful, and con- 
tinued to get worse till the 30th, when he took to his bed. By this 
time the sores on the chest had, he said, dried up, but that on the 
thigh was ** like a volcano," and extended over a space as large as 
the palm of his hand, the crust on it being heaved up by ichor and 
the thigh very painful ; smell firom discharge very offensive. The 
medicine was continued. On the 2nd of August he reports the pain 
as diminishing and the inflammation subsiding : the sores on the 
chest covered with crusts ("rocky cakes") as big as walnuts. 
Directly after this the crusts seem to have fallen off*, leaving holes 

• R. Pulv. ammon. chloridi 5j. 
Olei camphorati 5j. 
Glycerini 3ij. ad 5iij. 
Sulphuris sublim., 
Ung. simpl.» aa. ^. r\. 



2 2 2 Case of Impetigo rodens, 

which discharged yellow pus. On the 5 th he left his bed, but felt 
very weak, having generally slept very badly; unhealthy pus was 
discharging from the thigh. On the 7 th the sores were all secreting 
yellowish-white pus, with what the patient calls a peculiar dry smell, 
" like that from the paw of a smooth terrier.'* He was ordered to 
take the iodide of potassium again. 

The report of August 8th represents that he had up to that time 
continued the use of quinine and gentian. He now discontinued 
these, and from this time kept to the iodide of potassium. He had 
lived well but regularly, taking little in the way of stimulants except 
bottled ale. The sore on the thigh was still two and a half inches 
long and one inch and a half wide. On the 14th he went for a 
short distance from home in order to try change of air, took tepid 
baths and began the use of iodide of iron. Within two days after 
he reported himself as much stronger, and that crusts had formed 
over the sores on the chest ; that on the thigh his notes state to be 
at that time about two inches in one diameter by three in another, 
but getting shallower and looking healthier. On the 23rd he con- 
sulted me, being sent by Mr. Robert Taylor. I suggested iodide of 
potassium and strong decoction of sarsaparilla, a dose of calomel 
twice a week followed by a purgative draught, and nitrate of silver 
to the sores. Under this treatment a slow but steady improvement 
took place, and notwithstanding the depressing effects of a severe 
domestic affliction, he was able in about a month to lie on the right 
side. On the 28th of August he was ordered blue pill, for what 
particular reason does not appear, but I have no doubt it was a 
valid one, as he was under the care of a very attentive and judicious 
surgeon. This seems to have been the last medicine given him, and 
from this time he progressed steadily and rapidly towards a complete 
and lasting cure. By the 3rd of October the sores had all healed, 
and more than two years later he reported himself having been in good 
health ever since. Throughout his appetite had been good. He 
suffered from sleeplessness during about nine days in the beginning 
of his illness. He informs me that his hair never grew the whole 
time. 

Twenty-two years previously he had connection with a french 
woman, which was followed two days after by the appearance of a 
" large white pimple " on the glans, which the surgeon whom he 
consulted pronounced to be chancre. This gentleman ordered him 
blue pill, cauterized the sore, and applied black wash. The sore* 



Definition of Ecthyma. 223 

closed up within a month, the groin remaining merely tender, and 
the patient rather naturally thought he was quite well. About six 
weeks later he had sore throat, for which he took iodide of potassium 
and sarsaparilla; From this time up to the date of the present attack 
he seems to have had no symptoms whatever of syphilis. 



B. Ec'thyma (dr, atis^ neut.), exOv/jia, from ex^vta^ to break out. This 
is the usual derivation. I should think it more probably came 
from H (ix) and Qv^oui^ to inflame. The real meaning of exOutiv 
is to expiate by sacrifice. 

Definition, — An eruption of large, roundish or oval, separate, 
unhealthy-looking pustules, each seated upon a hard, raised-up, 
reddish or purplish base, followed by formation of thick, hard, 
dark scabs, which on falling leave a livid spot or superficial cicatrix. 
Most common on the lower extremities. Average duration of pus- 
tules, ten to twelve days. 

Divisions, — 1. E. vulgare, which corresponds to the characters 
above given. 2, E. luridum, marked by cachexia, purple colour of 
the patches, ulceration, sloughing, great pain and irritability. 3. E. 
vesiculosum, in which what is called the pustule is simply an unhealthy 
vesicle, very closely connected, if not identical, with the form of 
herpes perstans described at page 209. In many cases the crust 
seems to form by the same process as in eczema, the difference being 
here that the base is thickened, and that superficial ulceration, 
attended by the formation of ill-conditioned pus, goes on beneath 
the crust. 

Treatment, — Ecthyma is generally a very manageable disease, and 
I don't know that there is anything to separate its treatment from 
that of impetigo. For the lurid form Bateman recommends opiates 
and the warm bath, with a liberal use of bark. Mr. Wilson's favourite 
tonic in ecthyma seems to be nitro-muriatic acid and gentian ; arsenic, 
he thinks, is rarely called for. I have seldom found it necessary to 
give more than sulphate of iron in combination with sulphate of 
magnesia ;• aloes and myrrh may also be given in pills. Cod-liver 
oil has been found usefiil. Most cases of vesicular ecthyma yield 
rapidly to the use of the acid solution of iron and mild aperients, 
with zinc ointment followed by ointment of the nitric oxide pf 
mercury. 

• For formula see page 219. 



224 Vesicular Ecthyma. 

As an^instance of the vesicular form I may give the following 
case. 

A gentleman, aged 35, living in the country, placed himself under 
my care some years ago for disease of the skin affecting the left leg. 
Nearly the whole surface, particularly in front, from below the knee 
to the ankle, was one mass of large papules, vesicles, firm hard scabs, 
and cicatrices. The papules were dark red, very irregularly shaped, 
varying in size from a quarter of an inch to an inch and a half in 
their longest diameter, and raised in some places a Hne or two above 
the level of the skin. On some of the very smallest of these vesicles 
were seen in process of formation, and on one was a fully-formed 
vesicle, or rather a small bulla. On other papulae were seated small, 
clean, deep excavations, which looked as if they had been scooped 
out of the true skin ; from these an almost colourless serum was 
discharged in great abundance, saturating any dressings in a very 
short time ; in fact, it poured out almost worse than from an 
eczematous surface. On still older papules these ulcers had become 
covered with hard, tenacious, brown scabs, while last of all, the 
oldest had given way to deep puckered cicatrices. 

The disease had existed several months, and so far had resisted 
all treatment. Finding it so obstinate the patient tried to cure it 
himself, but the result was equally unsatisfactory. However, it soon 
yielded to the use of steel ; the tincture in full doses, three times a 
day, was ordered, and as a necessary accompaniment, a mild aperient 
pill two or three times a week ; the sore to be dressed with a weak 
ointment of nitric oxide of mercury. Improvement began almost 
directly, and went on unchecked ; the same treatment was continued 
till all the ulcers had healed, and vesicles had ceased to appear. I 
then advised the patient to go through a short course of arsenic, but 
he would not, and perhaps was as well without it, as, quite two 
years after, he had had no return of his malady. 

This disease does not correspond with ordinary vesicular or bullous 
affections'; the irregular thickening, elevation and hardening of the 
base, and its disproportionate size, entirely remove it from that 
category. In fact, it was more like ecthyma, but not ecthyma as 
described generally ; the vesicles were not seated on conical eleva- 
tions, there were no pustules, nor did the vesicles become either 
purulent or tinged with blood. The complaint did not occur in a 
broken-down constitution, but in a healthy, ruddy-looking country- 
man, very strongly built, living a regular life, a great deal out of 



Definition of Aaie ; Divisions, 225 

doors, and residing in a wild, open district. There was no history 
of syphilis, no reason to suspect it before or afterwards. The 
patient, who admitted having exposed himself often enough to such 
a source of danger, and who was quite familiar ^^dth the subject, 
assured me that he would not have thought of concealing such a 
fact if he had ever suffered from the disease, and I' certainly 
never had reason to think that he was concealing the truth. The 
complaint, too, yielded to remedies which possess no control over 
syphilis. There was no ground to suspect scabies. 

C. Ac/ne {acna^ ce^ fem.), aKv-q^ possibly from a and Kvaut, difficult 
to scratch, on the same principle as aKvrffrTir,, the spine in 
quadrupeds, so named because they cannot reach to scratch it ! 

Definition, — Occlusion of, sometimes, with increased secretion 
from, ducts of sebaceous glands, attended by thickening, hardening, 
inflammation or suppuration. Eruption seated on face, neck, 
shoulders, back, and breast. Maturation of such pustules as occur 
very slow. 

Divisions, — i. A. punctata (comedones, grubs), in which there is 
simply occlusion of the sebaceous ducts with formation of black 
specks at the orifices,' accompanied by elevation and hardening of 
the sides of the openings. Contents composed of epithelial cells, 
oil-globules, some fine hairs, and cholesterine. May inflame and 
turn to acne simplex. Wlien hard and homy, often called stone-* 
pock (a. indurata). 2. A. simplex, in which this state is accom- 
panied by formation of hard inflamed papules round the orifices of 
the ducts, and frequently by suppuration. 3. A. rosacea. More 
an erythema, accompanied by papulation, than a pustular disease. 
Distinguished by vivid red patches on face, sometimes with dry and 
furfuraceous state, at others by a greasy condition of skin. Suppu- 
ration occasional; pustules often painful and stiff*. Occasionally 
varicose dilatation of minute superficial veins. In still more aggra- 
vated cases, skin thickened and rough, with red or purplish knobs, 
greasy and shining (h)rpertrophic acne). 

In acne simplex, as generally met with, it will be observed, on 
examining the surface carefully with a good lens, that in some of the 
spots inflammation has occurred round the orifices of the sebaceous 
ducts, on the apices of which are seated small, brownish adherent 
crusts. At these places the hair-sack appears to have been torn out 

2 G 



226 Causes of Acne. 

by scratching, or to be imbedded in the crust. In others, where this 
process has not gone so far, we only see the firmly occluded hair- 
sack with its blackened orifice. I have never seen a hair issuing 
fi-fem one of these specks. As very often no sebaceous matter can 
be squeezed out of these places, I am disposed to think that the 
irritation set up is not due to the imprisonment of the sebaceous 
matter, but to a morbid action in the hair-sack itself 

Acne is one of those diseases which demonstrate the inherent 
weakness of any classification. Although it is in one form (a. 
simplex) essentially a pustular disease, and frequently so in another 
division (a. rosacea), yet suppuration, rare in the latter, is sometimes 
unknown through the whole duration of a case of the punctate 
variety. This is, however, no more than we find in other groups. 
Ecthyma is at times a vesicular disease, at others it forms by a 
process very closely allied to that seen in disorders called, sometimes 
impetigo, and again impetiginous eczema. Further illustrations 
of this unsatisfactory state may be found in the separation of 
small-pox from the vesiculae, though, so far as I can see, it is as 
essentially vesicular as herpes, and in the connexion of tinea 
circinata and pityriasis, which may pass into eczema, with tinea 
tonsurans and pit)niasis versicolor, which do not undergo this 
change. 

Causes, — Acne, especially in the form of rosacea, is often ascribed 
to exposure to heat, as in cooking, and to be connected in men 
(particularly severe acne simplex) with spermatorrhoea ; haemorrhoids 
and dyspepsia in both sexes, and painful or profuse menstruation in 
women, are often spoken of as general accompaniments of rosacea. 
Thinking it might be as well to ascertain if there were any grounds 
for this belief, I inquired of several patients, and give their account 
of the matter. I may observe that the cases examined were nearly 
all very severe. In order to avoid unnecessary repetition, the 
reader is given to understand, that when he finds no remarks made 
as to the state of the health, it is to be considered as satisfactory, 
and that nothing was elicited which tended to connect the disease 
of the skin with any internal disorder, beyond that slight amount of 
disturbance, shown merely by a coated state of the tongue, and 
perhaps constipation, or even some slight feeling of being rather out 
of sorts, which we find so prevalent among patients with all forms of 
skin disease. 

Cases of Acne simplex in Men. — J. T, B. Unusually severe case. 



Cases of Acne simplex. 227 

A hatter. Exposed to heat now, but his complaint began two 
years previously to his taking up his present occupation, and when 
he was a good deal out of doors. No cause made out. — G. B. O., 
draper, 17 years of age. Face almost covered. Much induration 
and inflammation. Not exposed to any heat. No cause. — R, E., 
aged 22, reader in British Museum. Not exposed to any heat. 
No cause. — A. 'A., aged 26, clerk. Not exposed to any heat. 
No cause. — ^J. Y., aged 18, engraver and drawer. Not exposed 
to any heat. No cause. — J. S., age 21, clerk. Not exposed 
to any heat. No cause. — R. G., age 17, tailor. Not exposed to 
much heat. No cause. — W. C., cellarman to a wine-merchant. 
Extremely temperate, according to his own account. Not exposed 
to any heat. No cause. — ^J. H. Not very severe case. Works 
in a hot place. — W. P., age 20, draper's assistant. Not exposed 
to heat. No cause. C. T., age 20. Very mild case. Much 
exposed to heat. — T. G., age 22, engineer. Not exposed to any 
great heat. 

Acne simplex in Womm. — S. S. Considerable induration. Not 
exposed to heat. Describes herself as being in perfect health. No 
cause made out. — E. W. Health delicate. Menstruates regularly. 
Not exposed to heat. — C. D., age 23, dressmaker. Not exposed 
to any heat. No cause. — S. A., shopwoman. Not exposed to 
heat No cause. — ^J. V. One of the worst cases I ever saw. Not 
exposed to any heat. Menstruation very painful. Latter symptom 
relieved without any change for the better in the acne. — T. R., 
housemaid. Not exposed to heat. No cause,— A . C. Unusually 
severe case. Milliner. Not exposed to heat in any way. No 
cause. 

Acne rosacea in Men, — A. G. Very severe case. Strong, healthy, 
middle-aged man, following an out^loor employment. Health 
excellent. No cause. — H. R. Excessively severe case. A joiner. 
Not exposed to any heat No cause. — T. W. H., salesman in a 
lace-warehouse. Not exposed to heat. No cause. — W. H., age 24, 
printer's warehouseman. Exposed to considerable heat at times. 
Occupation otherwise healthy, as is the patient. — E. C., age 55, 
gardener. Not exposed to any heat, except that from the sun in 
summer. No cause, — F. C, draper. Not exposed to heat No 
cause. — W. B., age 34, coffee-house keeper. Not exposed to much 
heat. — ^W. G., age 42, mason. Not exposed to heat No cause. 
— T. D., age 40, saddler. Not exposed to heat — F. S., age 35, 



2 28 Cases -of Acne rosacea. 

bootmaker. Not exposed to much heat. — W. H., age 31. Face 
almost covered with pustules, intervening skin thickened and almost 
like the rind of an orange in texture. Not exposed to heat — ^W. W., 
age 30, coachman. Very severe case : whole face invaded by the 
disease. Not exposed to heat. No cause. 

Acne rosacea in Women, — C. K, age 39. Had a good deal of 
cooking to do at the time the disorder came on. No other cause. 
Health good. — A. B. Was cook at the time the disorder began. For 
a considerable time past has been a housemaid, and consequently, 
she says, not exposed to heat. During this latter period the 
disorder has progressed as fast as ever. No cause. — L. L., age 34, 
nurse. Not exposed to heat in any way. No cause. — M. J., 
age 37. Not in any way exposed to heat. No cause. — S. L. 
Exposed to no other heat than that of gas in the shop for about 
half an hour daily. No cause. — E. M., age 35, works at a book- 
binder's. Exposed to considerable heat for two hours in the day : 
not at any other time. No one in the workrooms suffers from the 
complaint but herself. Health excellent. No cause. — J. G., age 
26, cook. Work not hard. No cause. — J. H., no occupation. 
Not exposed to any heat. Healthy. Menstruation, &c., good. 
No cause. — M. D., age 40, no occupation. Not exposed to any 
heat. — Caroline S., age 40. Health good. No occupation. Not 
exposed to heat. No cause. — Catherine G., age 32. Very severe. 
In good circumstances. Not exposed to any heat. Teetotaller. 

Indeed, judging from my own observations and statistics, I should 
feel disposed to conclude, that if the reader were to select any hos- 
pital, general or special, and pick out a number of patients equal to 
that given in the foregoing lists, but not suffering from any skin disease, 
he would find as much in the way of exposure to heat, disturbance 
of health, &c., operating as causes, and yet not bringing on acne or 
rosacea;* and I can only conclude, that though such causes as 
have just been examined may in some few cases have evoked 
the disease,t its appearance in a vast majority of instances is due to 
the operation of what I have elsewhere ventured to call the " law of 
. proportion of constitutions." 

* As regards menstrual irregularities I quite concur with Hardy, who remarks : 
** We are obliged to say, that in most of the observations we ipade the menstrual 
functions were executed with the most perfect regularity." 

t Acne simplex seems undoubtedly to be called forth in some persons by evoi 
a moderate use of alkalies. • . . ■ . 



Treatment of Acne, 229 

There are further one or two sources of fallacy which should not 
be passed over. Rosacea sometimes accompanies a tendency to 
haemorrhoids, diarrhoea, prolapsus ani, excessive and painful men- 
struation, and dyspepsia ; not as an effect, but complicated by them ; 
of course, any possible combination of these may appear without 
the skin disease being present. Now an accidental aggravation of 
any of these symptoms is generally accompanied by an exasperation 
of the rosacea, and what improves the one relieves the other ; but 
this simply proves, not that the two states are dependent on each 
other, but that both may spring from one cause. Again, it has, as I 
have just mentioned, been stated by some authors, and I believe it 
is rather generally thought, that acne, and especially acne simplex 
in young men, is connected with spermatorrhoea. I have known 
more than one surgeon and physician in hospital and dispensary 
practice convict every young patient suffering under this com- 
plaint of self-abuse, without listening to any protest. Now in 
, quite two thousand cases of spermatorrhoea, I have only foijnd 
one patient suffering under rosacea, not more than thirteen had 
acne, and only two of these were affected with it in a severe 
form. 

Treatment, — The slighter cases of acne simplex, and of the disorder 
known as stearrhoea, in which the skin looks greasy, the follicles 
secreting an excess of fluid fat, often require little more than using 
no soap and washing in hot water. If somewhat more severe, the 
spots may be bathed freely with the lead or bismuth lotion prescribed 
at page 162. 

But more advanced cases naturally require more energetic mea- 
sures, and in order to make perfectly clear what I have to say, I pro- 
pose to divide the treatment into four stages, embracing four groups 
of remedies. These are — i. Preparatory treatment, especially called 
for when the tongue is foul, the appetite bad, the health out of 
order, and the bowels constipated. 2. Treatment devoted to the 
restoration of the strength and nutrition. 3. A course of reme- 
dies directed towards the absorption of material deposited in the 
indurate^ parts. 4. A course of arsenic. 

I. The first set of symptoms require, in my opinion, saline 
aperients, with or without bitters, according to circumstances. Sul- 
phate of soda or magnesia, or the heavy calcined magnesia, may be 
given with nitrate of potass, in mint-water ; or when the appetite is 
bad, in some bitter aromatic infusion, such as calumba or serpen- 



230 Treatment of Acne. 

taria.* However slight may be the signs of improvement which 
follow the use of these medicines, I feel little hesitation in recom- 
mending their steady continuance along with some of the aperient 
pills already recommended.t I am the more particular in saying this, 
because I believe that in the treatment of skin diseases, the rock always 
ahead is the slow progress made at firsts and that it is most necessary, 
when we have once traced out mentally the path to be taken, to 
keep rigidly to it, unless indeed some quite unforeseen contingency 
should arise. At the same time it is to be quite understood that bad 
cases are rarely cured by such means, the principal value of which 
consists in clearing the way for further measures. 

Taking all things together, I should say that the first stage of treat- 
ment in acne need not differ materially from that required at the 
outset for eczema ; perhaps a more free use may be made of such salts 
as sulphate of potass or soda, and the administration of them may be 
continued for a longer time in acne (say a month or so), whereas in 
eczema it is rarely requisite to keep them up beyond a week or two ; 
but the difference is more in time and degree than in character. 

2. After salines and aperients, I would advise a course of steel. 
Perhaps the compound or aromatic steel mixture and the tincture of 
the sesquichloride are the best preparations for this purpose, and a 
full dose of one of these, say half a drachm to a drachm of the 
tincture, or an ounce of either mixture, may be given two or three 
times daily for six or eight weeks; I have, in some instances, both 
in those forms and in acne rosacea, observed that the sulphate of 
iron agrees better than the tincture, and in women of middle or 
mature age, I have more than once seen it effect a rapid improve- 
ment, especially in rosacea, after iodide of potassium, liquor potassse, 
Donovan's solution, tonics and aperients had been tried in vain. 
Dr. Cheadle recommends J a. combination of this salt with sulphate 
of magnesia, and occasionally quinine and strychnia, and a very 
useful combination it is. If any constipation arise from the use of 

• For instance : — 

R. Sodae sulph., 

Potassae nitratis, aa. 5ij. 
Syrupi flor. aurant. 3iv. 
Infus. calumbae ad ^^vj. ti\.. 
Capiat coch. amp. duo ter quotidie. 

t See pp. 12, 173. 

% Journal of Cutaneous Mediciney vol. iii. p. 418. 



Treatment of Acne. 231 

iron an aperient may be given. For this to be effectual three < 
ingredients should be present. First, aloes in the form of aloin or 
some preparation which will not irritate the lower part of the great 
gut ; secondly, a minute quantity of mercury, so as to act gently on 
the liver; and, thirdly, a powerful aromatic, such as myrrh, saga- 
penum, or assafcetida ; an aperient extract or pill may generally be 
added with advantage. Dr. Frazer says that'when emenagogaes are 
required, the oil of savin_, in doses of one drop three times a day, is 
a very valuable remedy in this eruption.* 

3. But i^ cases where there is no particular weakness or unhealthy 
state of the system ; no chlorosis or defective menstruation ; where 
dyspepsia or acidity of the stomach prevails ; where steel induces 
acidity, headache, giddiness, afid pain in the bowels, and where the 
acne is not benefited by the foregoing medicines, I think it will 
generally be found that an alkali is more suited to the cai^e. 
Perhaps it would be difficult to select a better preparation than 
liquor potassae, in doses of thirty to forty minims quite twice a day, 
in a tumbler of .milk. Dr. Underwood recommends bicarbonate of 
potass in punctiform acne. Dr. Hillier used to give the liquor in 
combination with hydrocyanic acid and a vegetable bitter. As an 
aperient, calcined magnesia may be prescribed along with the potass ; 
about half a teaspoonful to a teaspoonful of the heavy calcined is 
usually enough ; it also may be taken in milk and before breakfast 
Generally it acts more satisfactorily if pireceded by an aperient pill 
overnight. 

4. The probability however is, that after effecting a certain amount 
of improvement, the foregoing remedies will cease to exert any control 
over the disorder. So soon as ever this becomes manifest I should 
advise that arsenic in the form of Fowler's solution, without the 
spirit of lavender however, should be added to the liquor potassse. 
I have found the combination most beneficial in scores of cases. A 
young person of eighteen or nineteen, or an adult, may begin with 
thirty-minim doses of the potass, and five minims of the liquor 

* I subjoin a form : — 

R. Pil. aloes barbadensis gr. xviij. 

hydrargyri gr. vj, 

Sagapeni gr. xv. 
Extract! rhei gr. x. 

Olei sabinse minim, iv. in. f^. pil. xij. 
The oil of savin may of course be omitted when such a prescription is required 
for men. 



232 Treatment of Acne. 

arsenicalis, three times a day, taken in milk and immediately after 
meals. Younger and delicate persons should try smaller doses. 
After a time these quantities should be increased, but acne seldom 
seems to require very large doses of arsenic. So soon as decided 
improvement sets in, the potass may be given ^up and the arsenic 
alone continued. While giving either, however, five grains of the 
compound calomel pill may be advantageously prescribed, to* be 
taken two or three times a week at bedtime. Where expense is no 
object, the arsenic may be taken in compound decoction of sarsa- 
parilla, but to have any effect the dose must be quite an ounce to 
two ounces, and the decoction must be good. I have had ample 
opportunities of satisfying myself that what is constantly sold as 
some unfailing preparation of sarsaparilla exerts no control over 
acne, and most probably contains little more than a mere flavouring 
of this drug. It is no uncommon thing for hospital patients, espe- 
cially for those whose material interests are likely to be seriously 
injured by the presence of such a disease, as in the case of men- 
servants for instance, to spend almost their last shilling on sarsa- 
parilla before applying at a public institution for relief, and that 
without deriving any benefit whatever. 

Mr. Hunt seems to think time and money are simply wasted in 
trying any remedy except arsenic. I have given his plan a very fair 
trial, and feel now no hesitation in recommending as superior that 
which I have laid down. My experience is that the patient bears 
the arsenic always as well, and generally a great deal better, after 
a preliminary course of salines, acids, steel, and potass. Besides, 
arsenic will not set right coated tongue, loss of appetite, sluggish 
liver, &c., symptoms of which, as already mentioned, many persons 
complain at the outset. 

Some writers have thought very highly of acids (as the basis of 
treatment), sulphur, and antimony in acne. Dr. Willan used to 
prescribe oxymuriatic acid, I believe the sphere of mineral acids 
should be restricted to the cases for which I have recommended 
them. Bateman used to give antimony and sulphur along with soda. 
I tried them pretty extensively, but they appeared to me inert. 
Possibly taken in some hot drink on going to bed they might bring 
on perspiration, and thus, in the opinion of those who think there is 
some mysterious connexion between the suppression of this function 
and the breaking out of acne, a certain amount of success may be 
achieved. Tar and charcoal taken together in the form of pills 



External Tj'eatment of Acne. 233 

seem, according to the account sent to me by Mr. John Wetherfield, 
to have answered very well in acne punctata. The most extra- 
ordinary success however that I have yet heard of occurred from the 
use of glycerine in the practice of M. Giibler. He gave two dessert 
spoonfuls daily in acne punctata (acne simplex), and the pustules 
began to diminish in number and volume " fix)m the day that the 
remedy was first taken." * 

I need scarcely say that almost numberless external remedies 
have been recommended in acne. I have no doubt that the 
accounts given of the success said to have been attained by the 
use of them are all in good faith, but at the same time I feel bound 
to say that my observations have led me to a very opposite con- 
viction, namely, that very few local remedies possess any power over 
this disease, and that the control exerted by these is limited and 
uncertain. The best of them seem to be preparations of chlorine 
and iodine with sulphur or mercury as a base. It will be found that 
they all possess a certain amount of epispastic power, and it is pro- 
bably to this that they owe their beneficial action^ it being, so far as 
I can see my way into the matter, a very doubtful point whether they 
one and all equal in efficacy a blister. Foremost among these 
preparations stands the hypochloride of sulphur, with which the 
surgeon may begin at once. At one time I used to pre^Jude the 
employment of it by ordering first the ointment of the subchloride 
of mercury, and then of the ammonio-chloride ; but after watching 
their effects in a great number of cases, I am led to believe that the 
former, though recommended for skin diseases generally by so high 
an authority as the late Dr. Pereira,t is almost, if not quite, useless 
in acne, and the ointment of ammoniated meiteury not very reliable. 

The ointment of the hypochloride J should be smeared ptetty 
thickly on the spots at bedtime and allowed to remain on all night. 
In the morning it may be washed off with very hot water and the 
soap already recommended. It is, however, imperatively necessary 
that the ointment should be fresh made every four or five days, and 

* The Practitioner, September, 1870. 

t Elements of Materia Medico^ 1839, p. 472. 

X R. Sulphuris hypochloridi 3 v. 
Tinct. lobeliae m. xv. 
Spir. lavand. m. x. 
Potassse carbonatis gr. x. 
Adipis purificati 5vj. n\. 
2 H 



234 External Treatment of Acne. 

that only pure lard and newly-prepared hypochloride should be 
employed, as without such precautions 
it very readily spoils. 

When the hypochloride begins to lose 
its effect, biniodide of mercury oint- 
ment, fifteen or twenty grains of the salt 
to an ounce of lard, may be substituted. 
A very small quantity should be worked 
into each spot with the point of a but- 
cher's skewer. If there be any large very 
indurated spots, and if the patient be 
resolute enough, it is a good plan to 
pierce them with an exceedingly fine 
trochar like that represented in the B 
engraving (A), or a stout sewing-needle 
with the point ground to the same 
shape. The bleeding spot is to be 
bathed with very hot water. This is 
easily done by means of the little im- 
plement {B) engraved here. The round 
end (a) of the mandril is dipped into 
almost boiling water, shaken, and then 
pressed against each spot in succes- 
sion.* A blister acts still more efficaciously in clearing 
the way for the iodide, but then it is almost impossible 
to get patients to blister. I have not succeeded in 
doing so more than three or four times. When the 
patient can manage to take them, I always recom- 
mend a course of vapour baths towards the close of 
treatment. 

In common acne. Dr. M'Call Anderson 'nsest a 
compound of rumex ointment { and hypochloride of 

• Both these instruments can be procured from Messrs. Wallers S Co. 
+ Laitctt, 1S69. vol. h. D. 833. 

J R. Rumicis radicis 5xviij. 
Aquse destill. q.s. 
The root being thoroughly bruised, these ineredients are to be well boiled for 
two horns, strained and evaporated. Then add — 
R. Adipis prseparat. jxij. 
Cerse flane Jij. ni. 



External Treatment of Acne, 255 

sulphur. It is firmly rubbed into the eruption night and morning, 
just short of giving pain. I do not observe that he says what 
kind of rumex he employs. In acne attacking the face and back 
in young persons he employs a preparation of sulphur and gly- 
cerine,* directing it to be well rubbed in night and morning 
with a piece of flannel. M. Cazenave speaks highly of iodide 
of sulphur in indurated acne, fifteen up to twenty-four grains to 
an ounce of lard. Dr. Burgess recommends the bicyanuret of 
mercury lotion, two grains of the salt to an ounce of distilled 
water. This he employs in conjunction with bichloride of mercury 
and iodide of potassium internally, in the proportion of a sixth 
of a grain of the mercury and ten grains of the iodide three 
times a day. My experience, however, of the bicyanuret in this 
way was not satisfactory and I gave it up. Dr. Hillier had great 
faith in the bichloride of mercury in almond emulsion used as a 
lotion. He also applied a paste of one drachm of sulphur to an 
ounce of camphorated spirit laid on at night. I have tried both 
these ayplications, but could not observe any superiority in them. 
M. Klezinsky recommends t in the sebaceous form of acne painting 
with chlorhydric acid, on the ground that a portion of skin thus 
treated perspires twenty-seven to thirty per cent, more carbon, and 
seven to twelve less water than a part to which it is not applied^ 
Weak solutions of bichloride of mercury are an old and favourite 
remedy when the acne spots are indurated, but Dr. Frazer says^ 
that if too long continued they make the skin rough and indurated, 
and that a solution of borax is better ; after using it he directs the 
skin to be well rubbed with a wash of oil of rosemary or lavender 
dissolved in i^irit of wine, one part of the oil to ten or twenty of 
spirit. 

Rosacea may be fairly cited as one of the diseases which most 
strikingly point out the great improvement made of late years ia 
the treatment of cutaneous affections. It is not so long since Bate- 
man's time, yet then rosacea was universally thought incurable 

• R. Sulphuris 5vj. 

Glycerinae (Price's) 5vj. 
SpiritAs vini rectif. ^vj. 
Olei rosae minim j . tn.. 
Hebra, I believe, employs a somewhat similar preparation, consisting, however, 
merely of sulphur and spirit rubbed into a paste. 
t Brmtkwait^s Retrospect, vol. xl. p. 190. 



236 Treatment 0^ Rosacea, 

Bateman himself maintained that a perfect cure could seldom be 
accomplished, and this belief is still only too prevalent M. Bazin^ 
writing in i860, says that the arthritic form (couperose arth- 
ritique) " est trbs-t^nace et feit le d^sespoir du malade et du 
m^decin." Yet rosacea is not so unmanageable. In general it is 
much more curable than acne, and it may be safely said that 
the difficulty lies rather with the patient than with the com- 
plaint. Indeed, I believe there are few severe diseases of the skin 
in which the- progress of treatment can be more accurately calcu- 
lated, and a favourable prognosis given with greater confidence,, 
than rosacea. 

The treatment need not differ from that pointed out for the other 
varieties, except that in rosacea it is often quite unnecessary to 
give more than the salines and a short course of steel or alkalies. 
Arsenic is rarely called for. The external treatment is in every way 
identical with that of acne. 

Suppose, however, the surgeon has tried these means in an obsti- 
nate case of acne, and failed, are there any others on which he can 
rely ? I am afraid the question must be answered dubiously. There 
are, no doubt, remedies enough, but when we scrutinize the proofs 
fm which their reputation is based, we find little to encourage us in 
the belief that they possess any power of curing the disease superior 
to that of the measures already mentioned. However, I give a few 
of those which seem to have the best claim to confidence. 

Dr. Burgess mentions a case of obstinate rosacea of three years' 
standing cured by the internal use of phosphorus, iodine, and 
sulphur, aided by a wash of biborate of soda and glycerine. I have 
not been able to make out in what form and doses these remedies 
were given. A very severe and refractory case is said to have 
yielded to large doses of decoction of the water-dock {Rumex aqua- 
tied). Bazin has used the chlorate of potass with success in some 
of these cases ; and the tincture of cantharides is reported to have 
succeeded when other means have failed. My experiments with it 
were, however, most unsatisfactory. Finally, the waters of Lou^sche, 
in Switzerland, and of Bareges and of Aix, in Savoy, seem to have 
been of use in some rebellious cases. Those of Loubsche appear to 
act like blistering with cantharides and tartar emetic ointment, 
except that the blistering does not go on to vesication. The 
patient remains plunged in the bath for five or six hours each day, 
and at the end of a few days a regular erythematous and pustular 



Diet in Rosacea, 237 

eruption comes out, which materially changes the action of the 
unhealthy parts. Blistering is a very old, but, as in acne simplex, 
an impracticable remedy. It was employed by Ambroise Par^, and 
afterwards advocated by the celebrated Dr. Darwin. 

As to the dread some surgeons feel about curing acne, I do not 
share it ; on the contrary, I believe it to be as chimerical as that of 
giring eczema or ulcer. Dr. Copland says,* " that the apprehen- 
sions entertained by the older writers of producing internal disease 
by the sudden repulsion of the eruption were founded on observa- 
tion," and that affections of the stomach, bowels, chest, and head 
have been thus induced, and have been relieved upon a reappear- 
ance of the eruption. The answer to this is that no remedies 
possess the power of suddenly repelling any variety of acne. 

Diet — Many authors have laid it down as a rule, that one great diffi- 
culty we have to struggle with in rosacea is some error in diet, but I 
have not been able to trace more excess among these patients than 
among those suffering from other chronic skin diseases, and, indeed, 
many chronic complaints. Both among the sick and the healthy, there 
are always a certain number of persons who eat and drink erratically 
and voraciously ; and hasty, inordinate eating, especially of large 
quantities of uncooked vegetables and drinking mixtures of wine, 
beer, and spirits throughout the day, are spoken of as exciting causes 
of this disease ; possibly in some few instances with a certain amount 
cf truth. There is, no doubt, too much of this kind of thing pre- 
valent. Some people think that so long as they feel no effects from 
what they eat and drink none are likely to follow, and they take 
beer in the morning, beer to lunch, sherry before dinner and at 
dinner, port or beer with the cheese, port after dinner, grog after 
that, and often beer again. Such work as this, with over free in- 
dulgence in pork, goose, curries, ices, and so on, is not suited to 
rosacea ; but my experience is that very few cases can be traced to 
such causes. They may and do aggravate the disorder, but as an 
exclusively active or special cause of rosacea I believe they have 
Httle influence. Indeed many of those who suffer from this com- 
plaint are particularly temperate, and usually live rather low than 
otherwise. In upwards of sixty cases I found, in answer to very 
minute inquiries, no reason whatever to believe that there was any 
irregularity going on as to either eating or drinking. 

* Dictionary of Practical Mediciney vol. i. p. 30. 



238 Diet in Rosacea. 

A widely different opinion has, I know, been upheld by some 
physicians of large experience. Bateman paid great attention to 
diet, and his instructions on the subject may even now be read with 
benefit. But I see nothing in what they tell us that does not hold 
good of every cutaneous disease. The first step is to set right any- 
thing that is wrong in the habits of the patient, just as any disorder 
of the liver or stomach, of the bowels or womb must be corrected. 
Till this is done, neither steel nor arsenic can be well borne, neither 
will they do any good. Again, when a patient with any disease of 
the skin is suffering from overfeeding the diet may, for a short time 
at any rate, be very benefically restricted to such things as tea and 
toast, fish, white meat, boiled milk, farinaceous diet and well- 
cooked vegetables. But this is only a temporary state, and as such 
demands exceptional means. During a great part of many, and 
during the whole course of some diseases of the skin, exhaustion is, 
more or less, nearly always present, and I continually recommend 
the use of a moderate amount of wine and spirits with benefit, 
strongly opposed as I am to the habit of taking them in an)rthing: 
like excess. Rosacea offers no exception to this rule. I had not 
long ago two sisters under my care for this affection in a pretty 
severe form. . One, who was moderately well off, and took wine 
every day and hoUands at night, was quite well in four months ; the- 
other, who had to struggle with great hardships and rarely tasted 
more than one glass of poor malt liquor daily, was little better at 
the end of a year. 

Beyond avoiding excess, therefore, and interdicting such articles, 
of food as goose, |>ork, curry, &c., I see no reason for recom- 
mending any particular kind of diet The rules laid down in the 
chapter on eczema apply to rosacea as well as any I am acquainted 
with. I have found the Carlowitz sold by the Wine Agency Com- 
pany, which is far superior to that advertised by some wine-mer- 
chants, very useful in this complaint, and I believe it may be safely 
recommended as one of the most suitable beverages here. Not 
being a dear wine, it comes within the reach of all except the really 
poor. A very great deal of the stuff sold under this name is, however, 
totally unsuited to the case, and in point of fact is, to ft]^ thinking, 
not fit to drink. 

Mr. Startin's convictions are decidedly against the use of arsenic 
in this complaint. He relies upon chalybeates, mineral acids and 
bitters, mercurial or white precipitate ointment with camphor, and 



Star tins Treatment of Rosacea : A^eligans, 239 

in what he calls simple inTeterate acne, with hyposulphite of soda 
decomposed by means oi almn in the fonn of lotion.* In the 
more aggravated fonn, or genuine rosy-drop, his local treatment is 
to blister the spots with strong nitric acid, drying it off immediately 
with blotting-paper ; some cases he attacks still more energetically, 
dividing each little trunk that feeds a tubercle with blood, and then 
inserting a minute piece of nitrate of silver ; a practice not followed 
by any scar. Dr. Ross punctures the tubercles, and inserts a drop 
of nitric acid by means of a hair tube. Dr. Burgess speaks very 
highly of the bicyanide of mercury for this purpose, recommending 
a solution of two grains to an ounce of distilled water. This is 
brushed over the spots, and in a few minutes after is washed off 
with cold water. 

Dr. Neligan, in chronic rosacea, recommends the use of iodide of 
potassium, two grains in two ounces of decoction of fresh elm bark, 
with the addition of a quarter of a grain of iodine, at bedtime. I 
am not sufficiently acquainted with the properties of the bark to 
speak with certainty of its action ; but the iodide, which at one time 
I gave rather extensively, did not prove of much service in my 
hands ; nor does Dr. Neligan say that he actually saw benefit arise 
firom using it. Locally, he placed great reliance on the ammoni- 
ated mercury ointment, a drachm of glycerine being added to each 
ounce. Dr. Neligan advises that this should be washed off in the 
morning with a weak spirit lotion, containing twelve grains of 
carbonate of soda and half an ounce of glycerine to the pint. A 
preparation of this kind is, however, apt, if too freely used, to make 
the skin dry and scurfy, to which many patients strongly object. M. 
Bazin's treatment of acne is principally local, such' as the vapour 
bath and sulphur douche and bath, and the huile de cade, 

Mr. Wilson's treatment of rosacea is first a moderately nutritious 
diet, all stimulants being avoided. His principal internal remedies 
are laxatives, antacids, and tonics. He directs painful, congested 
pimples to be punctured and poulticed. Among Mr. Wilson's pre- 
scriptions for lotions are one composed of two drachms of sublimed 
sulphur, a drachm of camphor and four ounces of distilled water, 
and one containing bichloride of mercury dissolved in emulsion of 
bitter almonds or eau de Cologne. Mr. Wilson's favourite ointment 
is, I believe, that of hypochloride of sulphur, for which I give his 

• Medical Times^ vo). xiv. p. 347. 



240 Definition of Sycosis, 

formula,* though I prefer my own; he also uses the iodide of 
sulphur ointment, ten grains of the salt to an ounce of lard, and for 
allapng irritation, elder-flower ointment or simple cerate. 



D. Syco'sis (w, w, fem.), trvKuaic, from avKov, a fig. 

Definition, — ^An eruption of papulae, chiefly seated on the chin 
and upper lip. Papules become pustular and are pierced by a hair. 
Accompanied by a good deal of stiffness and heat in the affected 
part. Highly contagious; often attended by a distinct parasitic 
growth. Eruption in advanced stages resembling the inside of a 
ripe fig. 

Such is the definition usually given : it does not accord with my 
experience. The disease is spoken of by some authors as a pustular 
disease, by others as a tinea. According to my experience, it is in 
five cases out of six neither the one nor the other, and I think myself 
justified in saying that distinct disorders have been grouped together 
under this name. 

These are — i. True pityriasis, sometimes showing a white mealy 
secretion, generally attacking the moustachfe ; sometimes appearing 
as pityriasis rubra, and then not unfrequently spread over great part 
of the hairy part of the face (S. erythematosa). Either form, but 
especially the latter, may be irritated by improper applications so as 
to become developed into a real eczema, and may then be attended 
by congestion of the hair-follicles forming papules, or by pustules, 
but I have not seen an instance where these complications played a 
primary or important part in the disorder. The eyebrows are not 
unfi*equently involved. 2. True eczema of the hairy part of the 
face, sometimes accompanied by considerable heat, itching, and 
tingling. I have seen this complicated, in syphilitic patients, by 
warty growths and papules about the upper lip, chin, and comers of 
the mouth; but I need scarcely say that the eczema and warty 
growths were here two distinct affections, occurring accidentally 
together on the same site.t 3. An exceedingly obstinate form of 

• R, Sulphuris hypochloridi 5ij- 
Potassae carbonatis gr. x. 
Adipis benzoat. 5j« 
Olei amygd. essent. m. ij. n\. 
t Dr. Cheadle has also noticed a ** quasi " warty alteration of the skin in the 
pustular form (impetigo of the face). 



Prognosis of Sycosis ; Treatment, 241 

lupus eiydiematosus, b^^mning generally in the upp^ part of the 
whiskers, marked by a low, narrow, erythematous maigin, constantly 
but very slowly spreading ; followed by bleaching and thinning of 
the skin and more or less destruction of the hair-follicles. I have 
twice seen this disease in wcnnen ; once on both the upper and lower 
lip, once on the lower lip only. It is distinctly different from ordinary 
lupus erythematosus. Sometimes in man it is accompanied by small 
red papules, as also by so much eczema that it might readily be 
mistaken for this disease. 4. Impetigo of the lower part of the face 
(impetigo sycosiformis of some writers), in which the skin is often 
thickly beset with scabs, pustules, and suppurating foci ; not un* 
frequently accompanied by redness and swelling of the affected 
part The sycosis answering to the definition given in the pre- 
ceding paragraph and tinea sycosis I have not seen, nor have I 
traced any variety of sycosis to contagion. 

Prognosis, — ^All these diseases are obstinate, and if neglected may 
endure an indefinite time. I had a patient under my care in whom 
the lupoid form had, when I first saw him, lasted nearly thirteen 
years, and had in the course of that time destroyed nearly all the 
hair on his face, only a little on the upper lip being left Still I 
believe that with care they may all be cured. 

Treatment. — ^The eczematous and impetiginous varieties may be 
referred to their respective sections. Syphilis I do not propose to 
treat of here ; in fact, I think such disorders are much better separated 
from what are generally known as skin diseases. The erythematous 
form may however very well be examined separately, as also the 
lupoid. 

The principal remedies which have proved of use in my hands 
for these are — i. Purgatives; 2. Steel; 3. Arsenic; and 4. Epi- 
lation. 

1. I would in every case recommend a course of purgatives. I 
prefer calomel and magnesia to any I have tried. The former should 
be given every second night, beginning with grain doses and be 
followed by the magnesia in the morning. I leave it to the reader 
to decide in what form he will prescribe the magnesia. What I have 
said on the subject in the chapter on eczema is applicable here. 
This treatment is often exceptionally beneficial in the lupoid form. 

2. Steel is also useful, especially in slight and recent cases. My 
observations have been principally confined to the acid solution and 
the tincture of the sesquichloride, which may be given as in eczema 

2 I 



242 Treatment of Sycosis. 

3. Should the case however proVe obstinate, I would recommend 
immediate recourse to arsenic and use it as for lepra, accompanying 
it however from time to time by the purgatives. For instance, it 
may be taken for a month alone, and then for a fortnight in con- 
junction with calomel and magnesia. The surgeon has only to give 
this method a fair trial, in order to satisfy himself that it is superior 
to the use of arsenic uncombined ; and indeed the patients, when 
the purgatives are suspended, constantiy ask to have them renewed. 

4. Local treatment however plays a very important part, and one 
of the first things a patient should do is to procure a pair of tweezers. 
In general, the implements sold under this name are useless, the 




nipping edge forming too great an angle with the hair and so breakii^ 
it The ends ought to run nearly parallel with each other, as shown 
in the accompanying engraving. The patient should pull out a few 
hairs every day and then rub in a little hypochloride of sulphur 
ointment. If there be much heat and itching, a bismuth lotion or 
arrowroot poultice may be applied for a few days ; but in general 
the use of such things means simply wasting so much time and 
money. 



Treatment of Sycosis. 243 

I have now to add a few words on the treatment of sycosis 
recommended by others, but I must refer my readers to the works 
of these writers for an explanation of what they mean by sycosis. 

The principal remedies seem to be laxatives, steel, mercury, 
arsenic, and the removal of the hairs. As laxatives Mr. Wilson 
employs neutral salts like those of Seidlitz and Rochelle. Mr. Hunt 
speaks of cases cured with arsenic only. The hypochloride and the 
iodide of sulphur ointment seem to be general favourites. Mr. 
Wilson, I believe, uses the pharmacopoeia ointment diluted with twice 
its weight of benzoated lard. He also prescribes the sulphur douche, 
and follows up with the iodide of sulphur ointment He likewise 
employs an ointment composed of fifteen grains of the white pre- 
cipitate of mercury, a drachm of strong mercurial ointment, half a 
drachm of the solution of diacetate of lead, and six drachms of fresh 
pure palm oil. This combination makes a cream-like mixture of 
great utility in sycosis. Dr. Frazer recommends hot poultices of 
boiled rice. As to rooting out the hairs, opinions are greatly divided : 
some medical men consider there is no chance of recovery unless 
this be done, and most thoroughly too. Mr. Startin pulls out every 
hair; others are not so much impressed with the advantages of this, 
practice. Bazin's treatment of sycosis is pulling out the hairs, 
applying huile de cade^ and giving alkalies. 



( 244 ) 



CHAPTER IX.— FURUNCULI. 

A, Boil. B, Carbuncle, C. Charbon, D, Aleppo Boil. 

E. Delhi Boil 

A. Furun'culus {usy i, masc), from /an?, to rage. B. Carbuncle, 

Definition. — A deep-seated, limited inflammation of a portion of 
corium and corresponding subcutaneous cellular tissue ; marked by a 
deep but restricted hardness and redness, and subsequently a some- 
what livid hue of the surface, which becomes thickened and upraised. 
Slow suppuration, escaping by one orifice. Expulsion of dead corium. 
Great pain and stifihess of part ; formation of permanent scar. In 
carbuncle (carbun* cuius, us, i, masc, dimin. of carbo, burning coal; 
also anthrax, acis, masc, firom &ydpai, a live coal) the process is 
essentially the same, but surface larger, flatter, and presenting several 
openings. 

Treatment. — I know scarcely any common disease, the internal' 
treatment of which is in a more unsatisfactory state than that of 
boils, and the same may be said of carbuncle. I was once present 
at a discussion on this subject by the Medical Society of London, 
and it would have been amusing had it not been rather humiliating 
to witness the wide discrepancy of opinion as to the value of almost 
every remedy mentioned. I am afraid matters have not much im- 
proved since then. All the speakers agreed in admitting the greater 
or less insufficiency of all plans of treatment, and some stated can- 
didly enough that they had lost all faith in medicine. One gentle- 
man excited some amazement by saying that he had suffered from 
these pestilent things, and that he had trusted to port wine rather 



Treatment of Boil and Carbuncle. 245 

than drugs. He took a bottle out with him every day in his carriage 
when he went his rounds, and had a glass each time he called to see 
a patient; the result of which was that the bottle always came home 
empty, and that the surgeon felt much better than if he had taken the 
best tonics in the world ; indeed he reported the effects as something 
wonderful. I am inclined to think he was right, but the remedy 
would scarcely answer in hospital practice. 

Yeast no doubt does good in boils. Quite a tablespoonfiil should 
be taken three times a day. Dr. Hillier says that quinine taken till 
it affects the head is often useful. I have often found opium in 
conjunction with morphia and liquor ammonise acetatis very service- 
able in relieving the pain of both boil and carbuncle. From a grain 
to a grain and a half of opium, and from a quarter to a third of a 
grain of muriate of morphia, may be taken in a pill at bedtime, 
accompanied or not by a draught containing at least half an ounce 
of an inodorous spirit. Less headache is thus occassioned than 
when opium alone is trusted to. Chlorate of potass seems to have 
been useful in some cases.* 

There is one simple remedy which exerts great control over boils 
and carbuncles, and that is common white lead, laid on as 
thick as it can be made to lie, and protected from friction by a strip 
of linen bound over it. Treated in this way boils require neither 
cutting, medicines, fomentations, lotions, poultices, or any such 
messes. Patients have sometimes told me that the fluid has 
eased the pain within two hours; and judging from a fair ex- 
perience of its effects during several years, I should quite looTc for a 
speedy amelioration of the symptoms under its influence. In car- 
buncle the action of this remedy, especially when mixed with powdered 
opium, a drachm to the ounce, is almost equally satisfactory. 

Mr. French has recordedt some cases in which carbuncles were 
successfully treated by a very summary process. A small tenotomy 
knife was introduced and the carbuncle was freely divided under the 
skin. The relief thus afforded is described as surprising, and boils 
were treated with equal success. A gentleman, who saw some cases 
subjected to this treatment, assured nae that Mr. French had not in 
any way overstated the results. As to laying open carbuncles by a 



• youmcU of Cutaneous Medicine^ vol. ii. p. 452. 

t London Medical Review^ Sept. 1862. Mr. O. Fersall long previously advo- 
cated a similar plan. 




246 Treatment of Bail and Carbuncle. 

cradal incision I diss^prove of it most strongly. Sir James Paget 
says* very justly that cutting neither prevents the carbuncle from 
spreading, relieves the pain of it, nor accelerates its healing. Mr. 
Collis saysf this is because we do not cut deep enough and get 
through the fascia. Gutzeit uses % for carbuncles an ointment com- 
posed of half a drachm of powdered opium and two ounces of white 
ointment laid thickly on ; he says it reheves the pain in half an hour. 
I have tried the same and even a larger quantity of opium with 
spermaceti ointment, and certainly the opium is very useful as an 
addition, but I do not think that spermaceti ointment is as a vehicle 
equal to white lead. 

Dr. Rigby speaks § highly of tincture of iodine in boils ; he puts 
on three coats in succession for several nights together. Mr. Gay 
pierces the boil and injects a drop of the acid pemitrate of mercury. 
Dr. Marcet recommends, || when the carbuncle is rather superficial 
and is seen in the vesicular stage, that an ignited ludfer match 
should be held over it till it assumes a dull whitish appearance, owing 
to the coagulation of the albumen it contains. A red-hot wire, he tells 
us, may also be used. The pain, he says, is really trifling, while that 
from the carbuncle ceases in four or five hours, and with the cessation 
of pain there is an end of the disease. When the carbuncle lies 
deeper this method does not answer so well. Chlorate of potass seems 
to have been useful in some cases. Peruvian balsam and basilicon 
ointment are favourite applications with some practitioners. 

Dr. Frazer gives us the valuable infonnation that with arsenic we 
can check the ulceration and burrowing which sometimes follow 
anthrax. He recites one most instructive case. The burrowing had 
been going on for some months, and was arrested in forty-eight hours 
by the use of this drug. The mineral was then given up and the 
ulceration at once began again. The arsenic was now resumed, and 
the destructive process was stopped effectually, the remedy being 
this time continued till the patient was cured. Though not germane 
to the subject, I may mention that Dr. Frazer has found arsenic given 
in this way very rapidly cures onychia. 

* Journal of Cutaneous Medicine, voL iil p. 21 1. 
t Dublin Quarterly Journal^ 1859, vol xxviii. p. 20$. 

% See a paper in the Med, Zeitung Russlands quoted in the British and Foreign 
Medico- Ckirurgical Review f 1858, p. 271. 
§ Medical Times, 1858, vol. ii. p. 98. 
II Lancet J 1851, vol. i. p. 45. 



Definition of Charbon; Treatment. 247 

Professor Laycock has described a contagious furunculoid, which 
some years ago prevailed rather extensively in Scotland for a con- 
siderable period. It began as a vesicle filled with sero-purulent 
and sometimes sanguinolent fluid, leaving an excoriated surface when 
broken, followed by a crust Sometimes it wore the appearance 
of ecthyma, at others that of carbuncle; phagedaenic or even 
gangrenous action supervened in some cases, or erysipelatous action 
might be present. Occasionally some of these boils appeared in a 
cluster. The more common seats were the back of the trunk, 
buttocks, and thighs ; but the lip, eye, tongue, vagina, and scrotum 
might be attacked. An irritant, such as a bhster, sometimes evoked 
boils in the vicinity of the part it was applied to. Professor Laycock 
seems disposed to connect the outbreak of this disease with the 
importation of foreign meat ; a view, I think, quite open to question. 

There is not much said about the treatment, and what there is 
cannot be looked upon as reassuring. Painting the incipient boil 
with tincture of iodine shortened its duration. The tincture of the 
sesquichloride of iron and the nitrate of silver are said to have been 
serviceable. When gangrenous the sores were best treated with 
strong nitric acid. Suppuration and sloughing called for crucial 
incisions and water-dressings. 

C. Charbon. 

Definition, — A severe gangrenous affection of a limited portion of 
the true skin, marked by rapid, unhealthy-looking vesication, sur- 
rounded by erysipelatous redness on which vesicles are sometimes 
seated ; swelling, hardening, and sloughing of the affected surface, 
accompanied by great prostration, rigors, headache, loss of appetite, 
and cold sweats. Generally attacks hands or face. Supposed to 
be communicated by contact with putrescent animal matter. Pro- 
gnosis grave in bad subjects. 

Treatment — I believe all who have seen the disease are agreed that 
it is absolutely necessary to give stimulants as rapidly and freely as 
possible. At least ten grains of the chloride of ammonium may be 
administered every two or three hom^, in two ounces of cascarilla 
or serpentaria, and this should, if the pain and depression be not 
relieved, be supplemented by an occasional large dose of morphia 
and ether. To be of service, however, these drugs must be doled 
out with no measured hand, as the disease is one which will not 



248 Aleppo Boil; Delhi Boil. 

allow of any trifling. As an external application I should be dis- 
posed to place more reliance on the acid nitrate of mercury, freely 
applied to the base of the vesicle, than on anything I know. 



D. Aleppo Boil. 

Definition, — A small, very slightly raised pustule, of a furunculoid 
character, destroying the true skin. Maturates very slowly ; leaves 
a permanent mark. Granulation slow. Peculiar fo Aleppo and two 
or three other towns. Attacks the face; said also, on doubtful 
authority, to attack the limbs of strangers who reside there. 

Treatment, — Although I have searched rather widely, and have 
questioned patients who had suffered from this singular disease, I 
have not been able to find any trace of a rational or successful 
plan of treatment ; that adopted in the East, that is to say, when 
any treatment at all is adopted, being inert. Judging from its 
lupoid nature, I should be disposed to place as much reliance on 
acid nitrate of mercury as anything else. 

£. Delhi Boil. 

Definition, — ^A formation of slowly-growing, minute tumours in 
the skin and cellular tissue, which ulcerate and spontaneously heal, 
leaving a peculiar bleaching and puckering of the skin. 

According to a paper by Dr. Fleming,* the morbid growth affects 
the skin and subcutaneous tissue. I am not quite clear that I have 
mastered Dr. Fleming's meaning, but I understand him to say that 
a deposit takes place of a substance " transparent, shiny, and free 
from inflammation." In this are seen spots, consisting of small, 
roundish, yellowish bodies, with a glistening capsule. They are just 
large enough to be seen with the naked eye, and seem to consist 
of fluid contained in a fibrous envelope of eccentric laminae. Dr. 
Fleming hazards the conjecture that these may be the ova of some 
parasitic body. Surgeon-Major Smith holds that the disease is due 
to the presence of ova, and that these ova come from the water 
used to wash the affected parts. Mr. Dickinson saysf that Delhi 

• The Delhi Ulcer, By J. Fleming, M.D. F.R.C.S. Indian Medical Gazette, 
1869, p. 23. 
t Lancet, 1 870, voL ii. p. 882. 



Definition of Delhi Boil, 249 

boil begins with a small, hard, red, shining pimple, which looks much 
as if the skin had been bitten by a mosquito ; indeed, this phase of 
the complaint is known as the mosquito stage. This lasts a variable 
period, during which the only change is a slight increase in size. 
The tumour at this epoch is hard, round, and circumscribed. On 
pressure it gives the feeling of a pea or a duck-shot rolling under 
the finger. About the end of the fourth week it no longer moves 
under such pressure, and becomes larger. The surrounding skin 
becomes infiltrated, and the surface of the tumour rough and scaly. 
The tumour daily grows more prominent and vascular, spreads wider 
and deeper into the surrounding tissues, and there is a sensation of 
pricking and shooting in it. Next one or two vesicles form on its 
apex, which begins to discharge a pale, yellowish, sero-granular fluid. 
This is followed by ulceration, which spreads till it has destroyed all 
the tumour except the base. This has, in the mean time, become 
a " collar of brawn," leaving a deep ulcer, with thickened irregular 
edges. ^Then the skin becomes undermined and fungous, and a most* 
intractable sore forms. Ultimately this cacatrizes, leaving a scar of 
variable colour, which looks much as if a piece of skin had been cut 
clean out. This, however, was decidedly not the case with some scars 
which I have seen, as they were bleached, seared-looking, and almost, 
if not quite, on a level with the surrounding skin, resembling, in fact, 
very much the "marks left by erythematous lupus. 

Mr. Dickinson thinks the disease is clearly of miasmatic origin. 
It occurs most frequently after the autumnal rains, is often preceded 
by pyrexial symptoms, and accompanied by neuralgic pains. It 
disappears with change of air. There seems good reason to believe 
that its existence at Delhi was due to a large quantity of ground 
being covered with the rubbish of ruined buildings, to want of trees, 
and to the tanks and watercourses being choked up. In consequence 
of a valuable suggestion by Lord Mark Kerr, the rubbish was re- 
removed, the space planted with trees, and the tanks and water- 
courses cleaned out. The result of these beneficial changes has 
been, the troops are now almost free firom the disease. It was also 
found to diminish when men suffering from it were put under canvas 
near trees. 

Dr. Sisson describes * Delhi boil as a hard, circumscribed, inflam- 
matory tumour, beginning much after the fashion of a simple boil, 

* Jaiimal of Cutaneous Medicine, vol. i. p. 338. 

2 K 



250 Definition of Delhi Boil ; TreatmenL 

but larger, and spreading wider and deeper. It does not suppurate, 
but suppuration sets in around it and destro)rs all the boil, except 
the collar of brawn at its base, leaving a deep, ragged, indolent, 
intractable ulcer. He also thinks its origin may be malarious. 

Treatment, — The actual cautery is of use when applied freely in 
the mosquito stage. Black wash seems serviceable when there is 
fungus, and nitrate of silver is often beneficial. Mr. Dickinson has 
found benefit from the use of carbolic acid. When the disease has 
existed for some time, the patient requires quinine or iron. The diet 
should be light. The patient should live as high above ground 
as he can, and all the water he uses should be boiled and filtered. 
Dr. Sisson thinks local treatment all-important In the boil stage 
painting with tincture of iodine ; in the ulcer stage " sluicing " with 
blistering fluid, or painting the edges with it Inunediate change of 
air is evidently the principal remedy. 



( 251 ) 



CHAPTER X.— TUBERCULiE. 

A, Lupus, B, Scrofuloderma, C. Leprosy (Elephantiasis Grcecorum). 
D, Chelis, E, Epithelioma, F, Rodent Ulcer, 

A. Lupus (wj, /, masc), from lupus ^ a wolf. 

Definition. — Limited thickening, hardening, and redness of the 
affected portion of skin, followed by abnormally active perverted 
absorption, under the influence of which unhealthy matter deposited 
in the hardening is removed, resulting in the formation of extremely 
tenacious crusts, followed by bleaching, thinning, and discoloration 
of the part attacked. Scars permanent. Most frequently attacks 
the face. 

Divisions. — i. L. exedens, generally attacking the nose, especially 
inner surface of it, beginning with a papule or fissure, followed by 
thickness, tenderness, stiffness and sense of weight, and formation of 
tenacious crusts, under which deep, unhealthy ulceration goes on. 
May destroy septum and alae, eyelids and mucous membrane of 
lips. Occasionally, but rarely, attacks limbs. 2. L. non-exedens, 
the same disease in a milder and slower form. Begins with a pale- 
coloured papule, or limited erythema, with induration, followed by 
adherent, dirty greyish or yellowish crusts. Destroys principally 
upper surface of corium. Little pain present. Cicatrix often 
traversed by slender blood-vessels. Attacks cheeks, forehead, and 
scalp \ also seen on limbs and trunk. 3. L. erythematosus, marked 
by more redness and less hardness than the previous variety, which 
it often closely resembles. Begins by a small, reddish, unhealthy- 
looking, irregularly-shaped spot ; often when on nose or ear bearing 



252 Pathology of Lupus. 

some likeness to a chilblain, the maigins of which gradually become 
covered, wholly or in part, by a thin, dry, tenadoas crust; attacks cheek, 
nose, ear, finger, &c Indmiated at margins ; followed by permanent 
bleaching and thinning of the skin. 4. L. scrofulosorum, an eruption 
i^ soft, flat, red, moist tubercles, spreading very slowly, without 
suppuration. Cuticle thrown off early, and replaced by viscid 
secretion, or loose, soft, greenish crusts. Followed by thinning and 
bleaching of the skin. Cicatrix permanent 

Pathology, — ^The intractable nature of lupus, and the disfigurement 
which it occasions will, I hope, justify me in devoting considerable 
space to the subject A sufierer fi-om thiS' relendess malady is a 
perfect outcast, the loathsome appearance which it wears in its more 
destructive forms being enough to inspire the least sensitive with 
horror. The observations I have to make on this part of the subject 
are almost purely clinical, or a digest of numerous commimications 
made to me by various medical men, whom I b^ to thank for their 
kindness. 

In the spring of 1866 I published a paper* on this disease, in 
which were given the particulars of twenty-five cases of it The 
letters ^ich I received shordy after on the subject leave little 
doubt that lupus is looked upon as scarcely, if at all, removed from 
the range of incurable maladies, and that an immense number of 
remedies are used for it, to the exclusion of a more simple, if not a 
more valuable mode of treatment. It therefore seemed highly 
desirable to go carefiilly into the question, especially as an opinion 
has been expressed that some of the cases referred to were not true 
lupus. Throwing open the question to fi"ee discussion is the great 
remedy for the evils of divided opinion, for if no other good be 
effected, attention is sometimes thus directed to modes of treatment 
which might otherwise never be heard of; points of diagnosis, in 
themselves of the highest importance, are often brought to light, and 
even the obscure nature of the causes of disease may be made more 
clear. For instance, the connexion between syphiUs and lupus may 
possibly be thus decided. By discussion, it is true, men do not 
convince each other, but the conflict of opinion rarely fails to open 
up chances for such as will avail themselves of them. 

Under the head of lupus I propose to review, not only the 
recognized forms, such as the eating, creeping, and erythematous, 

• On the Treatment 0/ Lufus. Robert liardwicke. 



k 



Pathology of L upus, 253 

but some other varieties of disease, which, if not true lupus, are more 
nearly allied to it than to any other disease I am acquainted with; such, 
for instance, are the strumous lupus already defined, some kinds of 
lupus of til e limbs, and lupoid ulceration from bites. 

The strumous form of lupus, though a rare disease compared with 
the other varieties, may be easily recognized. It is quite distinct 
from scrofuloderma, but may be seen in the same class of patients. 
It begins with one or more soft, flat, red and moist tubercles, which 
spread very slowly, and neither suppurate like the cutaneous 
abscesses of scrofula, nor ulcerate like those of eating lupus. The 
cuticle is cast off" at an early period, and is not formed again. From 
the time it is shed the tubercles are always covered with a small 
amount of unhealthy-looking, viscid secretion, or loose, soft, greenish 
crusts. Generally as one part encroaches on the sound skin, another 
heals, or the whole patch may heal from the centre and spread at 
the edge. In the healing stage the identity of this disease with 
ordinary lupus is fairly revealed, the process being attended with the 
same thinning and bleaching of the skin as in lupus erythematodes. 
Indeed, I have observed the disease after a considerable time 
take on the characteristics of the creeping form. Dr. Purdon has 
recognized this affection, of which he has seen* two cases. 

I have already described, under the head of sycosis, a form of 
disease which I believe to be lupus. This disease again is easily 
recognized by the small, hard, red tubercles, the erythematous margin 
and the bleaching and thinning of the skin. I have known it con- 
founded with acne, and I have heard its lupoid nature openly disputed ; 
but the tubercles which surround, or rather envelop, the hair-follicles 
may be identified with those of lupus both in appearance and growth ; 
they are, it is true, smaller and harder, but in every other feature they 
are one and the same. When pierced, or laid open by tearing away 
the crust, they exhibit, in many instances at least, not the characters 
of a pustule, but a jagged cavity lined with the grey pultaceous 
or tough whitish, adherent secretion of lupus. The thinning and 
bleaching are identical with those of lupus. The duration of the 
disease is almost indefinite. 

All forms of lupus invade the limbs, but they rarely assume in 
this situation features identical with the same disease on the face. 
Lupus exedens may be seen on the elbow, when it is usually as- 

* Journal of Cutaneous MeduinCy vol. iii. p. 136. 



254 Pathology of Lupus. 

cribed to a blow, a belief for which there may be some foundatioiL 
I have also met with it on the outer side of the right arm and back 
of the right hand, making terrible ravages and sadly disfiguring the 
patient, a healthy-looking scotch girl ; outer side of the left arm ; 
behind and below the knee, and on the inside of the lower part of 
the thigh ; and Dr. Frazer has seen it perforate the knee-joint, 
causing death from absorption of pus. I have also met with two 
cases where it attacked the lower part of the leg ; and as I believe the 
circumstances are unusual, I give the particulars. 

The first was that of an elderly man, otherwise in good health, who 
had formerly been imder my care for lupus exedens of the elbow 
and radial side of the arm, which, taking together the healed and 
diseased parts, extended fi-om considerably above the elbow to half- 
way down the arm, and which had lasted then nearly three years. 
I questioned both him and his wife, but could not make out any 
history of syphilis. His only child, a daughter, was under my care 
at the same time for pityriasis rubra, but though I made every search, 
I never could find out that she had had a single symptom of syphilis 
fi"om her childhood upwards. The disease in this man yielded to 
treatment, but a few months later a large patch formed on the lower 
part and outer side of the right leg, just below the calf, which gradu- 
ally became covered with a remarkably hard and tenacious crust, 
under which lay an ulcer with every feature of lupus, and which 
steadily healed under the influence of iodide of potassium. 

The other case was that of a lad who had suffered for years from 
lupus exedens, which, before I saw him, had destroyed the tip of 
the nose and both lips. During the time he was under treatment 
as in-patient at St. John's Hospital, he contracted a severe cold 
accompanied by bronchitis, and followed by a bad cough and 
loss of appetite. With these symptoms came a nasty unhealthy 
abscess, over the lower and front part of the tibia, and near this 
some papules soon appeared. In the course of a very short time, 
the abscess, which was very superficial, and really more a large un- 
healthy bleb than anything else, and the papules, were seen to be 
involved in one common process of degeneration into lupus. How 
the case ended I am unable to say, as the boy was soon after 
removed from under my care. 

I am indebted to the kindness of Dr. Frazer for the particulars of 
two cases of lupus of the limbs and trunk. In one patient, a female 
of middle age, the disease attacked the right knee ; indeed it was a 



Pathology of- Lupus, 255 

recurrence of the complaint in the same part where it had appeared 
several years previously. The ulceration spread deeply, threatening 
to perforate the joint, but was thoroughly and rapidly checked by 
the use of chloride of barium in doses of one-eighth of a grain, 
aided by poulticing, strapping, and a strong solution of nitrate of 
copper. In the other patient, a man in the prime of life, the disease 
extended from the anus along the buttocks, healing sometimes, 
re-opening at other times, but always spreading by the growth of 
tubercles, which formed in the skin, softened and ulcerated. 

Dr. Purdon was kind enough to inform me, that out of nineteen 
cases of lupus treated at the Belfast Dispensary for Diseases of the 
Skin, three had the same disease in the limbs. In one, that of a boy 
thirteen years old, strong and healthy in appearance, tubercular lupus 
occurred on the back of the left hand. . In another case, that of a boy, 
aged nine years, who also had this disease on his nose; there was a 
small patch of tubercular lupus about the size of a penny on the inside 
of his right thigh ; and lastly in the case of a girl, twenty-four years of 
age, suffering under erythematous lupus of the nose and both cheeks, 
which had existed upwards of eight years, the disease likewise 
occurred on her left hand and little finger. 

I shall possibly be told that most of, if not all these cases, were 
nothing more nor less than tertiary disease ; at least from the tenor 
of the remarks made to me, I can come to no other conclusion ; and 
as, apart from the question of diagnosis, the existence or non-exist- 
ence of a venereal taint, is a point of vital importance to the patient, 
I am anxious to go fully into this part of the matter. 

In the majority of cases there was no antecedent history of 
syphilis. I inquired in every case most carefully into this point, and 
though some of the patients admitted having had gonorrhoea, often 
more than once, while others candidly stated that they had exposed 
themselves freely enough to the risk of infection, yet I could not 
find out that any of them had had syphilis. There were no histories 
of eruptions, sore throat, &c., to connect this lupoid disease with a 
soft sore mistaken for gonorrhoea or hidden behind a contracted pre- 
puce, no cicatrices from tertiary disease, no falling of the hair, no 
destruction of the hard or soft palate, or signs of previous ulceration 
of the throat. I should not have thought it necessary to say that 
the scars left by buboes and chancres are worse than useless as evi- 
dence of infection, had I not known that the presence or absence of 
these scars is daily misinterpreted, . and that their existence is con- 



256 Pathology of Lupus, 

sidered by many persons as positive proof of a syphilitic taint. It 
becomes therefore requisite to observe that a sore on any part of the 
penis is a most fallacious test ; the chancres which produce the most 
decided loss of tissue, the phagedaenic, are rarely if ever followed by 
either secondary or tertiary disease, while the most destructive and 
obstinate forms of constitutional disease may result from very small 
sores, which may heal up in a few days, leaving little if any mark ; 
or from the papular form of sore which disappears with scarcely 
a trace of its site remaining. In like manner the scar of bubo, if its 
history be superficially examined, only misleads the inquirer. The 
indolent bubo, which scarcely, if ever, suppurates, is succeeded in a 
vast majority of cases by general disease, whereas the suppurating 
bubo, which bursts and leaves a mark, is not followed by anything of 
the kind. But the patient may have had this form of sore, and also 
hard sore, with indolent bubo ; so that with or without a scar in the 
groin he may be thoroughly infected. 

Again in many of these cases of lupus of the limbs and trunk the 
disease was very much slower in its progress than syphilis usually 
is ; it was far less amenable to control, and was not marked by any 
of the concomitant symptoms which sooner or later start into life, 
when the patient is suffering under true tertiary disease. Syphilis 
will, it is well known, hang about a person for years, but usually 
this is because the patient does not submit to a proper course of 
treatment. When thoroughly destructive syphilitic action is set up, 
it is rarely in the shape of one solitary symptom ; it is usually more 
rapid in its course, and mostly some unmistakable concomitant, such 
as pain, falling of the hair, antecedent sore throat, swelling of a bone, 
osseous pains, or a gum tumour may be traced. In lupus there is 
nothing of the kind ; in the cases I speak of there was not one of 
these symptoms ; the disease slowly and steadily pursued its career 
of destruction for years ; the symptoms were as like those of lupus 
on the face as two diseases on different parts can be ; there was in 
some instances the same high health, always the same absence of 
pain that we see in lupus ; the same bleaching in the centre and 
spreading from the edge in an irregular ring ; the same pultaceous 
secretion in the sores when they pierced the skin. 

At the risk of appearing tedious, I venture to put some of these 
points in a more concrete form. One of the patients I speak of, 
suffering from lupus of the right elbow, attended at the hospital for 
quite two years, the complaint having existed several years when I 



Pathology of Lupus. 257 

saw him. During all the time he was in attendance I never could 
detect any signs of S)rphilis. Another person, a woman, entered as 
out-patient with lupus of the lower and inner part of the left thigh. 
It began as a narrow irregular opening of the skin just above the 
inside of the knee, which gradually spread in all directions, extending 
slowly in width, burrowing under the skin, and piercing deeply into 
the cellular tissue. When I first saw her it had existed three years, 
but it had not in that time reached beyond the size of a five -shilling 
piece, though near it were some soft, largish patches of thickened 
and discoloured skin, which had a very suspicious appearance. Here 
the patient herself was afraid that she suffered from syphilis, as the 
surgeon under whose care she first placed herself questioned her on 
this point, though he had, after a long observation of the case, 
come to the conclusion that the disease was dependent on necrosis, 
and not venereal. Probing however failed to reach the bone, and 
no dead bone came away then or afterwards. I had to see this 
woman occasionally for more than three years, and three years 
subsequent to her recovery she came to the hospital for another 
complaint, but during all that time, though I repeatedly inquired, I 
could never find any signs of syphilis in her or any of her children. 
Her husband, who died previous to my seeing her, always denied 
having ever had anything of the kind. Indeed the connexion between 
syphilis and lupus has still to be made out. Mr. Hunt says that 
erythematous lupus is not lupus but syphilis, yet it certainly appears 
in young ladies and women of irreproachable character. Mr. Wilson 
believes that lupus is due to inherited syphilis, but it most assuredly 
breaks put in persons who have never shown any other sign of syphilis, 
and against whose parents it is ^he only evidence. It is scarcely 
going too far when I say that this view is totally unsupported by any 
kind of proof. 

Lupus non-exedens will attack the limb. In two cases where I 
saw it on the arm and leg, the disease was rather a compound of 
the eating and creeping forms than a good example of either. In 
one very bad case, the outbreak of the worst symptoms was heralded 
in by the appearance of several slight but very distinct tubercles on 
the legs, which only yielded when the more serious symptoms were 
subdued. In another patient, a woman, whose face at the time, 
she began attendance was fiightfully disfigured by this compound, 
aflfecrion, there were repeated outbreaks of it on the arms, thighs, 
and legs, and I was on several occasions able to identify the two 

2 L 



258 Pathology of Lupus. 

disorders. I have seen the erythematous form of lupus on the 
fingers and leg, and Dr. Hillier says it has been noticed on the 
limbs. I had one case, and only one, of strumous lupus on the 
limb. The patient was a lad with all the unnatural fairness of skin, 
the blue eyes and tumid upper lip, which are held to be marks of a 
strumous diathesis. There was only one diseased patch, and that 
was seated on the upper and front part of the leg, and outer side of 
the tibia. It was about three inches long and about two wide at 
the broadest part It had lasted several years, and where it had 
healed the characteristic bleaching and wasting of the skin were 
very marked. 

A warty form of lupus (1. verrucosus) is described * by Dr. M'Call 
Anderson. It begins with small circumscribed, dusky-red or violet 
patches about the size of a split pea or bean, sometimes isolated, 
oftener confluent They may form a group the size of the palm of 
the hand. They subside, suppurate, or become covered with wart- 
like excrescences composed of epidermic cells. 

I do not know whether I am justified in referring to lupus those 
cases of peculiar and obstinate ulceration which sometimes follow 
bites, scratches, &c., but I am certainly disposed to look upon them 
as a traumatic form of this disease. I had under my care a lad 
whose hand had been severely bitten by another boy, the worst wound 
being in the hollow of the -knuckles between the first and second 
fingers. In the course of a few weeks an obstinate, red scaly ring 
had formed round this spot and gradually increased in size till it 
reached the wrist, and extended in the opposite direction over great 
part of the backs of the three first fingers, the skin being stifiened, 
painfiil, and apparently disposed to take on a dry ulceration at the 
edge of the diseased siuface. This form of disease is difficult to define ; 
the term ulceration might be objected to, inasmuch as there was no 
secretion of pus, but neither is there any in lupus, where yet the 
corium is invaded and permanent scars remain. Neither the patient 
nor his mother would hear of any painful application being made to 
the part, and mild measures seemed to have no effect whatever ; 
the disease got steadily worse for several weeks, and then the lad 
suddenly left off attending. The second case was from the bite of 
a cat, which fastened its teeth on the finger of a little child near the 
nail. The wound refused to heal, and the matrix of the nail became 

* ypumal of Cutaneous Medicine, vol. i. p. 96. 



Pathology of Lupus. 259 

involved. At last the suigeon took off the nail and then the disease 
healed. The third instance of the kind arose from the bite of a 
parrot on the lip. The disease very much resembled severe eczema 
siccum, and extended over a veiy considerable sur&ce ; it had existed 
several months when I saw it I endeavoured to secure the attendance 
of the patient for the purpose of having a photograph taken, but he 
failed to come, and was indeed all along very irregular in his visits. 
In a fourth case, that of a man who entered in 1866 at St John's 
Hospital, an ulcer the size of a penny, seated on the back, was stated 
by the patient, a man fifty-eight years of age, to have lasted from 
childhood, and to have followed the bite of a mule. In another 
case * undoubted lupus seemed to have been developed by a jagged 
cut from a stone. I was consulted by a lady who had a flat depression 
on the forehead about the size of a shilling, irregularly circular, having 
apparently gone through the greater part of the thickness of the 
corium. There was a narrow red line at the edge. I thad begun 
from a scratch with the finger-nail many years previously. I re- 
peatedly applied nitrate of silver and chloride of zinc to it, but 
without any permanent benefit At the present time the disease, 
which has existed quite nine and twenty years, has somewhat increased 
in extent The death of a gentleman at St Petersburg was mentioned 
not very long ago, evidently the result of constitutional irritation set 
up in this way. He had been bitten by a parrot, and morbid action, 
which nothing would check, was set up. The case was vaguely told, 
but there seems little doubt as to its nature. Dr. Purdon relates t 
a case in which the disease seemed to have followed a clean cut 
A boil having been lanced on the cheek of a woman thirty-six years 
old, lupoid action was set up round the cut, and twenty years later, 
when he saw the patient, there was at the part a cicatricial-looking 
tissue about three inches in diameter, smooth, glazed and white, 
except at the margins, which were of a violet hue. The skin was 
greatly wasted and thinned, and the hair-follicles and mouths of the 
sebaceous ducts obliterated. 

The high state of health which accompanies so many of these 
cases is extraordinaiy. True, many of the patients are thin, badly 
shaped, and strumous. But it is as certain as can possibly be, that 
on the other hand many are veiy healthy, ruddy, firm-set people, 

♦ On the Treatment of Lupus, p. 19. 

t American youmeU of SyphUography, vol. i. p. 212. 



26o Prognosis of Lupus, 

who, but for this, might have passed, if not for models of health, at 
any rate for giving promise of constitutions far beyond the average. 
I know a very contrary view has been asserted, but I have seen so 
many cases of the latter class that I should feel quite satisfied to put 
the issue of the question any day on the average of the patients 
treated at St John's. Dr. Frazer has also noticed the occturence 
of lupus in persons of robust health, but Dr. Purdon finds the 
majority of persons suffering under this disease to be strumous. 
Dr. Hillier * says that in the most severe cases of lupus exedens, 
when it extends its ravages very deeply, the patients are liable to 
chronic gastro-enteritis, and often die in a state of low fever with 
colliquative diarrhoea. 

Examinations of the diseased parts have so far only revealed 
formation of connective tissue in the corium, some injection of the 
vessels, and transparent blastema. Small white corpuscles, looking 
like dilated hair-sacks or sebaceous follicles, have also been seen. 
Wedl states that the connective tissue may extend into the muscles 
and fat, and even the bones. 

Prognosis, — ^Although the prospects held out to us of curing this 
formidable complaint are still gloomy enough, yet the treatment has 
been more improved within the last thirty years than men might at 
first be disposed to admit. At the time I speak of the eating form, 
then almost the only form recognized, was given up as utterly hope- 
less ; the very name of it, noli me tangere^ breathed despair, and all 
means of aid, sharp or mild, only served to exasperate its dreaded 
inveteracy. In Rayer's time treatment seems to have been utterly 
powerless ; of five cases which he quotes, only one offers an)rthing 
like a cure. Mr. Liston used to tell his class that he had over and 
over again seen patients suffering from lupus exedens " who had lost 
all their features ; lips, nose, and eyes ; nothing remained but the 
brain-pan and tongue, and they required to be fed by a fimnel, 
introduced over the base of this organ and into the phamyx." t And 
when Mr. Hunt began his researches, lupus in all its forms was still 
looked upon as a malady to be relieved, not to be cured. Even 
now many writers consider it as removed by a very narrow boundary 
from incurable diseases. In other parts of the world we now and 
then find an enthusiastic admirer of Hebra ready to tell us that the 
disease is manageable enough, and that our failures are due, like all 

• Op. cit.^ p. 196. t Lancet^ 1844, Sept. 21, p. 775. 



Prognosis of Lupus, 261 

our mistakes, to our stupid deference for tradition. But here opinions 
resolve themselves pretty well into two classes — one, that lupus is 
difficult to cure ; the other that it is simply incurable. 

I consider circumstances warrant me in saying that lupus is more 
amenable to treatment than is generally supposed ; extended obser- 
vation having confirmed rather than weakened the views expressed 
in the pamphlet spoken of. This, however, I could fairly anticipate. 
I simply wrote down what I saw. The notes were, for the most 
part, taken in the presence of others ; and therefore it was scarcely 
probable that any serious errors, in what was principally a recital of 
facts, would go forth. Since that time I have had the pleasure of 
showing several gentlemen more than one case then considered 
doubtful, but subsequently cured, to all appearance, or greatly re- 
lieved. One case was that of a poor woman, Mary Ann P , 

whose face, when she first began to attend, was so covered with 
crust and sores that not a piece the size of a shilling had escaped 
the ravages of the ruthless malady. She got quite well, and a con- 
siderable time after remained so, as she called at the hospital to show 
herself. Of three severe cases mentioned * in the pamphlet, it has 
been ascertained that long after there had been no relapse. In one, 

a very bad case, that of Mary Ann C ^,t the cure has now re- 

' mained complete more than seven years ; the patienf s sister has 
been several times under my care, and she always gives the same 
account. In another, that of S. R.,t it was found that quite five 
years after she had left oflf attending there had been no return of the 

disease. Another patient, Eliza G ,§ was seen in April, 187 1, 

up to which time she had had no return of the disease. Of the cases 
cured since theij, two have attracted particular attention. One of 
the patients, an elderly female living at Southgate, is still, at the end 
of five years, free fi*om any signs of the disorder. Another, a young 
and good-looking married woman, with lupus erythematosus of the 
right cheek, which she had suffered from for more than twenty years, 
had also had only one relapse, and that a very slight and apparently 
preventable one, at the end of a long period. 

Of course all the cases did not go on so well. In a very obstinate 
and disfiguring attack of lupus erythematosus on the left cheek and 
nose of a young girl, a teacher, where the disease had lasted for 

* On the Treatment of Lupm^ pp. 17, 23, and 25. t Op. tit. ^ p. 23. 

X op. cit.y p. 17. § op. cit., p. 25. 



262 Prognosis of Lupus. 

m 

years, preceded and then accompanied by slow strumous ulceration 
of the skin beneath and behind the jaw, the effect of treatment was 
at first rapid and satisfactory, the disease being to all appearance 
cured. Nothing could induce her after this to observe any pre- 
cautions, and at a later date the disease broke out again inside the 
nose and destroyed the septum, before she could be persuaded to 
attend properly to it Another patient had nearly got rid of lupus 
of the nose, when she was attacked, first by lepra and then by 
bronchitis. Diuing the treatment of these two complaints the lupus 
relapsed, and, just as she had obtained some relief^ she died quite 
suddenly. There is a woman now attending at St John's Hospital 
who has always some excuse for leaving off treatment just as she is 
beginning to get a little better, and who must have had at least four 
or five relapses. 

There is, I think, good reason to conclude that the disease may 
always be relieved, and generally, if not always, cured ; but this 
only holds good where treatment really has fair play. If patients 
will leave off treatment every now and then, if they will tiy all the 
remedies which fiiends suggest, if they object, as they often do, to 
take any medicine, imless they are assiured that it contains no 
mercury or arsenic, if they will be refiractory about diet and will 
expose themselves to agencies which aggravate the disease, the 
surgeon may struggle in vain ; the only plan is to throw the case up. 
He will do it no good, and it will do him no credit It seems a sad 
and strange thing that persons undergoing such fearful disfigure- 
ment cannot be brought to take the most ordinary precautions; 
but such is the case, and it happens so often, that I have sometimes 
asked myself whether the peculiar condition of tissues which de- 
velops this complaint is not attended with some peculiar disposition 
of the brain. 

I do not speak of cases where patients have got weary of attending 
in vain for months, or of suffering, equally in vain, the torture caused 
by caustics ; I speak of those where the most frivolous excuses are 
offered. One girl applied at St. John's with lupus of the face, which 
had lasted quite two years, and had destroyed a very considerable 
portion of the surface of the skin ; during the whole of this time she 
had never applied for relief; a woman, half of whose face was covered 
with lupus non-exedens, refused to go on with treatment of any kind, 
because a solution of nitrate of silver applied to it blackened the 
surface ; a young man, already fearfully mutilated by lupus exedens, 



Treatment of Lupus. 263 

was sent to the hospital by his master ; at the end of three or four 
days dislike of the restraint of hospital life so far prevailed over his 
desire to get well, that it was found necessary to watch him in order 
to prevent his tampering ' with the medicines, and thus getting an 
excuse to be sent home. 

Treatment — ^The first step towards forming trustworthy conclu- 
sions as to the power of any remedies over such a disease as lupus must 
be to separate them ; the second, to examine their action separately. 
Any knowledge otherwise acquired must ever be to a great extent 
empirical ; treatment based on such knowledge must remain an aflfair 
of individual experience, and teaching based on treatment of this 
kind is as insecure as anything can be conceived to be. A fabric like 
this may be increased in bulk and polished by toil, but it is unsound 
to the very core, and the whole structure may at any moment be 
sacrificed to the popularity of some new specific. 

One of the first results of such a process as that just pointed out 
would be the simplifying of our pharmacopoeia, and certainly a greater 
boon could not be conferred on medicine ; for what we want is, not the 
new drugs which are constantly being heralded into notice, but a 
more complete knowledge of the relative value of the more useful 
among those which we possess, and the ruthless elimination of a host 
of useless medicines which, at present, serve only to encumber the 
druggisf s shop and the author's pages, to puzzle the brains of those 
who have not, and to excite the disgust of those who have, the ill- 
luck to use them. People who are in the habit of examining the 
answers to correspondents in some of oiu: medical journals, must have 
noticed that it is no uncommon thing for a writer to ask what will cure, 
or what is best for, some particular disease, such as acne or pityriasis for 
instance, apparently under the impression that specifics are as nume- 
rous as maladies. It is seldom that he has to wait long for an answer, 
but in general he will have to wait a very long time before two persons 
suggest the same mode of treatment; indeed it would seem as 
if every person, who considered himself able to speak on such a sub- 
ject, must necessarily differ, more or less, firom every other person. 
Till some of this confusion is done away with, no novelties, unless 
they can be very strongly recommended, are required. 

There must be something radically wrong in our modes of obser- 
vation when men arrive at such opposite conclusions as they con- 
stantly do about the curability of diseases and the power of drugs 
over them. Disease is ever the same and the properties of drugs 



264 Treatment of Lupus. 

can be ascertained with tolerable certainty. Now there are but three 
elements in the question — the disease, the remedy, and the obser- 
vation bestowed on the two first These being, so to speak, constant 
quantities, error can only take its rise from the third. I trust my 
readers will pardon me for repeating here with so little variation 
what I have said in the chapter on eczema. I do so because I fed 
how important the matter is, and because I see so little done to check an 
evil of such magnitude. 

It was not to be expected that lupus should escape the common 
lot of all obstinate diseases — that of having such a large materia 
medica as rather to bewilder the brains of any one who attempted to 
grapple with the subject than to serve as a reliable guide. Indeed 
it is quite possible that were a student to go carefiiUy through the 
literature of this disease he would, what with the number of remedies 
and the discrepancies of opinion as to the value of this or that 
system of treatment, be less qualified to decide what plan to adopt, 
or what drug to begin with, than when he commenced his task. 
Some writers look upon medicines as useless, and caustics as the 
only things likely to do good ; while others rely on medicines and 
denounce the employment of caustics as wanton and useless cruelty. 
I need scarcely say that both cannot be right. 

It may save some misunderstanding if I admit beforehand that my 
own researches, though I hope carefiiUy made, are still very far from 
being what they should be ; but it seems to me that the cause of 
truth will be better served by stating even very imperfect results, 
than by falling back upon authorities which can be consulted at first 
hand, or by attempting to lay down general rules which the reader 
can do equally well for himself. Nor are these observations brought 
forward with the view of throwing any discredit on the systems adopted 
by other writers ; they are simply offered as a contribution towards a 
mode of recording facts which, if the writer's view be correct, might 
in course of time come to be as exact as the records of an observatory, 
and perhaps as widely separated from the usual method as meteoro- 
logical records are from the rough-and-ready guess of the shepherd 
or sailor. The latter may be useful in its way, may up to the present 
time have led to more valuable results in both fields of observation. 
That is not the point at issue ; the question is which system will in 
the end yield the most certain deductions. 

Interned Means. — The internal remedies for lupus may, I think, very 
safely be divided into three classes : (i) those which possess a certain 



Internal Treatment of Lupus. 265 

amount of value ; (2) those of doubtful value, and (3) those of no 
value at all. 

1. The only remedies which I have observed to exert an un- 
doubted control over lupus, and which will, I believe, in every 
case do some good, and in a certain proportion of cases effect a 
cure, are arsenic and calomel in lupus of the face, and iodide of 
potassium in that of the limbs. Of coiu^e there may be, and very 
probably there are, others — some known, such as chloride of barium, 
recommended by Dr. Frazer of Dublin, a most careful observer — 
some yet to be found out. I am limiting myself here to drugs the 
action of which I have tested, or the accounts of which I have been 
able to examine with sufficient care. 

2. Among the remedies of doubtful value I would put all the salts 
of antimony, soda, borax, mercury, iodine, and potass, with the 
exception of those quoted in the foregoing paragraph ; all combina- 
tions of salts of these, such as iodide of mercury, Donovan's solution, 
&c., all the oils, such as cod-Hver oil, and all vegetable preparations 
whatsoever. In ranking these remedies as doubtful, I do not in any 
way seek to invalidate the statements made by some writers respect- 
ing their power over lupus ; the chief obstacle to their value, and the 
chief argument in favour of the position I take up is, that were any 
given number of ca3es of lupus put before a surgeon, he would not 
be able to say that with these remedies only he could rely upon 
curing a certain proportion of them, or, perhaps, a single case. The 
disease is often undoubtedly benefited for a time by some of these 
remedies, for instance, by iodine and iodide of potassium in lupus 
of the face, but, in all the cases I have seen, the improvement was 
very slight, and soon came to a standstill. M. Devergie treated 
twenty-six cases in this way, aided by the use of Vienna and Canquoin 
paste, for three months. Not one of them was cured, neither does 
there seem to have been any very encouraging amount of improve- 
ment. Cod-liver oil often eflfects some amelioration of the health, 
but, as regards the disease, its action is just as uncertain as that of 
the others. Its true function, indeed, is that of an auxiliary ; it can 
rarely, if ever, be relied on to the exclusion of active means. 

3. Among remedies of no value, I think we may safely put steel, 
quinine, mineral acids, bitters, sedatives, alteratives, and sudorifics ; 
change of air, sea-bathing, baths of every kind, and, possibly, many 
of the preparations described as of doubtful value. This may seem 
going too far. I can only say that I see no other conclusion to be 

2 M 



266 Internal Treatment of Lupus. 

drawn, as I never yet saw a beneficial change produced in lupus by 
any of these remedies, and I have repeatedly tried them and seen 
them tried without any good whatever. For instance, I have notes 
of several cases where iron was prescribed, sometimes by myself, 
sometimes by others. Among the preparations used were the 
tincture of the sesquichloride, the magnetic oxide, the iodide, the 
sulphate, the freshly-prepared carbonate (made by mixing solution 
of the sulphate with carbonate of potass), and Griffith's mixture. In 
no one instance did the medicine exert the slightest appreciable 
influence over the disease. Sometimes the health underwent a 
certain degree of improvement, but generally there was not much to 
improve. In the same way when mineral acids, such as the nitric 
or nitro-muriatic, were given, the appetite became more keen, and 
the tongue grew cleaner, and possibly were the whole community 
treated in this way a certain number out of every thousand would 
exhibit the same results ; indeed, it would be folly to dispute the 
power of such remedies in promoting the health, their value as 
auxiliaries ; but as to their influence over the disease, they are, for 
anything I could see to the contrary, as capable of producing as of 
alleviating it. 

Some five or six years ago I showed several gentlemen a young 
woman, an in-patient at St. John's Hospital, suffering from erythe- 
matous lupus in a very severe form. She had been afflicted with it 
quite four years and a half, and had taken an immense quantity of 
tonics without the least improvement ; in fact, the first thing tried 
when the disease showed itself was a long course of iron. She then 
took iodine in large doses for a long time, and after that belladonna 
for some months ; yet so soon as she was put on arsenic, purgatives, 
and a proper diet, she began to improve ; and this case is only one 
of many in which I have pointed out how powerless such remedies 
are against lupus. 

For the purposes of treatment all cases of this disease may, I 
think, be advantageously divided into two great groups ; one em- 
bracing lupus of the limbs only, the other lupus of the face and head, 
complicated or not by affections of the limbs. The arrangement is, 
I admit, extremely unscientific, but I think it is useful for examining 
the power of medicines, the varying action of which over the same 
disease in different structures, and even the same structure in 
different parts, has not attracted the attention it merits. Some 
years ago I endeavoured to show that medicines which are valuable 



Internal Treatment of Lupus. 267 

against an inflammation in one part are powerless against it in 
another ; for instance, opium will often thoroughly check peritonitis, 
an inflammation of a serous membrane, whereas it will, at the ut- 
most, in many cases only relieve an inflammation in cellular tissue, 
as in erysipelas, simple bubo, &c, and is quite powerless against one 
in a mucous membrane, as, for instance, in gonorrhoea. It would 
lead me much too far out of the way to detail all the observations on 
which this view is based. I can only point out roughly the general 
principle, as a point round which future observations may gather, as 
crystals do round a nucleus, and as affording some excuse for the 
division now adopted. 

The internal remedies then are, as I have said, arsenic, calomel, 
and iodide of potassium. There is, of course, nothing new in them ; 
the difference in the treatment now to be described lies in the mode 
of giving them ; but this difference is just the most important feature 
in the whole matter, and one to which I was led, not by any desire 
to introduce a novelty, but by my utter failure with ordinary methods. 

So far as I have been able to make out, the most efficient remedy 
against lupus of the limbs is iodide of potassium. For the most part 
it only requires to be given in moderate doses, and the necessity 
which exists in syphilitic cases for constantiy raising the amount 
taken does not obtain here. When it cures the disease, I believe it 
always acts soon, and the action goes on till the part is healed ; when 
the improvement comes to a standstill, I am disposed to think that 
augmenting the dose will have no effect. When this very undesir- 
able result ensues, I would suggest a short course of mercury, as 
recommended further on for lupus of the face. 

The mode of prescribing it may be safely left; to the discretion of 
the surgeon. Perhaps one of the bitter infusions* will answer for a 
vehicle as well as anything. One precaution should never be 
omitted — that of getting the salt from a source where we can rely on 
having it pure. It is perhaps not so much adulterated as it used 
to be ; t indeed I have been told on very good authority that the 

* For instance ; — 

R. Potassii iodid. gr. xxiv. 
Syr. flor. aurant. 5iv. 
Tinct. cinnam. c. 5ij. 
Infus. quassige vel calamb. ad Syj. m 
Capiat coch. amp. duo bis quotidie. 
+ Pereira speaks of the adulteration being carried to the enormous amount of 
74, 75, and 77 per cent. — Elements of Materia Medica, 



268 Internal Treatment of Lupus. 

adulteration rarely exceeds ten per cent, though, judging from the 
great difference in the action of prescriptions made up at diflferent 
places, I should have considered this statement below the mark. 
Still even an admixture of ten per cent may make a very material 
difference. 

Should the bowels be confined, a mild pill may be given ; in fact, 
in this as in any other complaint, all complications should, as far as 
possible, be got rid of, care being taken at the same time not to 
interfere with the action of the iodide ; for instance, in gi^dng 
aperients, the alterative action of merciuy should be guarded against 
But I should think it was quite unnecessary to enter into details on 
such a point ; to keep on repeating that when gout is present 
colchicum combined with salines may be prescribed, and that iron 
is called for in anaemia ; that impaired digestion and painful men- 
struation must be relieved; that we must attend to the general 
health and improve the secretions ; every surgeon knows, or ought 
to know, all this. 

When we have to deal wkh lupus of the head or face, I believe 
the first remedy to be given is arsenic. Unless som6 disorder of 
the health, such as loss of appetite, great weakness, or anaemia is 
present, all preparatory treatment is, I think, wasted ; but when the 
tongue is coated and marked by the teeth, the breath foul, and the 
bowels confined, a saline may be given for a few days, followed by 
nitric acid in bitters.* The great question is the mode of giving 
the mineral and the dose suited to the case in hand. I have found 
De Valangin's solution answer very well ; t it is one of the best pre- 
parations ever yet found out, possibly superior to Fowler's solution. 
Twelve minims may be given at the outset three times a day, or, if 
the reader prefer it, five minims of the solution of the chloride 
(Pharm. Brit). The amount given daily of this or Fowler's solution 
must gradually be raised to twenty^five or thirty minims, of De 
Valangin's liquid to quite a drachm, before any good can be hoped 

• For formulse see pp. 149, 172. 
t The formula for De Valangin's solution is — 

R. Acidi arseniosi 5ss. 

Acidi hydrochlorici pond. 5iss. 
Aquae destillatoe Oj. 
The hydrochloric acid is to be diluted with an ounce of the water, and the 
arsenic is dissolved in this. The remaining part of the water is then added. An 
ounce of this solution contains a grain and a half of arsenic, whereas the same 
quantity of the Pharmacopceia solution contains four grains. 



Internal Treatment of Lupus. 269 

for. According to my experience, arsenic seldom produces much 
benefit till it brings on a certain amount of constitutional disturbance. 
As there are no signs to ^erve us in determining at the outset whether 
the patient will or will not bear arsenic well, the requisite knowledge 
betomes in each case a matter of individual experience. Some per- 
sons afflicted with lupus support it badly at first ; but this can always 
be overcome. I had a very healthy-looking woman under my care 
for this disease, who for a long time could not take more than five 
minims daily of Fowler's solution, and she only succeeded in retaining 
this on her stomach by swallowing it last thing at night ; yet, with 
care, she got to take fifteen minims daily. Other persons, by no 
means more healthy or stronger-looking, seem as if they could 
swallow almost any amount. The reader may be startled when I 
say that I have given from three hundred to four hundred minims 
weekly of the liquor arsenicalis, but I have repeated the observation 
so often that I feel no fear of the statement being contradicted. It 
is to Mr. Hunt that we are indebted for mdst of our real knowledge 
of the therapeutic effects of arsenic, a -debt which the profession 
seems in no particular hurry to acknowledge, although this gentle- 
man's discoveries are of infinitely more importance than whole 
chapters on the growth of cells and the development of fungi. 

When the tongue is much coated from the action of arsenic, it is 
well to suspend it occasionally and give a brisk saline, or to prescribe 
a dose of acid in bitter infusion occasionally before each meal. This 
is a point of great importance. With the assistance of these remedies 
it will often be quite easy to persevere in the arsenic, when without 
their aid the patient would most probably throw it up. 

But although arsenic will perhaps always effect some improvement, 
it cannot, in a certain percentage of cases, be relied on for a radical 
cure of lupus. It is, as I understand Mr. Hunt, a specific for the 
eating variety, but I have not found it such. So long as improve- 
ment goes on, however slowly, I would not interrupt the action of 
the medicine, as it will often, single-handed, cure lupus ; but so soon 
as ever the improvement comes to a halt, so soon as ever a sufficient 
time has elapsed to form a valid reason for believing that the remedy 
is doing no good, and still more so soon as ever there is even a 
threatening of relapsej the use of mercury should, I think, at once 
be resorted to. I know of no internal remedy which so quickly 
changes the action of lupus as calomel in purgative doses. The 
fact has been so often noticed by the patients themselves, that when 



2 70 Internal Treatment of Lupus. 

they have once taken mercury in this way they are often more 
anxious to continue or resume it than I am to prescribe it. They 
frequently volunteer the information that they have begun to mend 
" ever since they took the white powders," and not only do they 
feel better generally, but the sensation of heat, thickness and heavi- 
ness in the part, from which many suffer, begins to abate. One 
woman under my care for lupus of the nose told me that for two 
years previous to taking the powders, her nose, especially when she 
stooped, always felt three or four times as heavy as it did after the 
calomel had been given. Another patient, a young man who had 
suffered from lupus e^^edens for nine years, after taking calomel for 
rather less than three weeks, reported that the stiffness which he 
had felt almost from the first, was decidedly better. 

But there must be no mistake as to the mode of giving the calomel. 
Used as an alterative I never saw it do the least good; besides, 
when so employed it must, sooner or later, and often within a very 
short time, be abandoned on account of the soreness of mouth it 
brings on. // is therefore to be employed as a purgative. At first a 
small dose, as a grain for instance, may be given twice a week ; if 
the calomel be good, this will generally suffice for the first week or 
two. So soon as it begins to lose its effect, the quantity should be 
increased, and the action of the mercury be hastened by an aperient 
containing • magnesia ; half a teaspoonful to a teaspoonful of the 
heavy, calcined magnesia will generally answer very well, or a dose 
of saline mixture (p. 37), or one of salts and senna may be prescribed. 
Some persons are very easily acted on by a moderate dose of calomel ; 
others, some of them persons who cannot bear arsenic, seem almost 
insensible to its influence. I have had strong men under my care 
who could not take more than one or two grains. One man who 
did not suffer the slightest inconvenience from four hundred minims 
weekly of the arsenical solution never could get beyond two grains 
of calomel. Yet some delicate persons require from five to ten 
grains, and one woman who, by mistake, took a scruple weekly for 
more than a fortnight, not only suffered in no way, but said she felt 
all the better. Whatever quantity, however, may be necessary to 
act on the bowels, that quantity must be given. Purging is abso- 
lutely necessary — anything short of it I believe to be a mistake. 
Whatever incredulity the statement may elicit, I still think facts 
warrant me in saying that purging is one of the first elements of 
success. Two, three, or four loose stools should follow each dose. 



External Treatment of Lupus. 271 

The calomel may be given in the form of a powder or pill, as may 
be preferred. If given as a pill, any material likely to diminish the 
griping it is apt to occasion, such as aromatic or opium confection, 
may be added. With proper care there ought to be no action on 
the gums. Should any set in, the mercury must be given up, and 
only the magnesia or saline be prescribed till this symptom has 
passed off. To prevent all needless repetition, it may be said here 
that these directions hold strictly good with respect to giving calomel 
for lupus of the limbs, except that it is generally less often called for 
and for a shorter time. 

As lemon-juice seems to have succeeded very well in the hands 
of the late Mr. Weeden Cooke in the eating form of lupus, I would 
strongly recommend a trial of it, especially as it will not interfere 
with the action of any of the above-mentioned medicines. In my 
practice it proved of very little use. Dr. Wardell, of the Tunbridge 
Wells Infirn^ary, gave* the juice of three lemons daily in combination 
with carbolic acid, the result of which was an immediate improvement 
in one case and recovery in the other. 

External Means, — ^With very few exceptions, the external means 
•recommended in lupus are either useless or impracticable. For 
instance, soothing or cooling, antiphlogistic or alterative dressings, 
ointments and lotions I believe to be perfectly useless. Were they 
continued for a lifetime it is very doubtful if they would ever check 
the march of the ulceration. Again, all remedies strong enough to 
give severe pain, such as chloride of zinc, Vienna paste, Canquoin 
paste, are, and ever must be, inapplicable as a rule, for the simple 
reason, that however valuable they may be, a very large number of 
patients will never suffer them to be used ; others having once sub- 
mitted, will not allow a second trial to be made, and a third class 
will only consent when it is too late to prevent irremediable deformity. 
As to whether they effect a cure or not when they get fair play, that 
is beside the question ; the difficulty is getting them fair play ; and 
whatever may be said in their favour, I apprehend their use will 
always be restricted to a small proportion of cases, principally among 
patients not very susceptible of pain, or unusually resolute in bearing 
it, and not deterred by failure or relapse, for both will occur ; or 
when one solitary part is invaded by the disease. To a strong, 
healthy, resolute person it is perhaps not such a very serious matter 

• Lancet, 1870, Sept. 3. 



J 



272 External Treatment 0/ Lupus. 

to cauterize one or two ulcers, though that is bad enough. But 
when the disease extends over a large surface, when there are several 
ulcers, or when the patient is a child or very sensitive to pain, the 
suffering caused by powerful caustics is perfectly frightful, and must 
ever limit their use to a very narrow circle ; indeed, I have often 
found that merely painting a small patch with strong solution of 
nitrate of silver proved too much. When the patient can be placed 
under chloroform for a considerable time, much of the difficulty is of 
course done away, but I need scarcely comment on the difficulty of 
doing this in many instances. 

That lupus is occasionally arrested, and in a few rare cases cured 
by the free use of Vienna paste, chloride of zinc, nitric acid, iodized 
glycerine, nitrate of mercury, &c., I at once admit, because the fact 
has been stated on such excellent authority, though for my own part 
I have never been able to effect a cure with such remedies. I have 
destroyed all the disease, as I thought, three times in succession 
with chloride of zinc, and yet it has returned. Still worse, I have 
seen several cases of relapse after what must have appeared to the 
surgeon a perfect cure. Lupus is a very common disease, yet we 
find very few cures by such means recorded.* When we see such 
a long list of caustics, and such very vague statements about their 
real power over the complaint ; when an author tells us that chloride 
of zinc may be used, and should it fail then Vienna paste may be 
tried, or pite de Canquoin, or sulphate of zinc, &c. &c., it is enough 
to make one hesitate about taking their remedial power for granted, 
even in the hands of those accustomed to use them. Such phrases 
admit of almost any meaning we like to give. Were a writer to say 
that out of twenty cases of a particular kind of lupus in a certain 
stage, so many would very likely be cured if a particular caustic 
were used, we should be dealing with something that approached to 
tangible results, but many authors do not generally express them- 
selves so precisely as to let us grasp these points. If we attempt to 
grapple with their views, to extract from them some positive state- 
ment, they elude our hold as easily as the shade of Patroclus escaped 
from the clasp of Achilles. 

I believe that the principal value of external applications is 
restricted to excluding the air, and that these are the best caustics 
which effect this most certainly and with the least pain. Perhaps 

• '^tc^fCis^o Dublin Journal of Medical Science^ Sept. 1840, p. 98. 



External Treatment of Lupus. 273 

the nitrates achieve this result more certainly than any other means. 
When the patient can remain indoors, and does not care about the 
dark stains caused by it, the nitrate of silver may be used :♦ it is an 
excellent remedy, either solid or in saturated solution. In the lupus 
of children, however, even a weak solution can hardly be borne, and 
then it is a good plan to try and deaden sensibility by the use of a 
solution of sulphate of copper, three or four grains to an ounce of 
water. Dr. Purdon gives the patient chloroform, and then bores 
with the nitrate deep below the surface of the ulcer. This treatment 
seems to be very successful. The nitrate is also a favourite remedy 
with Hebra, Dr. Alexander Anderson, and others. The yellow nitrate 
of mercury may also be used in the form of ointment made with the 
oxygenated lard prepared by Mr. Squire ; it is chiefly adapted to 
those cases where there is only slight or superficial ulceration and to 
the lupoid form of sycosis ; it answers with those patients who cannot 
very well have anything applied which produces a visible mark. 
When employed in cold weather, it must be thinned down with a 
little almond or neat's-foot oil. 

Dr. Weisse states t that he has tried the acetate of zinc recom- 
mended in Dr. Neligan's treatise, and that he has found it a capital 
remedy in every form of lupus. He considers, that if carefully used 
it may be relied on to arrest and cure the ulcers without any other 
treatment, local or general, and he gives the particulars of a case 
which healed up under its influence after being open for thirteen 
years. His plan is simply to cleanse the part and apply a crystal of 
the salt. After reading Dr. Weisse's paper I tried the acetate freely in 
five cases, but though some temporary amendment took place, I did 
not effect a single cure ; the patients themselves, one and all, gave 
the preference to the acid nitrate of mercury. I not only used the 
crystals themselves, as recommended by Dr. Weisse, but had them 
rubbed down and made into a thick plasm with glycerine and 
bound on the part. 

When there is a large open surface the liquor plumbi may be 
used. The fluid should first of all be warmed by placing it over 
hot water, and so soon as it begins to smoke it should be painted 
several times over the surface. What is left had better be thrown 



* It was a favourite remedy with Rayex.— Theoretical and Pf-acticai Treatise, 
1835, p. 681. 
f American yaurnal 0/ Syphilograpky J vol. i. p. 316. 

2 N 



2 74 External Treatment of Lupus, 

away. It ought to be applied at least once daily, all crusts and 
exudations being previously removed, and if the patient think any 
relief is obtained from its more frequent use, then let it be used 
more frequently. I am indebted to some of my correspondents, 
especially Dr. Hinds of Birmingham, for information about its value, 
and the trials I have made dispose me to think favoiurably of it 

As a strong application perhaps scarcely anything excels the acid 
nitrate of mercury. It should be painted over the surface, previously 
cleansed, as far as is practicable, from all crusts, with a glass brush. 
At the outset it may be diluted with an equal bulk of water. When 
applied, a basin of water should always be at hand, and so soon as 
pain begins to be felt the surface should be freely washed. 

When the use of the acid is restricted to small surfaces and to 
patches in which the morbid action has been a good deal subdued, 
or which are healing, but so slowly as to justify a resort to any means 
which will hasten the process, it is often of great service. With 
proper care, the pain attending its employment is so trifling as to 
constitute no valid objection. The application should be repeated 
daily, both because the crust which is thus formed constitutes an 
almost impregnable barrier against the impact of the air, and also 
because the acid acts more painlessly than when only occasionally 
laid on. How it acts I do not profess to understand — ^possibly by 
coagulating the albumen in the epidermis or the blood. Subsequent 
applications I think superfluous, except in the eating form, when 
water dressing may be employed : the principal thing is to protect 
the surface from the air, especially cold raw east winds, under the 
malignant agency of which lupus will sometimes relapse in a few 
hours as much as has been gained in a week ; indeed, as far as 
possible I should say the patient ought to be confined to the house. 
Dr. Gilchrist of Torquay gave me the particulars of a case iu which 
a lupoid ulceration of the nose was cured apparently solely by 
excluding the air. In nictation of the septum of the nose Pereira 
recommends an ointment of the nitrate of bismuth, a drachm to an 
ounce of lard. Dr. Purdon mentions a case in which a cure was 
effected by this preparation after nitrate of silver, tannic acid, gly- 
cerine, &c., had all failed. I tried it in three cases, one of which 
I was very anxious to cure, but I cannot say that I observed any 
particular effect from the remedy. 

To my thinking, a lupoid surface should only be washed with 
very hot water, and the only soap which seems to agree is that made 



External Treatment of Lupus. 275 

for St John's Hospital. It is often very difficult to persuade patients 
suffering under this complaint to enter a bath of any kind ; the only 
plan is to substitute the free use of very hot water. My experience 
of cold baths and of river or sea bathing is most unsatisfactory ; of 
the value of exercise too during the cure of lupus I am far from 
being persuaded. It is quite certain that the disease will hold its 
course unchecked even when patients are breathing as pure air as 
can be found in England and taking active daily exercise, and I 
have been repeatedly struck with the improvement that has followed 
when a patient has been confined to the house, and by the persistent 
exasperation of the disease from going out daily even for an hour. 
One patient was under my care who always had an excellent reason 
for not doing what was prescribed. Although following a sedentary 
employment, he could always discover some incontrovertible ground 
for being out of doors. At last he scalded his foot very badly, and 
was obliged to lie by for a week or so, during which period his case 
made more progress than all the rest of the time he was under 
treatment — some three or four months. The fact is, a lupoid surface 
bears the action of the air almost as badly as do the walls of an 
abscess, and though, if one could at the same time cut off the air 
and yet allow the exercise, the latter would be most desirable, yet 
as this is almost impossible, the first consideration is, I think, to 
keep the parts guarded against irritants in whatever form they may 
come. 

Change of air and sea-bathing are often recommended in this 
complaint, as they would be for the results of overwork, anxiety, 
and confined air ; for mischief beginning in the brain, lingering relics 
of bronchitis, gout, &c. Yet lupus has nothing in common with any 
of these. It pursues its relentless course with equal severity on open 
places and in crowded alleys ; among the humid, dripping hills of 
Cumberland and in the bracing air of the east coast; in the dry, bright 
climate of France and the perpetual drizzle of Ireland or West 
Scotland ; and often rages with greater severity in the place the 
patient is sent to than in that which he has just left. Under such 
circumstances only a very sanguine mind could look for benefit. 
Amelioration, it is true, sometimes follows change of air, but so 
does a very decided relapse, and the circumstances which may 
determine either have not been so far elucidated as to enable us to 
say more than that it is a hazardous step. Change of air and scene 
may certainly do away with some of the sameness that always attends 



2 76 Diet 

a long and tedious complaint, but it is rarely that this compen- 
sates for the arrest of all progress. I therefore do not advise 
change. 

I am well aware that a widely different opinion is held by some 
writers. Dr. Copland, for instance, looked upon good food, wine, 
beer, and pure mild air as indispensable. Such things may be very 
serviceable, not only for the health but for the local disorder, though 
I have never seen any benefit from them myself, and I am quite at 
a loss to know where a pure mild dry air is to be found in England, 
and how patients, especially those at hospitals, are to take advantage 
of it if it were attainable. Possibly a long sea voyage might be of 
service in some cases, as Dr. Frazer has remarked that lupus is rare 
among sailors. 

Diet, — This ought to be good, and essentially the same as in 
eczema. Too much meat, strong soup, and, indeed, any kind of 
high feeding is always injurious, overtaxing the powers of digestion 
without aiding the nutrition, — a mistake particularly to be guarded 
against while taking tonics. Malt liquors are to be avoided- Riun- 
and-milk is a most useful form of stimulant Young persons may 
begin with two teaspoonfuls of rum and eight or ten of milk, and the 
dose may be gradually increased to four times this amount Grown 
persons can begin with two tablespoonfuls of rum and eight or ten 
of milk, gradually increasing the former, but never going beyond half 
a pint of milk. I often give quite five or six tablespoonfuls of this 
spirit daily, and in one of the worst cases of lupus I ever saw, where 
the patient seemed sinking from exhaustion, I prescribed a quarter 
of a bottle of rum daily, and a capital medicine it proved. Some- 
times it causes a little headache at the first, but this soon passes off, 
and therefore does not constitute a reason for abandoning the 
medicine. 

When we analyze the treatment adopted by the most successfiil 
practitioners, we find that mercury, iodine, and arsenic enter more 
or less into the prescriptions of all. Mr. Hunt has* almost un- 
bounded faith in the virtues of arsenic against the eating form of 
lupus (L. exedens). He speaks of one case of twenty-four years' 
standing checked in two months by the use of this mineral, and of 
another of six years' duration which also yielded. In the creeping 
form the remedy was less efficacious ; out of seven cases not one 

♦ Medical T'unes and Gazette^ ^^85 1, voL i. p. 120. 



Dr. Thompson's Treatment, 277 

was quite cured. Dr. Willshire speaks* of superficial lupus which 
had lasted fourteen years, getting rapidly and thoroughly well under 
the use of arsenic and cod-liver oil, results which I have never seen 
from such remedies. Mr. Startin relies+ on small and long-continued 
doses of mercury, either in the shape of calomel and opium, or the 
mercury mixture recommended by him ; he also gives cod-liver oil. 
In the paper describing this treatment an attempt is made to explain 
the great success of mercury in this complaint, by supposing ihere 
may have been a syphilitic taint, a point on which I have already 
spoken. Dr. Anthony Todd Thompson, who used to be very 
successful in the treatment of lupus, relied upon iodine, arsenic, and 
biniodide of mercury, with the occasional use of cod-liver oil and 
quinine. When he began the treatment, if there was anaemia, he 
gave the patient cod-liver oil for ten or fourteen days, with iodide of 
iron; he then ordered an alterative treatment with biniodide of 
arsenic, and when this could not be borne he gave the liquor 
potassae arsenitis. He found conium very useful, and often touched 
the edges of the ulcers with nitric acid or a solution of nitrate of 
silver, two or three drachms to the ounce. If pale, unhealthy, 
fungous granulations shot up, he employed ointment of the iodide 
of sulphur, or a very weak ointment of the biniodide of arsenic or of 
either of the iodides of mercury. Four cases of the eating form of 
lupus are recorded in his workj in which the above treatment was 
adopted with perfect success. Two of these were indeed cured 
very quickly, one in twenty-eight, the other in thirty-four days ; and 
though only one is reported cured at the end of half a year, yet, as 
the mean time is only eighty days in each case, the treatment must 
be regarded as unusually successful ; indeed I do not understand 
lupus being even affected by internal means in four weeks. 

These cases afford as strong evidence as I could wish to bring 
forward of the difficulty there is in getting at exact facts in such 
matters. Dr. Thompson's practice would naturally afford many 
instances of lupus j he was a successful practitioner, and an earnest, 
truthful man ; not less so his editor Dr. Parkes ; yet all we have to 
guide us is a brief analysis of four cases, none of them of any great 



* Lancety 1 859, vol. ii. p. 186. 
+ Medical Times and Gazette, 1858, vol. ii. p. 237. 

J Monthly Journal^ ¥Q\>iVL3^xy, 1849. Also Braithwaite's Retrospect, vol. xxL 
p. 189. 



278 Dr. Copland's Treatment. 

severity or calculated to give any idea of the usual proportion of 
cures to failures, the only statistical results worth knowing. Till we 
have evidence of this kind, men will always be able to draw from our 
written records almost any meaning they like^ and gloom, hope, or 
despair will predominate according to the convictions of the reader 
rather than the facts of the case. 

Dr. Copland enumerates* the oil of Dippel, arsenic, mercury, and 
iodine, as if they were the remedies to be preferred, and quotes the 
testimony of Byron, Graves, Carmichael, and others in favour of 
Donovan's solution, even in cases which had withstood iodine, 
arsenic, and mercury, when separately or otherwise employed than 
in the form of an iodide of arsenic and mercury. I believe, however, 
that some of our most experienced practitioners are agreed that 
Donovan's solution is not in any way to be relied on ; in my hands 
it quite failed; besides, it contains fixed proportions of the salts of 
which it is composed, and lastly. Dr. Frazer says that it keeps 
indifferently and is difficult to make. 

The late Mr. Weeden Cooke cured a case t with lemon-juice 
internally, using at the same time a lotion of the bichloride of mer- 
cury, a grain to an ounce of water, and zinc ointment. The 
ulceration had destroyed the columna nasi and threatened the alae, 
it extended up to the inner canthus of both eyes; yet it was 
effectually checked by the use of an ounce and a half of lemon- 
juice daily. Mr. Cooke subsequently informed me that the patient 
remained cured, and that he attributed much of the improvement to 
the lemon-juice. Since then 1 have used this remedy in several 
cases, just as Mr. Cooke prescribed it, getting the lemons fresh 
every day from Covent Garden, but I regret to say with very little 
avail ; certainly I never was able to cure a case with it. Barium 
seems to be useful in the creeping form ; Bateman saw the muriate 
very materially amend the complaint, and Dr. Frazer mentions that 
this salt, given in doses of one-sixteenth of a grain three times a day, 
produced good results. He kindly sent me the particulars of a case 
in which the use of it checked the spreading in a bad case of lupus 
of the knee which threatened to open the joint. The external 
application used in this case was a strong solution of nitrate of 
copper. He also thinks a weak coat of carbolic acid to cover the 

* Dictionary of Practical Medicine^ vol. ii. p. 792. 
t Lancet^ 1859, vol. ii. p. 662. , 



Caustics in Lupus. 279 

surface of the ulcer is useful. Simon, of Hamburg, relates* a bad 
case which was cured by mercurial inunction. 

In the erythematous form we are recommended to paint the part 
night and morning with liquor plumbi ; strong iodide of lead oint- 
ment, two parts of the salt to one of lard, has also been favourably 
spoken of. In the Boston Medical and Surgical Review f it was 
stated that this form of lupus always yields to the application of 
iod-glycerin in a concentrated form. J The use of iodide of ammonium 
has also been suggested. The dose is two to three grains twice or 
thrice a day ; for external use a drachm is dissolved in an ounce of 
glycerine, the solution being brushed over the part night and morn- 
ing. Another remedy said to be very deserving of notice is the 
phosphate of lime ; it may be given in the form of the s)nnip of the 
superphosphate, or it may be obtained by burning bones, such as 
the ribs of mutton, and then rubbing them down in a mortar \ half a 
drachm or more may be given two or three times a day. § 

Mr. Hunt says that the practice of using caustics in lupus is not 
only barbarous but useless, || and M. Rayer distinctly says that what- 
ever caustic may be used it must always be repeated, often twenty 
or thirty times. Dr. Parkes, a most able and careful observer, 
entertains If a very indifferent opinion of their value. It is true that 
views utterly opposed to these have been held by very good surgeons. 
Mr. Liston, for instance, thought that local treatment was alone to 
be depended on, and used the chloride of zinc unsparingly. Mr. 
Gay, too,** has seen the best results from the use of the pemitrate 
of mercury. Professor Bennett seems to entertain a similar view. 
M. Cazenave thinks there is nothing like the biniodide of mercury 
suspended in oil, but he admits that its action is very painful. Pro- 
fessor Hardy also clings to the biniodide. Dr. Hillier eulogizes the 
iodide of starch recommended by Mr. Marshall ; he says its use is 

* Ricord's Lehre von der Syphilis^ zweiter Theil, S. 62. 

t July 30, 1863. 

J The formula for this is : — 

R. Potass, iodidi, 

lodinii, aa 5j. 

Glyceringe fl. 5j. x\ 
§ Treatment of Diseases of the Skin, By Dr. W. Frazer. 
II A Guide to the Treatment of Diseases of the Skin, 1857. 
IT A Practical Treatise on Diseases affecting the Skin, By the late A. S. 
Thomson. 1850. 
•• British Medical Journal^ i860, Jan. 18. 



almost anaccampaned by pain. Dn Fsusr asnrs that w baievcx 
medidiie be ^en. loczl nestmeit is smL at jiiiuar y impanance. 
Dr. P:xnioii rnnsideri chzDmic ifid, gc rca ro ^. of wotez: wd 
adapted to Inpas. as it penernnes ie^iv. does net apnad. omsmns 
little pain, and bzni§5 an aniy slight reacnan. Mh Lymu of West- 
minster EEospitaL tziid me that he had yen die acstaie <3£ copper 
J3sed m oinnnenr with great inrrrgL E^ Hhwfe at Riiii i iiit^haut . in 
a comnmnication he was ^ood enan^ to acvaar me with, spesiks 
hi^v of die lienor pimnhi nfar?v Trnifrlntgd ; he irisisib on die 
M«^ fe remoViiHE aa the crosts ':«ui (fisdmi^ b^ffiie as^ 

Dr. Danzei of Hamborg Looks * on soinrfon of hydrochlonde of 
gold as more powerfoL and Less painml dian adusr remedfei : sdU it 
is dear, finm what he says* that its opaation is most severe. He 
uses a solntion of half a scrapie to a scrapie in. a dnrhm of disdlled 
water, and woria it deep mto the bed of the nicer by means c^ x 
fish-4Mne or glass style. Hehra relies ^ on the solid TiTiratP oi alver, 
freely applied, and iodized glycerine, the latter being principally 
employed m the erydiematons form. Cod-liver oil is ahnost hcs 
sole internal remedy. Dr. Moriz Kohn recommoids emplastnmi 
hydrargyh in erydiematons hcpos ; a piece of lint is spread wtdi it 
and applied every twenty-fenr hours. Dr. M*CaII Anderson finds 
die acetate of soda, recommended by Drs. Weisse and Sattedee^ 
nsefiil in L. erodens, as also in stnnnoos diseases; bat he uses it 
twenty grains to an onnce, and they only advise eight grains^ The 
sohitioa is well qxmged on the part. Professor Thiry cnres hipos 
vorax in a month by caoterizing every ten days widi aod nitrate of 
meraxry, dien nibbing in over the swollen parts mercnrial ointment 
double die osnal strength, and covering the whole with a bread 
pocdnce. He also gives calomel in grain and halfgrain doses fireely,, 
foUowiz^ it trp with ntrate of magnesia. 

B. Scrofuloder'jca (tf, atasj neat), from scrofula (Cds^ this again 
being derived from savf€L, an old sow, thi^e bdng from the 
eaiiiest times a nodon that pigs were subject to scrofula), and 
cspfio, a skin, hide. 

D^im/um. — ^Superficial ulceration of the skin occurring in scrofulous 
subjects. May be complicated with glandular swellings (especially 

* DuS/in Medkal Press, March 21, 1S64. 
t Wiener Sfital Ziitting, i860. No. 6. 



Caustics in Lupus. 279 

surface of the ulcer is useful. Simon, of Hamburg, relates* a bad 
case which was cured by mercurial inunction. 

In the erythematous form we are recommended to paint the part 
night and morning with liquor plumbi ; strong iodide of lead oint- 
ment, two parts of the salt to one of lard, has also been favourably 
spoken of. In the Boston Medical and Surgical Review \ it was 
stated that this form of lupus always yields to the application of 
iod-glycerin in a concentrated form. J The use of iodide of ammonium 
has also been suggested. The dose is two to three grains twice or 
thrice a day ; for external use a drachm is dissolved in an ounce of 
glycerine, the solution being brushed over the part night and morn- 
ing. Another remedy said to be very deserving of notice is the 
phosphate of lime ; it may be given in the form of the S)nnip of the 
superphosphate, or it may be obtained by burning bones, such as 
the ribs of mutton, and then rubbing them down in a mortar ; half a 
drachm or more may be given two or three times a day. § 

Mr. Hunt says that the practice of using caustics in lupus is not 
only barbarous but useless, H and M. Rayer distinctly says that what- 
ever caustic may be used it must always be repeated, often twenty 
or thirty times. Dr. Parkes, a most able and careful observer, 
entertains If a very indifferent opinion of their value. It is true that 
views utterly opposed to these have been held by very good surgeons. 
Mr. Liston, for instance, thought that local treatment was alone to 
be depended on, and used the chloride of zinc unsparingly. Mr. 
Gay, too,** has seen the best results from the use of the pemitrate 
of mercury. Professor Bennett seems to entertain a similar view. 
M. Cazenave thinks there is nothing like the biniodide of mercury 
suspended in oil, but he admits that its action is very painful. Pro- 
fessor Hardy also clings to the biniodide. Dr. Hillier eulogizes the 
iodide of starch recommended by Mr. Marshall ; he says its use is 

* Ricord's Lehre von der Syphilis^ zweiter Theil, S. 62. 

t July 30, 1863. 

J The formula for this is : — 

R. Potass, iodidi, 

lodinii, aa 5j. 

Glycerinae fl. 53* ^ 
§ Treatment of Diseases of the Skin. By Dr. W. Frazer. 
II A Guide to the Treatment of Diseases of the Skin. 1857. 
IT A Practical Treatise on Diseases affecting the Skin. By the late A. S. 
Thomson. 1850. 

•• British Medical Journal, i860, Jan. 18. 



282 Treatment of Scrofulorderma. 

jand thus do good for a time ; but, so far as I can judge, they do 
not cure the disease, for the simple reason that they do not possess 
any property necessary for effecting such a purpose. Moreover, 
their control over even such symptoms is more limited here than 
might be supposed ; quinine and cinchona are very apt to disturb 
the digestion, produce headache, nausea, and intolerable dislike for 
them. Again, steel, which is so useful in some forms of common 
anaemia, seems to have little if any power of increasing the propor- 
tion of blood-globules in the scrofulous. ' Over and over again I 
have, after a long course of it, seen either no change at all in the 
anaemia, or a very slight and transitory one ; certainly nothing that 
I should think atoned for inflicting so much discipline on the child 
and so much expense on the parents. Strengthening diet in my 
hands never yielded any result corresponding to the impression the 
term naturally awakens in the mind ; this was also the case with cod- 
liver oil accompanied by tonics. At one time I gave Lugol's method 
of employing iodine a very fair trial, but nothing save disappointment 
came of it. 

As scrofulo-derma tends almost certainly to get well of itself 
sooner or later, it is easy to understand how it happens that it also 
gets well under treatment of every kind. But if this be the real 
explanation of the disparity between the results which I have seen 
and those noticed by others, then a stronger proof in its way of the 
necessity for reforming oui: system of observation could hardly have 
been found ; seeing that the progress of a disease under the influence of 
remedies really capable of curing^ or even affecting ity is a widely 
different process from such hit-or-miss work as an occasional coincidena 
of events. 

The only remedies from which I have ever seen the slightest 
benefit in this disease are purgatives, and from the use of these I 
have often witnessed the best results — not that I mean to extol them 
as a means of cure, but because the judicious employment of them 
rarely fails to do some good, and in a great many instances brings 
about a rapid and permanent closing of the ulcerations, with an 
unmistakable improvement of the health. Several surgeons, who 
have noticed these facts at St John's Hospital, have expressed their 
wonder at the rapidity with which amelioration followed the use of 
these remedies. 

What are the best purgatives I am not prepared to say. The 
subject requires, to my thinking, far too full and prolonged an 



Treatment of Scrofulo'derma. 283 

investigation to admit of its being decided out of hand by any one 
person. I believe that nothing answers better than rhubarb, or jalap, 
and mercury at night, and a dose of black draught in the morning. 
The worst of these medicines is that they induce so much repugnance 
as to make their continuance, especially with children, a very difficult 
matter. Consequently we have often to take refuge in more tasteless 
but, perhaps, less efficacious remedies, such as simple giey powder 
or calomel, followed by effervescing citrate of magnesia, and so on. 
Along with these the acid solution of iron (p. 37) may be occasionally 
given once or twice a day during this course of treatment, but not in 
any way as a substitute for these remedies, unless other reasons 
should absolutely compel their discontinuance. The purgatives should 
be given quite twice or thrice a week, and, unless any soreness of 
the gums set in, should be persevered in steadily. While purgatives 
are being taken, and especially when the patient is underfed, De 
Jongh's cod-liver oil may be given ; but the reader must not expect 
even from this valuable preparation the same benefit that might 
ensue in some other diseases. 

The one remedy excepted from the list of those which I have 
tried is injection under the skin, strongly recommended by Dr. 
Purdon. I regret to say that I have not as yet been able, after many 
trials, to induce a single patient to submit to it. Dr. Purdon injects 
swellings threatening to ulcerate with pepsine or tincture of iodine, 
four to eight minims, using an ordinary hypo-dermic s)ainge. 

The most valuable topical application that I have seen tried in 
this disease is the acid nitrate of mercury, applied so as to give the 
least possible pain. With scarcely an exception, all the ointments, 
lotions, dressings (such as oiled silk, spongio-piline, &c.) which I 
have ever used or seen used, are, according to my judgment, worse 
than useless ; inasmuch as, while they do no good, they cause 
expense, trouble, and filth. The diet cannot be too plain. Plenty 
of bread made with Chapman's wheat flour, and pure milk, a very 
moderate amount of light meat not more than once a day, fat ham 
or bacon daily, well-boiled vegetables, red wine, and a fair amount 
of fiiiit, will, unless I have deceived myself, do all that diet can do. 
Such patients should be as much in the open air as possible, without 
being exposed to more fatigue than necessary. For those who must 
toil to live, outdoor employment should be selected, however delicate 
the patient may be. As to bathing, a hot bath once or twice a week 
for four or five minutes will do all that the most elaborate system 



284 Leprosy. 

can effect. Bathing in the sea will do good, perhaps, in one case 
out of ten ; iodine baths, both local and general, did not seem to me 
of any service in the two or three cases where I saw them tried. For 
general washing only very hot water should be employed. Mineral 
baths and waters of every variety to which credulity has yet opened 
its ears, are here, as in only too many other diseases, of no more use 
than charms and spells. Change of air is occasionally beneficial, 
though much less so than might be imagined, and seems clearly due 
to the change, not to the superior quality of the air to which the 
patient removes. I have seen scrofulo-derma in quite as severe and 
obstinate a form among the natives of our mountain districts, as, for 
instance, in many parts of Cumberland, and our sea-coasts, as in 
the crowded and foetid alleys of London; and I have been informed 
that it exists to a fearful extent in Guernsey, which is swept by sea 
air the whole year through ; the fact, I suppose, being that where 
the laws of health, sense, and consanguinity are violated, there we 
shall find the disease. 

C. Leprosy {Elephantiasis GrcBCorum), Elephantiasis (is, fem.), 

i\e(l>avTia(rig, from eXifag, an elephant 

Definition, — A slow eruption, often preceded by distinct attacks 
of pyrexia, of large, red tubercles, accompanied by permanent dis- 
coloration, also total loss of sensibility in certain parts of the skin, 
falling of the eyebrows, thickening of the nostrils and ears, hoarse- 
ness, wasting of the muscular tissue, and peculiar destruction of 
certain bones of the extremities ; occasionally impaired sense of 
smell and taste, loss of power of the retina, intolerance of sound 
and light. 

Dr. Newton describes,* among the characteristic s)anptoms, pain 
between the ankles and knees, universal change in the texture of 
the skin, which becomes thick, harsh, dry, and homy. He totally 
doubts the fact of interstitial absorption of bone taking place, having 
in every case detected a cicatrix, through which the carious bone 
had escaped. Latent pain, elicited only by pressure, in the nose, 
ears, larynx, and costal cartilages, tendons of wrists and legs, or 
some of the thoracic or abdominal viscera, is peculiarly characteristic 
of leprosy. 

* Aiuesthetic Leprosy^ with especial reference to its Diagnosis and Treatment in 
certain Stages. 



Report on Leprosy 285 

Divisions. — i. L. ansesthetica, principally marked by gradually 
increasing, and ultimately total loss of sensibility in the part affected. 
2. L. tuberculosa, in which the tendency to form tubercles pre- 
dominates. 

The report on this fearful disease issued by the College of Phy- 
sicians contains, with the appendix and extracts, pretty nearly all 
that is known on the subject; and I therefore proceed to give a 
careful (though brief) digest of this work, which, as regards the prac- 
tical value of its contents, is an honour to the men who compiled it 

And yet, I suppose this report, bearing so many famous signatures, 
and issuing from the press of Her Majest/s printers, is the worst- 
written book in existence. Irrespective of many confused expres- 
sions it contains quite two hundred unpardonably bad errors. A 
singular verb is constantly made to agree with a plural nominative, 
and, possibly with a view to strict impartiality, a singular nominative 
is over and over again yoked to a verb in the plural. The verb is 
sometimes made to agree with the apposition of the nominative 
instead of with the nominative itself, and is now and then entirely 
omitted from a sentence, its place being supplied by a present 
participle. Sometimes an incomplete sentence is made the nomina- 
tive to the verb ; sometimes part of a sentence is clipped off as an 
incumbrance. Occasionally an adjective belonging to the ampu- 
tated or forgotten member of a sentence is, by an unnatiu"al opera- 
tion, made to adhere to the stump. A case is repeatedly spoken of 
as if it were a human being ; definite articles and apostrophes are 
every now and then omitted without any reason, and the generally 
admitted dependence of the subjunctive mood upon certain con- 
junctions is entirely ignored by some of the writers, who possibly 
esteem it an old-fashioned prejudice. 

I do not know who is responsible for such errors as goiter, 
sclOTOtic, livl/hood, dysentry, affections, lin^xment, iodide of potass^, 
albin^/sm, dependd^nt, ble«:hed, djsseous, ca/aplasms, tend^bly pain- 
ful, a papulae, squam-^j-df, flexions for flexors, had for add, cutaneous 
for simultaneous, "there inciu-ability," "the Dr. Storell," "being 
being ; " or for passing over such mistakes as classing strophulus 
among the pustular and vesicular affections, describing a man as the 
son of his father, a town as a stone wall structure divided into six 
rooms, and a disease as extending outwardly from the small toes ; or 
for retaining such expressions as too much of fish, healthy offsprings, 
a refractory cells of wood, &c. ; but I do know that such faults are 



286 Unity of Leprosy. 

utterly inexcusable, and that had they appeared in a memoir issuing 
from a special hospital, we should have heard plenty of abuse 
of them. 

It seems now established beyond challenge that leprosy is always 
one and the same disease, and that there are two and only two 
divisions or varieties — the tubercular or superficial, and the anaesthetic 
or deeper seated, lepra mutilans. There may be any grade of severity 
of either ; the morbid appearances may in one person be restricted 
to a very small surface, and in another invade the whole firame. 
They may exist separately, or both may assail the same patient. In 
one case one set of symptoms may take precedence in point of time 
or severity ; in another the order may be reversed ; but amidst all 
complications of this kind the absolute identity of the two forms can 
be clearly seen. All varieties beyond these two, even comprising 
the eighteen described by the intelligent native doctor of Jhallawar, 
spoken of in the report, are either unnecessary subdivisions, or 
they are diseases which have been confounded with true leprosy, 
such as lepra vulgaris, lepra nigricans, s)rphilis, to which indeed it 
bears at times a very strong resemblance, struma, boucnemia, 
Aleppo boil, eczema, and impetigo, one or more of which may be 
confounded with it. It is not an oflfspring of yaws, syphilis, or 
struma, though possibly in some cases the symptoms of leprosy are 
aggravated by the presence of one of these diseases. The tubercular 
form of leprosy seems the most common, except in East India, 
where the anaesthetic variety is thought to be more prevalent ; but 
the relative proportions of the two diseases are differently given by 
different persons, one gentleman computing the number of anaesthetic 
cases at one-fourth of the whole, while another merely states that 
the tubercular variety is the more frequent. 

Dr. Carter, who is an authority, speaks in the report* very briefly 
of a disease called the white leprosy, which he says is probably a 
variety of the leuke of the Greeks. I presume, therefore, that it is 
distinct from true leprosy as well as from lepra vulgaris. Possibly 
the scaly brightness of the skin spoken of in some of the answers 
may refer to one of these two affections ; which it may be I am 
unable to determine. Dr. Bell says t that white leprosy strongly 
resembles, not that it is identical with, lepra vulgaris. It is very 
much like the affection described under the name of vitiligo, and yet 

* Page xvi. t Ibid. 



Nature of Leprosy. 287 

bears a strong resemblance to lepra. It is known as " barras," and, 
as described by Mr. Bose, appears to be identical with the berat 
lebena of the Arabs ; sensibility is not affected in it, neither is it in 
the dusky lepra (berat cecha of the Arabs). Both these affections 
may co-exist with either form of leprosy. The general opinion, 
however, is that in berat cecha the centre of the patch at any rate 
loses its sensibility, and that in the other form, which is a variety of 
leuke, the whole patch becomes insensible. 

Nature of Leprosy, — ^As to whether leprosy is hereditary or not 
we find every shade of opinion. Some writers maintain that it is 
decidedly so. Dr. Day, who seems to have taken great pains with 
his cases, sa)rs in the report, that in twenty-seven cases out of forty- 
six there was no evidence of hereditary transmission. Dr. Porteous 
found none in twenty-nine cases out of thirty-one. Another writer 
sets down the per-centage of hereditary cases at only fourteen ; the 
answer from Loodiana is that out of nineteen cases not one appeared 
to be hereditary, while Furreedpoor is represented by a third form of 
conclusion, the numbers being pretty evenly balanced. Out of two 
hundred and fifty-five patients examined in the Batavia Hospital, 
Surinam, in 1857, only twenty-four were of leprous parentage. Dr. 
Davidson, who evidently believed firmly in the hereditary nature of 
the disease, is yet driven to admit* that in sixteen cases he could 
not discover ^any traces of such a cause. If, however, the question 
be made to depend on the number of votes, it must be decided in 
favour of the view that it is hereditary, an opinion to which the 
majority will incline when the point can be raised at all. It ever 
has been, and probably ever will be thus. Owing to our defective 
powers of reasoning and observation, conclusions are adopted rather 
because they tally with deep-rooted convictions than because they 
are forced on the mind by a strictly critical examination of the facts 
of the case. It must be obvious to any one possessed of the power 
of observing at all, that it suffices to say a disease is hereditary to 
convince any number of hearers that such is certainly the fact No 
evidence is required beyond the statement of the speaker that he has 
observed it to be so, and is satisfied that the disease is of this nature. 
In fact, that disease is often hereditary seems, if not an innate idea, 
one of the forms of thought into which the mind will run. 

* An Account of Tubercular Leprosy in the hland of Madagascar^ Edinburgh 
Medical Journal, 1864, p. 39. 




288 Nature of Leprosy. 

It is scarcely very reassuring for medicine when we find different 
observers, with ahnost the same facts before their eyes, arriving at 
such diflferent opinions as are contained in this report. But so it is, 
and probably ever will be. Had the number of answers been 
multiplied ten or a hundredfold, the proportion of believers in 
heredity and contagion to that of unbelievers would have remained 
unaffected ; a fact possibly, nay probably, due to the operation of 
some great unknown law, which regulates the distribution into groups 
of different forms of physical and, as a necessary result, brain con- 
struction. That some law of this kind is in operation we have 
every reason to believe. If we were to take a hundred or a hundred 
thousand men, we should find in each a relative proportion who held 
particular opinions on all matters — ^religion, politics, medicine, &c, 
just as surely as we should find a certain number prone to eczema, 
gout, and consumption, or any other disease. 

Leprosy is probably hereditary in so far that a leprous child is 
sometimes bom of parents similarly affected, and that one or other 
of those parents (themselves perhaps healthy) is again descended 
from a leper. Such evidence there undoubtedly is; and in the nature 
of things ever must be, and such proofs will always be triumphantiy 
adduced irrespective of any amount of negative evidence. The facts 
which establish a theory or strike the imagination are caught at and 
accepted; somehow they always come to the fi-ont; while those 
which would make shipwreck of the hypothesis are apt, with all 
possible good faith on the part of the reasoner, to rest in obscurity. 
But then this is just what happens in ordinary life ; a fortune made 
by a bold stroke fascinates the imagination ; the thousand victims of 
unfortunate speculation sink unheeded. There were votive tablets 
enough hung up in the temple of Poseidon in memory of those who 
had been saved from shipwreck, but there was not one to tell of the 
myriads that had perished. 

There is a certain amount of evidence that leprosy is contagious. 
The number of those, however, who believe in its contagious power 
is small compared to those who deny it The report states* that, 
out of sixty-six answers, only nine speak of it as contagious, while 
forty-five represent it as non-contagious, and twelve are silent on the 
subject. The mode in which it is supposed contagion may be con- 
veyed is a moot point. Some authorities look upon inoculation as 

• P. vii. 



Nature of Leprosy. 289 

an indispensable step. Mr. Macnamara, who published a very able 
report on leprosy in the Indian Medical Gazette (1866), considers it 
necessary " that the discharge from leprous sores should enter the 
blood of the healthy person," a mode of propagating the disease not 
at all likely to happen among Europeans. The once prevalent 
belief that leprosy matured and spread through Europe by the 
medium of contagion derived from the returned crusaders and 
pilgrims is entirely negatived by facts. Leprosy was known in 
Ireland as early as the beginning of the sixth century, if not much 
earlier ; ♦ while in Great Britain a law existed as far back as the tenth 
century, by virtue of which a woman could obtain a separation from 
her husband if he were found to be afflicted with this disease. 

Yet the arguments of the contagionists have wrought conviction 
among some observers here. They consider it proved that, though 
people may with impunity live in the same house with a leper, yet 
that the discharge has in some cases conveyed the disease. In other 
cases leprosy appears to have resulted from connexion,t and Dr. 
Pollard, who looks upon leprosy as contagious in every stage and 
form, mentions the case of a family who permitted their children to 
play with a leprous negro boy, in consequence of which they one and 
all became infected, and the majority of them fell victims to their 
fatal indiscretion. A rather strange statement, and certainly in con- 
flict with all other testimony. Were leprosy so direly contagious as 
this, it would be easy to accumulate irrefragable proofs in support 
of the doctrine, whereas the evidence proving it to be so is very 
doubtfril, while it is as certain as anything can be that people remain 
for years exposed to contagion in every form without being affected. 
Dr. Drognat Landr^ goes % quite as far as Dr. Pollard ; he main- 
tains that the disease is propagated exclusively by contagion. 

Leprosy is said to be increasing in the Sandwich Islands, the 
Windward Islands, the "out-islands" of the Bahamas, Guiana, 
Jamaica, Demerara, Mitylene, Ceylon, Singapore, Penang, Molucca, 
Mauritius, and the Bombay Presidency ; to be on the decrease in 
Sweden, Ireland, Italy, Trinidad (some writers, however, think it is 



* "A monastery appears to have been erected here (Swords) as early as the 
year 512 by the famous saint Columbkill, who appointed St Finian Lobhair, or 
the Leper, as its abbot."— /r^/am/. By Mr. and Mrs. S. C. Hall, voL ii. p. 346. 

t Report, pp. xliv. and xlv. 

X De la Contemn, settle Cause de la Propagation de la Lepra, Paris, 1869. 

2 P 



290 Nature of Lepro^. 

stationary here), and Smyrna; and stationary in Norway, New 
Brunswick, Barbadoes, Tobago, Scio, and the Madras Presidency. 

The fading away of this strange malady out of our land, and, 
indeed, out of great part of central and western Europe, is one of 
the most mysterious events in the history of medicine. A mortal, 
hopeless sickness, such a source of terror that bulls were issued and 
an order of knighthood was founded to stay its ravages,* which 
made the face like that of a satyr, and led men to think that the 
blood of those afflicted with it must be as sluggish and full of corrup- 
tion as some lethal muddy ditch ; which invaded all parts of the 
frame, and so transformed its victims that men recoiled in horror 
from them, and gave them up like maniacs to the filth, chains, and 
horrors of leper-houses, or drove them away like wild beasts to dwell 
in tombs or caverns, and to lie at the gateways or by the roadsides; 
the scourge of the most powerful and civilized nations, which on one 
side projected its fearful and lurid shadow from Syria to the Atlantic 
and North Sea, and on the other stretched lowering over Asia to the 
banks of the Ganges and Indus ; which raged with equal fury among 
the sandy plains of Asia Minor or the mud-covered fields of Egypt, 
amid the smiling fertility of Sicily, and on the desolate coasts of Ice- 
land ; has, over a considerable part of our continent, collapsed like 
the geni when wiled by the fisherman to re-enter the casket, and has 
become a wonder and a show in the lands where once kings and 
statesmen legislated for its myriads of victims. Now and then a 
fellow countryman, who has contracted the disease abroad, comes 
back to die of it at home, or a colonist sends his child attacked by 
it to see what english skill can do for it ; and occasionally a person 
who has never been out of England may be seen suffering under 
either variety, but to a limited extent, and in quite a local form. 
Thus the anaesthetic kind has been met with in this state in several 
instances, and even the tubercular form is not unknown. A case is 
mentioned in Guy's Hospital Reports.t The patient had lived for 
twenty-four years in Ireland, then came to England, and had never 
been abroad when attacked by the disease. The symptoms were, 
however, very slight compared with those generally seen in its 
favourite haunts. In the third volimie of the Journal of Cutaneous 

♦ See a most interesting paper by the Rev. J. F. S. Gordon, Journal tf 
Cutaneous Medicine^ vol. iv. p. 207. 
t Third Series, vol. v. p. 151. 



Causes of Leprosy. 291 

Medicine^ I reported three cases of L. mutilans seen in Germany by 
Dr. Steudner, of Halle. And traces like these are now pretty well all 
that we see of the disease in lands once swarming with leper-houses ! 
Causes. — It is, perhaps, rather a waste of time to speculate on the 
reasons why leprosy has ceased to scourge western Europe, and the 
real causes of its occurrence at all. Still the accumulation of facts 
and the suggesting of paths by which investigation might be pursued 
are always legitimate objects of research, however hopeless the goal 
may seem. Possibly, then, climate may have had something to do 
with this great fact ; changes in the electricity, habits, and food may 
also have had their share of influence. There seems historical proof 
enough that climate has altered materially over a great part of 
Europe, owing to the draining of great bogs and small lakes, the 
felling of forests, and in some places the upheaval of the land ; all 
over England the rainfall seems decreasing, perhaps owing to the 
decrease in the evaporating surface. For quite a century the winters 
here have on an average been getting colder and the summers hotter. 
A hundred years ago men chronicled a heat of 78° or 80° in the shade 
as something wonderful 5 in 1868 a temperature of 94°, 96°, and 98° 
in the shade was registered. Prior to the beginning of this century 
a fall below zero was almost unknown. Within the last twelve years 
the thermometer sank in one winter to —6°, in another to — 10". 
Meanwhile the country gets, on the whole, drier and drier. Streams, 
ponds, and meres disappear to be seen no more ; every river in the 
kingdom is stationary or shallowing. Droughts, which a quarter of 
a century ago only occurred very rarely, are now rather the rule 
than the exception. During the spring of 1870 the rainfall was 
more than three hundred tons per acre below the average. The 
want of storeage for water has of late years been felt several times 
in England ; to the best of my knowledge such a want was quite 
unknown in former years.* Now, if my information be correct, it 
is essentially within the time that these changes have been most 
marked, and progressed most rapidly, that leprosy has finally dis- 
appeared. My fiiend. Dr. Cattell, assures me that in his youth 

* The difference effected by drainage in many parts of England, even within 
the last three quarters of a century, is, I believe, greater than most men think ; 
in fact, I doitbt if those not familiar with the condition of the country before that 
time realize what it was. For instance, Mr. Smiles tells us that so late as 1813, 
the only way of getting along some of the roads in the county of Northampton 
during rainy weather was by swimming ! — Lives of the Engineers^ vol. i. p. 232. 



292 Causes of L^osy. 

patients afflicted with this disease used to come to Willonghby Spa to 
drink the waters of that place. The state of the magnetism, too^ 
and electricity, also in England, has in all probability undergone a 
considerable change within the time I speak o£* Clothing has 
altered very materially; oiu: ancestors wrapped iai more warmly 
than we do, either because they took less exercise, or to counteract 
the moisture of the air, as is now done in Ireland, where they wear 
woollen when we wear cotton. Moreover, our fathers eat much 
less fresh meat than we do, butcher's meat being less easily pro- 
cured during winter. The introduction of spirituous drinks may 
have had something to do with the matter. According to Mr. 
Tovey,t the Jews of Morocco are thought to preserve themselves 
from elephantiasis by the use of brandy distilled from raisins, pears, 
figs, and dates. 

The testimony of the report is not, however, calculated to make 
us place much reliance on most of these causes. For instance, diet 
is constantly spoken of by some writers as a factor, but the evidence 
is conflicting in the extreme. One gentleman thinks that salt fish, 
pork, and bad oil promote the development of leprosy. Yet pork 
is not likely to be a cause of the disease among the Jews and 
Behemmenas, both of whom abhor it and are subject to the malady. { 
Bad oil was scarcely likely to have been a cause of the disease in 
Scotland and England. Again, the Chinese in Victoria, who sufier 
greatly from leprosy, live principally on beef, mutton, and rice. The 
Chinese prisoners in. this colony were at one time allowed for diet 
maize, bread, fish, meat, potatoes, sugar, and salt ; but the disease 
increased so rapidly under this kind of feeding, that it was thought 
better to put them on short commons, under the influence of which, 
it is said, the malady came to a halt. The Somalee tribes, among 
whom leprosy is very prevalent, never eat fish under any circum- 
stances ; and the inhabitants of Furreedpoor, who eat more fish than 
then- neighbours, are not more subject to the complaint The 
disease is rare in Burmah compared with the western coast of India, 
yet fish forms as large an item of diet in the former as in the latter 
place. Again, the exclusive use of meat for diet is looked on as an 
aggravating cause at Nevis,§ while Dr. Steventon, of Moulserrat, 

* The Stream of Life on our Globe^ p. 399. 
+ Saturday Review^ Aug. 27, 1 864. 
X Edinburgh Medical Journal^ 1864, p. 40. 
§ Reporiy p. 18. 



Causes of Leprosy. 293 

says that the leprous patients of that district confine themselves 
entirely to a vegetable diet ; and Dr. Gardiner tells us * that leprosy 
occurs at Santa Lucia, though the diet of the people is mostly 
vegetable. Finally, the evidence respecting the influence of bad 
grain, unripe fruits, bad cooking, and the use of spirituous liquors, 
mentioned as possible causes of leprosy, is not a whit more con- 
vincing. 

The authors of the report seem clearly of opinionf that the disuse 
of salted meat and unsound food, and the change firom the filthy 
habits and scarcity of firesh vegetables, which prevailed in England 
till within quite a recent period, have contributed to the extinction 
of leprosy here. In addition to these causes, the wearing of linen 
next the skin, and the giving up of fish diet at Lent, are mentioned. 
The influence of any or all of these causes may be doubted. Un- 
sound food is only too much used now among the poor. Our police 
reports tell us constantly of the seizure of tons of meat and fish in 
a state not fit for human beings to touch. To the disgrace of our 
age, vast numbers of poor toiling creatures live on diet little better 
than garbage, while gluttonous, idle servants are permitted to con- 
sume each two or three pounds of meat daily. I am afiraid, too, 
that linen is not generally worn next the skin, especially by the 
working classes and seafaring men. I suspect also that till quite 
lately our sailors used to eat throughout a great part, of their lives 
quite as much salt meat as ever did their forefathers in the days of 
the Henries and Edwards. Many of the stricter Catholics in this 
country still eat fish all through Lent, yet leprosy does not prevail 
among them. In short, I am rather puzzled to make out what can 
be the use of bringing forward such evidence, unless it be with the 
view of warning others against treading in the same path, and being 
refuted in their turn. 

Want of cleanliness is fi*equently brought forward in the 
report as a cause of leprosy ; but it might be justly urged against 
such a view, that dirt reigns as supreme in some of the districts 
which leprosy has quitted as in those which it still haunts, and that 
it would be difficult to find people filthier than some of the lowest 
classes in our large towns. Again, leprosy is said to be much more 
common in the south of India than in the north, though the natives 
of the latter are far less cleanly than the southern Indians ; and the 

* Report, pp. 22 and 26. t Ibid., p. Ixxiv. 




294 Causes of Leprosy. 

people of Norway are not dirtier than very many of the poor and 
degraded of many parts of Europe, where the disease is never seen, 
lastly, as a proof how much the views of different observers vary 
on such subjects, it may be mentioned that one writer thinks a most 
potent means of cleanliness, the hot bath, develops the complaint 
by weakening the system. 

In some of the answers the unwholesome state of the huts in 
which the lepers live is adduced as a cause. They are described as 
ill-ventilated, wretched, dirty, and confined — ^badly supplied with air 
and light. But again, if such causes had much influence, leprosy 
would never have died out in Great Britain. Till quite lately, even 
the middle classes in towns lived in what we should consider a 
horrible state of dirt ; and as to the present day, hundreds of our 
foetid courts will parallel anything to be found in the dwellings of 
the coloured races. Besides, there is evidence enough in the report* 
that the disease attacks plenty of people living in clean, comfortable, 
»airy houses, most of whom never entered a hovel in their lives. In 
some few places the well-to-do and poorer classes suffer equally. 
Mr. Shaw reports having seen leprosy in Europeans who could 
command every luxury, and Dr. Nicholson, Dr. Carrington, and 
Dr. Young give similar testimony. Of course the great majority of 
victims in this, as in almost every other disease, are found among 
the poor, miserable, vicious, and degraded; but alas ! this is because 
they form, and, with few exceptions ever have formed, the mass of 
the community. 

And when we come to the question of climate we get no nearer 
the goal. When leprosy settles in a district its baneful influence is 
only too apt to spread over every part : town and country, mountain 
and valley, green field and sea-coast alike feel the weight of the 
horrible scourge ; and it might almost be compared to the great bat- 
lizard {pterodactylus\ which, being able to fly, swim, or travel on the 
land, could always overtake its prey. Thus, while it is so common 
in marshy districts and ill-drained alluvial soils, by the sea-coast and 
large rivers, that attempts have been made to refer its origin to 
miasmata, we find it in the dry, sterile plains of northern Persia, 
though it is believed by the consul to be unknown in the dampest 
regions of the same kingdom. It is seen among the Hottentots in 
one of the finest climates in the world, among the mountaineers 

• Pages 30 and 35. 



Greater Prevalence among Males. 295 

of Lebanon, and the inhabitants of some of the elevated parts of 
Hindostan. It occurs frequently at Conjaveram, a town standing 
about forty miles inland in a flat, dry, sandy soil, while it is rare in 
Tirhoot (Bengal), where the land is low and marshy, the v^etation 
luxuriant, and where malaria prevails. It is very prevalent at Banda, 
where the climate is extremely hot and dry. Spain is more infested 
with leprosy than most european countries, and in Portugal the chief 
seat of the disease within recent times has been the hilly district of 
Lofoes. And if it be more frequent in the vicinity of river-banks 
and deltas, it is to be remembered that such parts are usually more 
densely peopled than hilly regions and sterile plains. 

To sum up then — unless the dying out of leprosy be due to those 
obscure geologic and climatic causes which have extinguished so 
many races of mien and animals, I cannot offer even a conjecture as 
to what has brought it about. 

Age at which Leprosy appears, — ^The general opinion seems to be 
that leprosy is rare in early life. Some of the answers represent it 
as almost unknown before the tenth year ; other writers explain this 
by saying that the little patients are kept in seclusion, the disease 
having really been seen in children in arms, and even at the time 
of birth. Several instances have been recorded of its appearing in 
the fourth, fifth, and seventh years of life ; but there is no resisting 
the evidence that it rarely occurs before puberty, from which time it 
may break out at any age, and it has been known to begin as early 
as the forty-fifth year of life. 

Greater Prevalence among Males, — Leprosy is certainly more 
common among males than among females, and although the same 
explanation has been given as in the case of children of its greater 
rarity among women, it will not apply in many cases, and is over- 
thrown by stronger opposing evidence in others. The opinion, 
however, that it attacks some races more than others, even when 
both are living in the same place, is better supported. Thus there 
seems every reason to believe that Europeans are less subject to its 
malignant power than the natives of the districts where it is seen 
and Jews ; in Afiica the Hottentots are said to be more liable to 
it than the negroes, and the negroes more so than the whites. In 
Mauritius it is said to be more frequent among the asiatic and african 
than in the european or Caucasian races ; in Egypt leprosy is chiefly 
found among the Jews, being rare among the Arabs *; whereas in 
Damascus it is not known to have occurred among the Jews or 



296 Pathology of Leprosy. 

negroes, being confined to the lowest classes of the mountain 
peasantry. 

Pathology. — ^There is not much to say on this head. Mr. Macna- 
mara, in five post-mortem examinations, could not, either with the 
eye or the microscope, detect any lesion of the nerves, brain, or 
spinal cord ; but Dr. Carter, though he observed no uniform morbid 
appearances in the brain or spinal marrow, found the nerves very 
frequently diseased, enlargement and diminished opacity at certain 
selected spots being the chief phenomena. The morbid changes 
seem to have chiefly affected the fimiculi, the tubercles being sepa- 
rated and compressed by the intergrowth of a clear nucleated tissue 
which in the end destroyed them. Dr. Fiddes has seen the large 
nerves of the arm increased to the size of the little finger, and in 
cases of spontaneous cure of leprosy has noticed that this symptom 
disappears and that the sensibility is restored. Danielssen and Boeck 
say that this change is owing to infiltration of the cellular tissue of 
the sheaths surrounding the nerves, and of the nervous fibrillae, with 
a viscous glutinous fluid similar to that which is deposited in the 
skin. According to them the skin is thickened, and on section 
exudes a viscous fluid. There are also tubercles, consisting of a 
delicate fibrous network, in the meshes of which are seen numerous 
adherent whitish granules. The sebaceous follicles are enlarged. 
With the enlargement of the tubercles the fibres and granules dis- 
appear, and oblong cells, larger than exudation corpuscles, are 
found. Each granule contains a grey nucleus, which almost fills 
it ; this nucleus encloses seven or eight brownish granules. In a 
patient who died in University College Hospital, numerous granules 
and round and oval nuclei were found infiltrating the fibrous stroma 
of the skin. 

Dr. Brunelli, who has given ♦ a very careful account of this disease 
as it is seen in Candia, found that the venous blood had a deeper 
hue than natural, but never saw it of an intense black. In every 
case it was more or less wanting in brightness, ot was turbid as if 
agitated. In the more aggravated cases, and at an advanced stage, 
it had the appearance of lees of wine mixed with water. When 
allowed to flow on glass, a fine marbled stain formed in twenty to 
thirty seconds ; under a low magnifying power this was seen to be 
composed of groups of globules, not in the form of pillars, but in 

* Annali di Otnodei, Dec. 1866 and Jan. 1867. 



Prognosis of Leprosy ; Treatment. 297 

clusters of different sizes, separated by spaces, containing isolated 
granules, more or less colourless. In fifteen per cent, of the cases 
the serum of the blood was red, in twelve it was milky, and in the 
rest greenish or yellowish. Brunelli could not trace any constant 
relation between the buffy cup of the clot and any particular form of 
leprosy. He does not attribute leprosy to a dyscrasia, but thinks 
that, besides excess of fibrine, there may be in the blood other 
morbid principles, each of which may have a special chemical 
influence on one or other of the different tissues or organs. 

Dr. Scheida noticed that the blood was deficient in blood-corpus- 
cules, and one gentleman in the report represents all the tissues as 
attacked, but principally those which make up the venous system. 
" In one case," he says, " where death resulted from pneumonia, 
the crural, femoral, and iliac veins exhibited knobby appearances, 
and, on being opened, the deposit of a caseous substance resembling 
tubercular matter." Destruction of the bone is said to be effected 
by interstitial absorption, but may take place through caries or 
necrosis. 

Prognosis, — Unfavourable in the highest degree. There are, how- 
ever, many cases of cure recorded, some spontaneous, others 
seemingly due to a happy selection of remedies. Frequently, too, 
the disease, having reached a certain stage, especially in the muti- 
lating form, remains stationary for a long period ; but these are 
exceptions, and in a vast majority of cases the rule is that the 
disease proceeds more or less swiftly to a fatal end, the patient often 
sinking under some slight attack of another malady, such as bron- 
chitis or dysentery. Persons, however, suffering from leprosy may 
live many years, and even attain an advanced stage. Dr. Hyorth 
saw * a leper between seventy and eighty years old whose general 
health was not much affected. 

Treatment. — Mercury is generally denounced in this complaint as 
injurious. Arsenic seems in a few rare instances to have done good 
service. Dr. Bowerbank saw one case in which it seemed to have 
kept the disease in check. One answer speaks of decided benefit 
having ensued in every case where the patient was long enough 
under the influence of arsenic given internally, and of sulphur baths 
and frictions to the parts which had lost their sensibility. One 
writer at Bhutteawa recommends as useful, preparations of arsenic, 

* Report^ p. loi. 
2 Q 



298 Treatment of Leprosy. 

and iodide of potassium with infusion of hemidismus indicus in 
ounce doses three times a day, or chaoul moogra pills, with chaoul 
moogra, or bipchee ointment for external applications. The answers 
in the report from Salonica make mention of two cases in which 
recovery is said to have taken place under the influence of iodide of 
potassium, accompanied by cauterization of the ulcers : they were 
both in the first stage. Two cases are recorded in which a perfect 
cure ensued under the use of arsenic, iodine and iodide of potassium. 
One gentleman speaks of a case where a cure was effected in six 
weeks with nitro-muriatic acid, sulphur ointment, sulphur vapour 
baths, and generous diet. Another tells us of the benefit derived 
firom the administration of dilute nitric acid and chiretta, slightly 
stimulating applications to the skin, daily bathing, and attention 
generally to the health. Brunelli saw what he calls the hypertrophic 
form often materially checked, for a time at least, by antiphlogistic 
and lowering treatment, followed by the use of iodide of potassium 
and arsenious acid, entirely excluding wine, which proved injurious. 

Daily ablution with cold water is said to have been of use in the 
treatment of the Chinese leprous prisoners in Victoria. The tepid 
bath twice daily, and inunction with olive oil, thoroughly rubbed 
into the skin each time after the patient comes out of the bath, are 
said to be very serviceable.* One gentleman, writing from Mqnghyr, 
reports haying seen considerable relief from hygienic measures, 
well-regulated diet, and the use of arsenic, asclepias gigantea and 
chaoul moogra (or chaoul moojin). Indeed, there is a good deal 
of valuable evidence as to the influence which this drug exerts over 
leprosy. It is given in the form of pills, five grains each ; poultices 
are also made from it. Dr. Newton, however, found it so nauseous 
that he did not insist on its being taken. The Lawsonia inermis, 
employed in the form of poultices, is also said to have proved useful 
Counter-irritation over the spine, too, is stated to have acted 
beneficially. 

Dr. Beauperthu/s treatment is said to have acted beneficially, 
and I, therefore, give an analysis of it, taken from the Medical 
Times,\ It consists in ordering good diet and fresh, dry air, rather 
difficult things to get at in most cases of leprosy. Salt meat, salt 
fish and pork are prohibited. Bichloride of mercury, in doses of one- 
fifteenth of a grain, and quinine are given ; the latter only where 

* Edinburgh Medical Journal ^ 1864, p. 42. 
t 1870, vol. i. p. 550. 



Treatment of Leprosy 299 

considered necessary. Frictions with cashew oil are also employed, 
and a strong solution of nitrate of silver and copper is painted over 
the tubercles. The patient is also rubbed all over with cocoa-nut 
oil, a bath of soap and water being employed each day previous to 
the friction. When the feet are much affected, baths of hot cocoa- 
nut oil are used. 

What may be the real success of this treatment I am unable to 
say, as the author does not give us any positive results, and as I 
believe Dr. Beauperthuy is dead, I presume we shall never know 
with exactness how it succeeded in his hands. In mine quinine 
proved injurious, all the symptoms relapsing under its influence. 
Bichloride of mercury in any doses whatever was useless or injurious, 
as was iodide of potassium. I could never heal a single ulcer or 
remove a single papule with nitrate of silver, either solid or in 
solution, though I tried it long enough. Frictions with oil have 
been frequently tried by other observers, and I believe in every 
instance, where their effect was carefully watched, with only moderate 
success, acting simply as a palliative. 

Dr. Newton's treatment consists in prescribing sound food, fresh 
air, muscular exercise, and mental occupation. He insists on a 
short walk every day. He finds a mixture of carbolic and nitric 
acids* very useful. To this he adds a cholagogue laxative pilLt 
When the functions of the liver are much disturbed, five minims of 
dilute nitro-hydrochloric acid may be added to each dose of the 
mixture, or one or two grains of quinine may be given with it when 
the digestion requires improving. He also gives drachm doses two 
or three times a day of tincture of lal chitra (the rhizome of plum- 
bago rosea). Externally he employs equal parts of glacial, acetic, 

* R. Acidi carbolici m. iij. 

acetici diL P. Brit. 5iss. 

Spiritiis sacchari 5iij. 

Syrupi 5iss. 

Aquae 5iv. ad Jvj. 1*1 
To be taken twice a day, directly after a meal. 
+ R. Resinse podophylli gr. vijss. 

Aloes, 

Ipecacuanhse, 

Extracti tarax., aa. gr. xlv. 

Olei cajeputi vel menth. pip. 5ss. 

Liquoris potassse q. s. ti\, ft. pil. xxx. 
I understand Dr. N. to say that he gives one every night 



300 Treatment of Leprosy. 

and carbolic acids as a caustic; if there be fetid snppnratioii, 
bromiDC and chloride of zinc After the bath the skin is to be 
anointed with chaoul moogra, poppy ok linseed oil, containing 
some antiseptic substance, as tar, k^osine, oil of turpentine, or 
tincture of iodine. For deep-seated pain a blister is usefuL This 
treatment seems to have been very successfiil ; one case " improved 
wonderfully." Three patients out of twelve declared themselves well 
at the end of a month or six weeks ; in two, who were in a most 
shocking state, the ulcers had all healed, the complexion become 
fresher and clearer, the pains had ceased, the appetite had improved, 
and they had gained strength. 

Some few years ago M. Baum^ reported a case treated success- 
fully, the principal remedies being three hundred baths in one year, 
diluent and sudorific drinks, and a nutritious unstimulating diet 
Drs. Danielssen and Boeck say they have found the iodide of 
potassium in small doses produce some diminution of the tumours 
in the tubercular form, but the improvement did not last ; in the 
anaesthetic form this salt relieved the pain in the bones, as did the 
chlorate of potass. Taken all in all, these remedies were of service 
in some cases in the practice of these celebrated observers ; one 
patient, suffering under both the anaesthetic and tubercular forms, 
recovering so completely that in four months he was at work again, 
and another being freed from the tubercles by the same means, 
powerfully seconded by blistering and counter-irritation. The turkish 
bath seemed to be very useful in some cases. 

Possibly emigration to the United States or Canada might check 
the spread of leprosy in a patient attacked by it, or at any rate 
render his condition more comfortable. Dr. Hohnboe, surgeon to 
the General Hospital at Bergen (Norway), who travelled through 
Illinois, Iowa, Minnesota, and Wisconsin, and who investigated 
the state of the disease among the norsk settlers there, came to the 
conclusion that leprosy when exported to America runs, as a rule, 
a longer and milder course than in Norway, and shows a stronger 
tendency to improvement and even recovery. 

I now proceed to give the particulars of two cases which were 
under my care for some months. Both the patients were in St 
Jolin's Hospital at the same time, and both their histories were 
recorded and given to me by the younger of the two, a gentleman, 
who had been well brought up, but suddenly reduced to very narrow 
( ircuiiistances by the death of his father in India, where the seeds of 



Cases of Leprosy. 301 

this disease were sown in the son ; while the other patient had con- 
tracted his malady in Trinidad. They were also both Irishmen, and 
it was difficult to refrain from moralizing on the strange chain of 
events which had brought together in a small London hospital, these 
two men, natives of the same land, and yet so long sojourners at 
what might be very justly called the extreme ends of the world. 

Case I. — Thomas C, aged 18, was admitted into St. John's 
Hospital, under the care of Mr. Milton, April 16, 1867, suffering 
under well-marked symptoms of leprosy. He is of anglo-irish parent- 
age (his mother being of pure irish, his father of mixed english and 
irish descent), but was bom in the Madras Presidency. He has one 
brother and one sister, neither of whom has shown any traces of the 
disease. When a child he was sent over to Ireland to be educated. 
Four years after leaving India, or in May, 1863, the disease first com- 
menced in the shape of a pricking sensation in the right little finger, 
which was gradually followed by complete insensibility of the part, 
the insensibility slowly extending along the ulnar side to the wrist. 
It next attacked the ulnar side of the third finger, and then the same 
side of the second finger followed, the forefinger being the last 
affected, and then in a less degree. During the next two years the 
anaesthesia continued to spread steadily till, on the inside of the 
arm, it reached almost to the armpit; on the radial side it extended, 
however, only as high as the elbow ; indeed on this side it spread 
altogether more irregularly and slowly. In November, 1865, he 
first of all noticed a thickening of the skin over the right eyebrow, 
with some redness ; by Christmas this had completely developed 
into the form it wears now — that of a tubercle. Another soon 
formed below the right eye, and by the summer of 1866 his face 
was 'pretty well covered with them. In the spring of 1866 
several small hard patches, accompanied by tubercles, came out on 
the posterior and upper parts of both thighs ; they were at the 
beginning more prominent than they are now, and were from the 
first devoid of sensation. Anaesthesia now attacked the left leg, all 
the lower part of which became insensible ; subsequently to this the 
right leg was affected in the same way. At this time too the left 
arm likewise became slightly affected ; but for some time previous 
to his admission the disease seemed to be stationary there, whereas 
on the legs the stains and tubercles continued to develop themselves. 
About the time at which they first showed themselves wasting of the 
muscles of the right thumb began to appear. 



302 Cases of Leprosy. 

His face is now (April, 1867) entirely covered with tubercles of 
a dusky colour, of every size, from almost imperceptible risings 
of the skin to the bigness of half a small walnut. They are for the 
most part smooth, only one here and there bearing a few small 
scales, and are quite painless. The hairs have not as yet fallen out 
of any part invaded by them. For some little time past he has 
suffered a good deal from pain in the right arm, and there seems to 
be an inflamed lymphatic gland near the elbow ; a l)anphatic vessel 
too shows itself in the form of a long reddish streak running in the 
middle of the arm from below to above the elbow ; otherwise he 
has not suffered anything in the way of pain, and his health is not 
perceptibly affected. There are several tubercles on the under part 
of the chin and on the sides of the neck, but nothing of any con- 
sequence on the back of it. Nearly the whole of the right arm and 
hand is covered with brown stains of every shade, but on the left 
arm there are only some irregular patches of this kind, varying in 
size from that of a pea to that of a crown piece. In every part 
where there is a stain sensation is quite lost, and he has, he tells me, 
frequently amused himself by cutting one of these places with a 
knife, a performance which caused him no pain. The blood flowed 
as from a cut in other parts, but he thought it seemed blacker 
than natural. A specimen, however, which he procured for me 
in this way seemed quite normal. The stains on the legs have 
begun to spread very much, but the distribution of them varies 
considerably on the two limbs. The pulse is 96, soft and mo- 
derately full. I subjoin a photograph of him taken very shortly 
after this date. 

The summer before the disease first appeared he suffered from 
what the medical gentleman who attended him called scarlatina, and 
in the summer of the following year he was again attacked by a 
similar affection, which this gentleman pronounced to be a return 
of the scarlet fever. I am, however, disposed to think it was in 
both cases an outbreak of that feverishness, general disorder, 
and erythema, which sometimes precede the appearance or exacer- 
bation of leprosy. 

Throughout the progress of the disorder he noticed that it was 
always worse in winter, at which season indeed its worst symptoms first 
of all made their appearance, and that the relapses and progress of 
the complaint invariably took place at this time of the year, whereas 
in summer it either remained stationary or improved a little. 




PHOTOGRAPH OF YOUNGER LEPROSY PATIENT. 



Cases of Leprosy, 303 

It would be difficult to imagine anything more wretched than the 
condition of this youngs gentleman — objectively speaking at any 
rate. It is no exaggeration to say that he was an utter outcast. 
His nearest relatives, his mother and sister — the very persons who 
under other circumstances would have been the first to nurse him, 
shrank in dread from him ; they not merely feared to touch him, 
but were in constant dread lest he should touch them or anything 
belonging to them. The reader may therefore judge what the feel- 
ings of others must have been towards him. One surgeon turned 
quite ill after seeing these two patients, and several who had seen 
them once refused to do so a second time. One, therefore, ceases 
to wonder at finding that the leper has from time out of mind been 
an object of fear and abhorrence, especially among the ignorant and 
superstitious, and that he has ever been driven out from society, 
and caged up with his fellow lepers, as though he were some 
pestiferous and unclean thing upon which God had set the sign 
of His wrath. Yet this poor fellow himself scarcely seemed to 
realize his position in the least. He went out but little in the day- 
time, it is true, but in all other respects he hardly appeared to 
consider that his state was to be pitied, much less that he was 
stricken with a hopeless and horrible malady. Though, in answer 
to all his repeated inquiries, I felt that I could only reply vaguely, 
and that I never could hold out any hope of being able to do him 
any good, indeed, I did not consider that I was justified in doing 
so ; though one system of treatment after another failed to benefit 
him to any material extent, and the relentless malady continued to 
progress more or less slowly, he was full of hope up to the very last 
day that he continued under my care. 

I tried a large number of remedies in this case — calomel, 
bichloride of mercury, grey powder, nitric acid, nitro-muriatic acid, 
strong decoction of sarsaparilla both hot and cold, quinine, steel, 
and various purgatives, the Zittman treatment, &c., but without 
doing any permanent good. Some of the remedies, as quinine for 
instance, though given in what I considered very moderate doses — 
one grain in solution two or three times daily — seemed to act in- 
juriously from the very outset, and were therefore very soon given 
up ; others had a long trial. For a time pretty large doses of 
calomel, beginning with a grain and gradually increased up to three, 
and occasionally four grains, given at night, followed by the use of 
tolerably strong doses of black draught the succeeding morning so 



304 Cases of Leprosy. 

as to produce a very free action of the bowels, seemed to arrest the 
progress of the fell malady both in this and in the succeeding case ; 
but having had no previous experience in the treatment, and having 
been able to find no clue in books to any consistent and feasible 
system of medication, I gave up this plan so soon as ever the mouth 
became even very slightly affected. The patients, however, soon 
felt themselves so much worse for the change that they of their own 
accord asked me to give them the purgatives again, and I therefore 
did so, but it was useless now to make the attempt. The medicines 
seemed to have lost all power of arresting, or even ameliorating, the 
disease, and I never again recovered the same control over it. The 
patient, however, took a more hopeful view of matters: he con- 
sidered that the action of these remedies had been to restore the 
sensation to a considerable extent in the feet, especially in the outer 
side of the right foot. 

With one short interval the patient remained in St. John's 
Hospital up to June, 1868. During this period there was, so far 
as I could see, but very little change, and that little was upon 
the whole always for the worse. Now and then the disease 
appeared to be stationary, especially under the influence of the 
purgatives, but this, as I have said, was of very short duration. 
The hue of the skin gradually became darker, the tubercles spread 
a little, a firm scale formed over one elbow, while a large thickish 
crust appeared occasionally on the outer side of the left nostril; 
but with these exceptions there was not any material visible change, 
nor at the present time does there appear to be any. Except 
occasional attacks of pain in the right arm, the liver, and diaphragm, 
of which the patient complained a good deal, he did not appear to 
suffer much. He was energetic enough, occupying himself busily 
in writing and reading, and his mental faculties seemed in no way 
impaired. 

At the expiration of four years this patient has again come 
occasionally under my care. He tells me that he has at intervals 
taken the purgatives, but never more than once a week, and that 
he has always found benefit from them ; indeed, he thinks he has 
greatly improved, the anaesthesia on some of the old surfaces having 
broken up into small patches, instead of being continuous, and 
the tubercles having, except one on the forehead, levelled down. 
The nose has, however, sunk in considerably, and the conjunctivae 
are more opaque and pearly. He tried homoeopathy for some time, 



Cases of Leprosy. 305 

and then a course of carbolic acid and tonics, but thought he 
relapsed under both. 

It is not in my power to record anything of interest connected 
with the pathology of the case. I saw nothing but what has been 
seen before and recorded several times. I made some examinations 
of the urine, and proceed to give the results, which, however, are 
not very complete, excessive occupation at the time having pre- 
vented me from devoting sO much attention to the subject as I 
could have wished to do. I believe, however, they are substantially 
correct, and that the reader may fully rely upon them, crude as 
they are. I have entered them here in detail, so that any inac- 
curacies may be rectified. The method of analysis followed was 
that laid down in Dr. Golding Bird's work,* and the portions 
examined, both in this and the succeeding case, were, when express 
mention to the contrary is not made, always parts of the whole 
bulk of this secretion passed during the twenty-four hours, the 
patients being strictly enjoined to make water before going to 
stool. 

The urine, I may here say, had almost from the first a most dis- 
agreeable faint smell, and was very often of a pale, dirty-green hue. 
It was for the most part strongly acid, and the sp. gr. generally 
varied from I'ooS to i'oi2. 

Some rather hasty observations having shown a remarkable 
absence of urea, further search was made to see if this view was 
well founded, as also to discover whether there was any albumen 
in the urine. 

A specimen of the urina sanguinis examined June 4th, 1867, 
showed no trace of albumen. Sp. grav. 1*012.; the sp. grav. of 
another specimen passed June 7th was also i'oi2.t 

A specimen taken June i6th was intensely foetid, with a fish-like 
smell; sp. gr. i'oi5. An ounce of this urine was evaporated to a 
fluid drachm, and the capsule containing this set out to cool. When 
cool the bath was rather more than half filled with cold water, to 
which three drachms of nitrate of potass and the same quantity of 

• Uiinary Deposits, Fifth edition, 1857. 

f Dr. Newton sajrs, "The urine appears to be always normal. In no case 
was there any trace of albumen ; the reaction was acid in all but one specimen, 
where it was neutral ; the specific gravity cUone seemed to be a little lower than the 
normal average^ In every case it presented a healthy colour, was dear and free 
from sedimentary deposit." — Aiursthctic Leprosy. 

2 R 



3o6 Cases of Leprosy. 

hydro-chlorate of ammonia were added. This was briskly stirred, 
and the capsule being replaced over the bath, half a drachm of cold 
colourless nitric acid was added and the mixture briskly stirred with 
a glass rod. To my great surprise, this amount of urine only yielded 
rather less than a quarter of a grain of nitrate of urea (/), and as the 
average quantity of urine passed by the patient in the twenty-four 
hours varied, without exception, from twenty-two to thirty ounces, 
he could scarcely be considered to expel at this time more than 
about three grains daily of urea. 

A third observation was made on the urine passed first thing on 
rising, June 23rd. The urine was strongly acid. Sp. grav. i-oi6. 
Two ounces treated in the same way gave less than gr. ss of nitrate 
of urea. Three days later, five ounces were treated in the same 
way, except that instead of the crystals of nitrate of urea being 
placed, as before, on thick blotting-paper, and a stream of ice-cold 
water poured gently over them, this was very gently allowed to cover 
them, and then the supernatant fluid very carefiilly removed with a 
syringe. The capsule was then replaced over the hot-water bath, 
and a gentle heat applied, which was attended with the formation of 
orange-coloured crystals. These, when collected and dried, weighed 
exactly four grains and three-quarters. Calculating this at the pro- 
portion of 48 parts of urea in 100 of the nitrate, which is pretty near 
the mark, we find that the quantity of urea in five ounces was equal 
to gr. 2*28. 

On the 9th of November, 1867, after he had been some time 
under the influence of purgatives, and had begun to think he was 
better, an opinion in which I shared at the time, a specimen was 
again procured of the urine passed first thing on rising. It was 
entirely free from the dirty-green tinge, and did not smell so offensive. 
The colour was a fair yellow ; sp. grav. i '020, showing 46*60 grains 
of solid matter in the 1,000 ; strongly acid. An ounce of this urine 
was treated as on former occasions, by evaporation and addition of 
nitric acid, but the mass, as in every previous instance, did not 
become nearly solid as it would have done had the normal quantity 
of urea been present ; on the contrary, the solid matter did not 
appear to form more than one-tenth of the whole. The solid matter 
was next placed upon a piece of thick white blotting-paper, and a 
very slender stream of extremely cold water was poured very gently 
over it. When very nearly dry it yielded nearly six grains of nitrate 
of urea, in the shape of pale orange-coloured laminae. The proba- 



Cases of Leprosy. 307 

hility then is that, as the amount of urine passed on the day this 
specimen was tajcen amounted to twenty-six ounces, not more than 
about seventy-five grains of urea were at this rate daily extruded 
from the system. 

In order to test the presence of uric acid, an ounce of the urine, 
gently warmed, was poured into a glass containing thirty minims of 
hydrochloric acid, and set aside, after being covered with paper. 
At the end of twelve hours it was examined, and again at the end of 
twenty-four hours, but in neither case could anything like a pellicle 
be detected. A few very minute dark specks were all that could be 
made out. The urine having been briskly stirred with a glass rod, 
these specks of uric acid were collected and weighed. They formed 
a mass hardly bigger tihan a pin's head, and when placed in a very 
delicate balance did not at all affect a weight of the tenth part of a 
grain. Nitric acid and heat showed no albumen, and no white 
deposit was elicited by heating in a perfectly clean test-tube to boil- 
ing point. A thin layer of the urine was poured into a white saucer, 
and a few drops of nitric acid were allowed to fall into the centre of 
it, but no play of colours ensued nor was there any loss of trans- 
parency; only a very faint tinge of purple took the place of the 
natural hue. There was accordingly no reason to infer the presence 
of either bile or blood. Although with such a moderate specific 
gravity, the search for sugar or excess of nitrate of urea might seem, 
and probably was, quite superfluous, yet it was diligently made, but 
none of the tests proved the existence of either. 

Dr. Bird recommends that in searching for creatine and creatinine 
an ounce of urine should be evaporated to a s)mipy consistence. It 
appears to me that it would have been more clear had Dr. Bird 
stated the exact amount to which this quantity should be reduced. 
It is difficult for a student to understand how such directions should 
be carried out, or how urine free from sugar is to be rendered 
syrupy. I may, therefore, state that the quantity spoken of was 
evaporated to something less than a fluid drachm, and that after it 
had been set aside to cool, a piece of chloride of zinc the size of a 
pea was added to the decanted liquor first warmed in a watch-glass, 
when the whole became converted into a yellowish-brown, jelly-like 
mass, in which I could not discover any traces of the crystals of 
the triple compound of zinc and chlorine with creatine and 
creatinine. Examination with the microscope failed to show any 
crystallization. 



3o8 Cases of Leprosy. 

There was not much deposit of mucus, and what there was 
seemed almost unaflfected by nitric acid. A small quantity put into 
a test-tube, and agitated with an equal quantity of liquor potassse, 
became slightly flocculent and cloudy. There was, therefore, no 
reason to assume the presence of exudation corpuscles. There 
were traces of oxalate of lime. An ounce yielded three grains and 
an eighth of earthy and alkaline salts. 

Another specimen was taken for examination on December loth, 
1867. It was of a marly colour, or rather of the hue seen in the 
darker kind of clay of which ink- or ginger-beer bottles are made. 
The total quantity passed during the twenty-four hours was Jxxvii. 
There was no great amount of mucus in" it. Sp. grav. 1*026 — 
distinctly acid. 

An ounce was evaporated to about a drachm, and this, after being 
carefully chilled down, was mixed with cold colourless nitric acid, 
and replaced upon the bath containing the freezing mixture spoken 
of previously. Ice-cold water was then poured very gently over the 
crystals, and the supernatant fluid drawn very carefully off with a 
syphon. The mass was then carefully dried and placed in the 
balance, when it was found to weigh 2 3 "40 grains, a result which 
again so much surprised me, that I repeated the observation, but 
with substantially the same result. An ounce treated exactly as in 
the previous observations for uric acid gave three-tenths of a grain. 
The reader will; therefore, observe that there was here also a remark- 
able change. An ounce was now evaporated, and the residue 
treated by combustion, yielding 4*9 grains. Triturated with water, 
and again calcined, this yielded six-tenths of a grain. No traces of 
albumen were fbund, but there was a considerable amount of urate 
of ammonia. There was no excess of bile. Liquor ammonise 
brought out the stellar crystals of phosphate of magnesia and 
ammonia, but microscopic examination only detected urate of 
ammonia. I may remark that the patient had been very freely 
purged in the interval between these two examinations, but that he 
had lived in the same way as before, being constantly in the hospital, 
and allowed the same quantity of meat. In respect to fluids, he 
voluntarily restricted himself to a very moderate amount. 

If we now place these two observations in juxtaposition with a 
table of the normal constituents of urine as given by Becquerel, the 
reader will see what a very great disparity exists between both of 
them and the natural state : — 



Cases of Leprosy. 



309 





Becquerel. 

z,ooo grains of 

Urine. 


T. C— First Observation, 
November Q. ^ 
x,ooo grains of Urine. 


T.C.— Second Obser- 
vation, Dec. iQ. 
z,ooo grains of 
Urine. 


Weight of Urine passed 
in 24 hours 

Spec. Grav 

•Solids in 1,000 grains . . 

Urea .. .. . .. .. 

Uric Acid 

Earthy Salts 

Alkaline Salts.. .. 1 

Extractive Matters / 

(Organic Matters and Vo- 
latile Saline Combina- 
tions of Becquerel) . . 


19*516 
10189 

311 

12*8 

0-391 
7-63 

9*26 


9.817 

1-020 
46-60 

7*0539 

A trace, 
not searched for 

** ** 
*» »» 

Total, 39*5561 


• 

Z2,Il8 

1*026 

60-58 
25-685 

•686 

1*3714 
9S386 

23*009 



The next case was that of George H , aged 38, a native of 

Ireland, who was admitted May 17th, 1867, labouring under this, 
disease, which he had contracted whilst engaged as an engineer in 
Trinidad. He was suffering from both anaesthetic and tubercular 
leprosy in a very aggravated form. The disease commenced more 
than eight years previously, and, according to the patient's version, 
the first symptoms, which appeared in the left leg, were called into 
being by an injury to this part occasioned by a fall while riding 
down a hill. About a year before this he suffered severely from 
what he called ringworm, being almost entirely covered from head 
to foot with patches from an inch to a foot in diameter, and about 
nine months after the first appearance of this syriiptom his face 
became remarkably flushed and. puffy. Finding that the symptoms 
of leprosy got no better, he returned on leave to Ireland, and placed 
himself under the care of an eminent physician in Dublin. In a 
few months he had to all appearance recovered, and finding himself 
so much better he returned to Trinidad, but in a short time the 
symptoms returned and gained ground rapidly. He now put himself 
under the treatment of a gentleman in Trinidad, who, he was in- 
formed, had been staying there several years for the express purpose 
of studying this disease. This gentleman put him for several months 
through a course of arsenic and purgatives, increasing the dose of 
the former to such an extent that towards the close of the treatment 
the patient says he took four grains of arsenic daily. Of course 
this was a complete mistake on his part. He improved, however, 

* According to Dr. Bird's table, calculated from Dr. Christison's formula, the 
amount of solids in 1,000 grains of urine of sp. grav. I '018 is 41 '94. 



310 Cases of Leprosy. 

so rapidly under this treatment that at one time he thought he was 
getting quite well, but unfortunately he neglected to take his medicines 
and another relapse ensued. He then came home again, and once 
more placed himself under the care of the medical gentleman in 
Ireland whose treatment had previously been beneficial. But his 
aid was now of no avail ; the patient got worse, and then went to a 
remote country district and consulted a third practitioner, where 
however he underwent no change for the better, ulceration of both 
lips and of the tips of the fingers and of the balls of the toes setting 
in, among other s)rmptoms. The treatment employed seems to have 
principally consisted in giving iodide of potassium and purgatives, 
and applying zinc ointment to the ulcerated surfaces. He stated 
that these parts often healed up, and that he got better when using 
the purgatives ; indeed he seemed at times so much better that both 
his medical attendant and he fancied he was really to get well, but I 
need scarcely add that improvement proved always only temporary. 
At last, as he grew worse on the whole, he decided to enter at 
St. John's Hospital, which he did just three yjears after his return to 
Ireland. 

He was, as may be seen from the accompan3dng photograph, in a 
much worse condition than the other patient. His lips were so 
ulcerated and the tongue so thickened, tender, and fissured that he 
could scarcely swallow anything. He was utterly unable to dress 
or wash himself, owing to the excoriated state of the tips of his 
fingers. His voice was thick and hoarse, the nose sunk in, the 
muscles of the arms and legs shrunk to the last degree, the hands 
incurved, and nearly all the skin stained with the characteristic hue 
of leprosy. The skin of the face was tuberculated and dirt-coloured, 
and there were several large tenacious crusts on it. The hair of his 
head looked as if he had been rolling in the dust. From the very 
first we had the greatest difficulty in getting any nurse to attend on 
him, even when offered double the usual wages, and one nurse after 
another left, refusing to continue such an unpleasant task. Towards 
the close of his stay, indeed, we could not induce any gne to under- 
take the work, and as he was dissatisfied he was removed (January 
22nd, 1868) to Middlesex Hospital, where he soon after died 
(April 14th), sinking quite suddenly. During the latter part of the 
time he was under my care the stench from him was perfectly awfuL 
The chimney of the ward in which he was placed communicated 
with that above, in which the secretary and his assistant lived during 




PHOTOaRAt>H OF ELDER LEPROSY PATIENT. 



Cases of Leprosy. 3 1 1 

the day, and I suppose it was by this path that the stench made its 
way to them, for it did not appear to go up the stairs. Be that as it 
may, they were more than once made quite ill by it, and on one 
occasion it was so overpowering, that after being seized with violent 
vomiting, they rushed out, declaring they could not stay in the 
hospital. The patient used to cover himself over with the bed- 
clothes, in fact quite bury himself in them, when he went to sleep, 
and it was when he threw them off in the morning that the dread- 
ful smell diffused itself so much. I never smelt anything like it, and 
am quite at a loss to describe it. There was no particular foetor 
such as that about gangrene \ it was a faint, yet hot, so to speak, 
pungent smell. The other leprous patients did not seem to suffer 
from it. 

The same treatment was put in force in this as in the preceding 
case ; there is therefore no occasion to give it in detail. It will 
suffice to say that it was useless, though the purgatives sometimes 
appeared to do good, and at one time I really thought he was 
getting better. The ulcerations of the lips healed up, and those on 
the fingers were so much better that he could dispense with gloves 
occasionally, a thing he had not been able to do for months \ he 
could swallow food with more ease, and even sit up in bed to read 
and write a little. With the elastic spirit of his race he now fancied 
that all his troubles were over, and that he would be ultimately 
restored to perfect health. Indeed the matron said that he con- 
tinued to assert to the last that I could have cured him if I Hked, and 
that if I had only continued the purgatives he would have recovered. 
But in his exhausted and hopeless state I was afraid to do so, 
especially as one ingredient in them was a dose of calomel at night 
(followed by a strong dose of black draught in the morning), and I 
need scarcely say how strongly the use of mercury to any great 
extent has been decried in this disease. I therefore suspended the 
medicines, and shall always regret that I did so, as he relapsed almost 
immediately ; and when at the expiration of a short time I resumed 
the use of them, they seemed to have lost all hold on the disease. 
The fact, however, that they did so much good, both in this and the 
preceding case, and that twice in his previous history the patient 
had been materially benefited by the administration of them, tends 
to show that it is in this direction that we must look for aid. 

A specimen of this patient's urine was taken for examination, 
November 15th, 1867. The whole quantity passed during the 



3 i 2 Cases of Leprosy. 

twenty-four hours amounted to eighteen fluid ounces. The colour 
was a good yellow, presenting in this respect a remarkable contrast 
to that passed by the former patient. Sp. grav. I'oio ; acid. An 
ounce treated in the same way as in the second examination of 

C ^^ urine yielded only gr. -fths of urea, while two careful 

searches for uric acid produced simply twenty or thirty specks about 
the size of the point of a pin, the largest not being bigger than the 
fourth part of a very small pin's head. The accompanying marks /. 
are quite as large. Treated with an equal weight of nitric acid no 
crystals were formed at the expiration of several hours, and the nitric 
acid test after heat did not show any brown deposit. No excess of 
colouring matter was found. Two ounces treated after heat with 
chloride of zinc were converted in great part into a gefeitinous 
yellowish mass, almost like pus, in which there was a slight mixture 
of blood. No sulphur was detected by the silver test. The deposit 
from this urine seemed to be principally made up of healthy mucus. 
It was not ropy, opaque, or viscid, and threw down no sediment. 
An ounce of urine evaporated, calcined, and triturated with water, 
gave gr. If of alkaline and gr. ss of earthy salts. 

Another specimen was taken December i6th. The patient had, 
as in the preceding case, been freely purged in the interim. The 
urine was brown, and very turbid. Sp. grav. 1*020 ; strongly acid. 
An ounce yielded gr. i^^V of urea. There was scarcely a trace of 
uric acid when treated with hydrochloric acid, but the microscope 
showed crystals of this salt. There was no albumen, but blood 
discs were seen under the microscope. An ounce yielded gr. \\ of 
alkaline salts and \ gr. of earthy salts. 

With the view of not occupying the reader's time unnecessarily, 
I have not tabulated these results. As regards the cause of the 
results, I have no conjecture to offer. Whether in the widespread 
changes of tissue taking place in these men urea was being changed 
into carbonate or cyanate of ammonia, or what was really going on, 
I cannot even guess at, and therefore leave it to chemists to solve 
the riddle. Their food cannot be considered as a factor in the 
departure from the normal state. They had for breakfast a moderate 
amount of tea, coffee, or cocoa, with a little ham or bacon if they 
liked ; for dinner about \ lb. of meat with bread and vegetables, and 
half a pint or pint of beer ; tea and bread and butter, followed by a 
light plain supper, as bread and cheese, and perhaps half a pint of 
beer or a glass of port wine. On an average they must have taken 



Definition of Ckelts. 313 

quite three pints of fluid each daily. It is interesting to observe 
that the relative proportion of the uric acid to urea, about i to 3.0, or 
8*1 to 255, was closely preserved. The greenish tint spoken of in 
the urine of the first patient was totally different to everything I have 
seen. Though very pale, it was of a decidedly green tint. At the 
same time the urine differed very considerably in appearance from 
that of hysteria, in which this hue is said to make its appearance 
sometimes, and there were no indications of bile, which occasionally 
lends an apple-green tint to this secretion. 

D. Che'lis (x^'Xic) {is, is, fem.), from x*?^')? ^ crab's claw, but more 
essentially the notch where the claw branches ; keloid from the 
same (or x'^^^^y ^ tortoise), or more properly from x*?^^* 2. 
scar, as from being branded, and el^oc, resemblance. The 
Keloid of Alibert. 

Definition. — A formation of small, slowly-growing, hard, shining 
tubercles, almost cylindrical in form at first, but may be roundish 
or quadrilateral, gradually thinning towards the edges, the whole 
assuming a pinkish-white colour, subsequently taking on the ap- 
pearance of a cicatrix. Sometimes attended with itching, shooting, 
pricking, or dragging sensation; frequently sending out spurs or 
roots. Skin between these smooth, soft, and permeated by small 
blood-vessels. Section reveals hypertrophy of the fibrous tissue of 
the corium and absorption of the papillary layer. Usually attacks 
front of chest or back of neck. 

A very similar disease, spurious or scar-keloid, the Narben-keloid 
of Dieburg, sometimes forms on scars of bums or wounds from 
flogging.* The keloid of Addison may, I think, be advantageously 
referred to scleriasis. 

Treatment, — No very reliable remedy seems yet to have been 
found for this strange complaint Removal with the knife cannot 
be said to have answered well ; the disease has generally, if not 
always, re-appeared, and when it has returned the secondary disease 
has invariably proved more dangerous and active than the first 
attack. Taking along with this the fact that the tumour, if let alone, 

• Section of a tumour in a case of scar-keloid, reported in the Photographic 
Review of Medicine and Surgery^ showed it to be principally composed of "con- 
nective and elastic tissue." Fat in fine globules was also present. 

2 S 



314 Treatment of Ckelis. 

rarely gives any serious ground for alarm — that, according to Bazin's 
observations, it does not influence the health at all, the value of 
excision becomes very doubtful. Caustics seem equally impotent. 
Alibert mentions two cases in which he succeeded in curing it with 
nitric acid. Rayer saw some benefit from pressure, and Cazenave 
and Schedel found the sulphur vapour douche useful in softening the 
tumour. Mr. Wilson has removed the false chelis, which springs up 
in the scars of burns and scrofulous ulcers, by the use of three-grain 
doses of iodide of potassium three times a day, and a Plummer's 
pill at bedtime. Hardy says that absorbent means (les fondants) 
have sometimes proved efficacious in procuring a diminution 
of the tumours ; he therefore recommends iodide of potassium 
internally, iodureted pomade, vigo plaster, and blisters. 

Dr. Pick mentions * an instance of what seems to have been cure 
of chelis. He first saw the case in July, 1866, and by February, 
1867, the disease seems certainly to have been effectually checked, 
the piercing pains having long disappeared, and the artificial scars 
formed by caustics having contracted a good deal. There was 
reason to believe that some time after no relapse had occurred. 
The treatment consisted in first letting the growth alone to see 
whether or not it was increasing, and then employing iodized 
glycerine, under the operation of which it was at the end of six 
weeks decidedly worse. Dr. Pick next applied caustic potass to the 
tubercles, and renewed the application in fourteen days. After the 
scab from the second burning fell off, he touched the granulations 
every second or third day with nitrate of silver. Under this treat- 
ment complete cicatrization followed towards the end of November, 
the offshoots in the meantime growing smoother and paler. 

Dr. Pick examined a small piece of the tumoiu: under the micro- 
scope. He found very hard connective tissue with elastic fibres 
embedded in it. The stnicture of the skin had entirely disappeared, 
and there was no trace of hair-follicles or sebaceous glands to be 
seen. 

Since reading Dr. Pick's paper I have only had one case of chelis 
under my care. It was a very well-marked instance. The patient, 
a strongly-built but highly nervous man, slightly advanced in years, 
declined to let anything be done, so that I had not an opportunity 

• Wiener med, Wochensch, 1867, Juli 17, 26. See also Journal of Cutaneous 
Medicine^ vol. iii. p. 73. 



Definition of Epithelioma. 315 

of tr3ring the potass. The disease was seated on the^ back of the 
neck. 

As an instance of the obscurity which at one time prevailed, and 
perhaps prevails, about some of the more rare diseases of the skin, 
I may mention that many years ago I was in the out-patients* room of 
a London hospital, when an old Irishwoman came in with a pecuHar 
growth on the inside of the calf of her leg, which a hospital surgeon, 
since dead, at once pronounced to be a cheloid ; but the growth here 
in no way tallied with the descriptions I had read of either cicatricial 
or genuine chelis, for it was nearly circular, about an inch wide and 
nearly as thick, and rose abruptly from the skin. It was of a deep 
yellow colour, and looked more like a gigantic com than anything 
else. At my request the patient was placed under my care. The 
old woman poulticed the growth till it turned soft, and she then 
picked it off. Beneath where it had grown, the papillae of the cutis 
were dilated to large, red, conical bodies, deprived of epidermis. 
On the under-surface of the tumour were hollows, into which these 
prominences had been received. The growth was submitted to an 
eminent histologist, who pronounced it to be a horn. 



E. Epithelio'ma (^, atis^ neut), from epithelium^ derived from cVl, 
upon, and 6»?X^, the nipple. Another instance of derivation 
run riot, as epithehum, used to express the covering of the 
mucous membranes, really means the skin upon the nipples. 
Also known as epithelial cancer, or cancroid epithelioma. 

Definition, — A slowly-growing, generally nearly circular, low, flat 
tubercle. Very small at first ; seldom elevated much above the 
skin. Hard, pale, and yellowish, looking like a flat wart. Subse- 
quently covered with a scale, under which the surface cracks and 
pours out a thinnish ichor, followed by sluggish ulceration ; occa- 
sionally accompanied by itching, numbness, heaviness, and aching 
in the part. Generally seated on face, especially cheek, eyelids, or 
lower lip ; may appear on prepuce and in chimneysweeps on 
scrotum. Possibly originates in the epithelium of the sebaceous 
follicles, and, when it attacks the coral of the lip, in the connective 
tissue. 

I do not know whether attention has ever been directed to the 
possible connexion between this disease and horns, and therefore 



3 1 6 Comiexion of Epithelioma with Horns. 

place the following case on record. A remarkably healthy-looking, 
square-built man applied at St. John's Hospital with a very small 
horn on the lower lip. As well as I could make out the dimensions, 
It was about five-eighths of an inch in length, and about three in 
diameter at the base. I had a photograph taken of it, and then, by 
the repeated application of acid nitrate of mercury, removed the 
horn, which grew from the median line of the lip. On steeping the 
horn in liquor potassae and breaking it up, it was found to consist 
of conical bundles of filaments. Four years after this man again 
appeared at the hospital. The horn had not returned, only a 
diamond'Shaped depression being left where it had been, but he had 
now got distinct epithelioma on the right side of the same lip. Shortly 
after this he had a fall from a scaffold, and almost immediately the 
epithelioma began to get rapidly worse. On my proposing an opera- 
tion, he disappeared, and then went to Middlesex Hospital, where 
he died. 

Hebra communicated to the Wiener med, Wochenschrift * a paper 
on epithelioma developed on lupoid patches. This paper he sub- 
sequently reproduced in the form of a pamphlet. From these two 
communications the following particulars are extracted. 

Weber and Devergie have both related cases of this nature. 
Hebra's first patient with this malady was a bookseller sixty years of 
age : the disease was seated on the face. The patient refused to 
have any operation performed, and soon sank. The second case 
was in a woman ; the lupus was on the left cheek, and the malignant 
growth sprang up in the very centre of it. This patient also suc- 
cumbed very shortly, the disease making rapid progress in spite of 
the most energetic cauterization. The third case was in a man 
twenty-nine years of age. Here also the disease broke out on the 
left cheek. The patient sank in less than two years from the time 
when Hebra first saw him. The fourth case was in a man: the 
disease had attacked the face. It had penetrated both wide amd 
deep, but the patient was progressing satisfactorily under the appli- 
cation of a paste composed of arsenic, opium, and creosote, when 
the sudden death of a boy who was undergoing the same treatment 
made Hebra give it up, though Rokitansky's decided opinion was 
that the lad died a natural death from oedema of the lungs. The 
patient left improved, and Hebra heard no more of him. The next 

* 1867, p. 65. 



Treatment of Epithelioma. 317 

patient was a workman, forty-six years of age, who had suffered from 
his earliest childhood under lupus of the face, where, at last, the 
cancroid disease developed itself, beginning in a potato-like growth 
on the right cheek, which, at the time of his admission, had reached 
the size of a child's fist. To this growth Hebra applied Landolfs 
paste, consisting of equal parts of chloride of zinc and antimony, 
with just sufficient liquorice-powder to give it a proper consistence. 
The use of this caused considerable pain, which lasted till the next 
day ; it was, however, repeatedly applied afterwards. Subsequently 
the epithelioma was treated only with the caustic potass. This com- 
pletely destroyed the disease, and such rapid granulation then set in, 
that lapis infernalis had to be employed to check the growth of 
proud flesh. The disease seemed to be completely cured. 

Treatment. — Although I have never seen, and never expect to see, 
epithelioma radically cured, as a rule,, because it is one of the 
diseases patients will very rarely attend to until it has reached such 
a pitch that a fatal result is inevitable ; yet I have observed very 
considerable benefit firom the use of the acid nitrate of mercury, of 
the superiority of which over chloride of zinc and caustic potass I 
feel little doubt myself, though I have not seen enough of its action 
to justify me in asking others to rely on my experience. In some 
cases the benefit effected by this powerful application is very remark- 
able. Three or four years ago Mr. Robert Taylor placed under my 
care a Frenchman, sixty-four years old, suffering from an affection 
of the lower and left eyelid, which certainly seemed to be epi- 
thelioma. It had invaded a considerable part of the lid, and was 
of some standing. The acid produced an immediate and steady 
subsidence of all the symptoms, and the lid seemed to be, after a 
time, quite clear of the disease, the edge of the tarsal cartilage, which 
had been, at the beginning, quite buried under the morbid growth, 
showing clear and in its natural outline. Unluckily at this stage, 
being anxious to give the disease the coup-de-grdce, I applied too 
much acid, which had the effect of bringing on such severe pain that 
the patient would not allow it to be used again, especially as he 
persisted in asserting that there was now nothing the matter with 
his eye, and I saw no more of him. Mr. Gay too has, I believe, 
been very successful with the acid nitrate in at least one case of 
epithelioma. Dr. Alphonse Milcent is said * to have healed epi- 

• jfounial of Cutaneous Medicine^ vol. i. p. 360. 



3i8 Rodent Ulcer, 

thelioma in a state of ulceration by appl)dng a paste of chlorate of 
potass, one part of the salt to three of honey or water, laid on with 
a brush. Dr. Delagarde, of Exeter, says, that if he operates before 
the absorbents are affected, he expects a lasting cure. 



F. Rodent Ulcer. 

Definition, — Slow ulceration, beginning with a pimple or warty 
growth, which falls or is picked off. Ulcer deep and painless. 
Edges hard, everted, uneven, sinuous, dry, and brownish. Sur- 
face glassy, or covered with a darkish crust. Base may be smooth, 
dull reddish-yellow, not very moist ; granulations absent ; secretion 
odourless. Generally seated on upper two-thirds of face, especially 
below the eye, but may attack the scalp, vulva, lips of the uterus, 
and margin of the anus. Not surrounded by tubercles as lupus 
often is. Lymphatic glands in vicinity sometimes matted together. 
Almost painless. Shows no tendency to heal ; usually seen in 
persons of middle age. May destroy deeply and widely. 

Mr. Hulke, in an excellent paper read before the Pathological 
Society* asked whether this disease is cancerous or not. The 
question has been mooted repeatedly, and in my opinion must be 
answered in the negative. Rodent ulcer, however obstinate and 
serious it may be, — ^however like cancer in some of its characteristics, 
is as distinct in its nature as lupus or scleroderma. 

Treatment, — ^The most effectual destruction of the ulcer and the 
adjoining tissues that can possibly be effected by the most powerful 
caustics or the red-hot iron should be essayed without the least 
delay. In some few cases this bias been successful, and the chloride 
of zinc has occasionally been of great service. Internal treatment 
seems to be of no more use than in cancer. 

• January 3, 1871. 



( 3^9 ) 



CHAPTER XL— PARASI'TIC^. 

A. Scabies. B, Phthiriasis. 

A. Sca'bies (es, «, fem.), from scabo, to scratch. 

Definition. — An eruption of papules, vesicles, and in more severe 
cases of pustules, accompanied by excoriation, redness, and a scaly- 
condition of patches of the cuticle. Excessive itching, especially 
when the patient is warm. Papular form most common. The usual 
haunts of the acarus are, in adults, the skin of the wrists and that 
between the fingers, the ulnar side of the hand, penis and axilla ; in 
children, the palms of the hands, soles and sides of the feet. Rarely 
found on scalp, nor often on face, but may occasionally be seen on 
both. Seldom attacks neck and shoulders ; when found on the 
latter it is principally the spots where the itching from the clothes- 
louse is observed. The norwegian six-legged acarus is possibly the 
same insect, but before its final moult.* 

I have notes of so many cases in which the irritation of scabies 
has developed eczema in a severe form that I feel assured the cir- 
cumstance is far from uncommon. What is more, this eczema 
becomes subsequently independent of the scabies. At the onset 
the same remedies which cure the parasitic disorder remove the 
other. I^ater on the most extensive and thorough use of sulphur 
preparations, accompanied by fumigating the clothes, seems to exert 
no control over the eczema, and, indeed, often makes it worse. Nor 
does it in some persons show very particular tendency to go away 
of itself. 

* Medical Press f 1865, June 7th. 



320 Diagnosis of Scabies. 

Diagnosis, — However characteristic the signs of scabies may be 
thought, I have no hesitation in saying that the diagnosis is often 
by no means easy. The itching is sometimes slight, and the co- 
existence of papules, pustules, and vesicles, when it occurs, though 
strong evidence, is not proof. Besides, this co-existence is too rare 
to rely on as a general rule. I have seen scabies in a lad twelve 
years old evoke symptoms which bore every appearance of lepra. 
In many cases, as I have said, it generates severe eczema. 
Symptoms analogous to those of prurigo and phthiriasis are often set 
up by it in elderly persons, and its sequelae have been mistaken for 
urticaria by very good judges. Dr. Fagge mentions* a case in which 
errors of diet aggravated the itching, such articles as onions and 
Worcester sauce producing a severe exacerbation, so that urticaria 
might easily have been suspected. Finally, as I have already men- 
tioned, the detection of the acarus by the ordinary methods is not 
easy. 

Under these circumstances, the test proposed by Dr. Hilton 
Fagge t acquires the highest value. This gentleman in one case 
scraped the edges of the burrows, and put the scrapings under 
the microscope, when he found eggs and a portion of the 
framework of the acarus. In another case in which scabies was 
complicated with eczema impetiginodes, he boiled the crust in a 
solution of caustic soda, 5ss. to 5j- of water, and found in the 
flocculent deposit left after pouring off the clear cooled liquor, the 
skeleton of an acarus, two young acari, one egg, one egg-shell, and 
the fore-legs of an adult. Mr. Frederick Durham also succeeded 
in finding in part of this fluid nine other young acari and three or 
four eggs. 

Scabies is no longer a disease of dirt and poverty, a denizen only 
of filthy lodging-houses : it has made its way into the comfortable 
homes of the upper and middle classes. Within a brief period I 
have seen it in a number of persons in very good position — officers, 
wealthy clergymen, men of independent property leading a retired 
life, civil engineers, and young unmarried and married ladies. It is 
often quite impossible to account for its appearance among the 
latter \ but that they not unfrequently suffer from scabies is beyond 
all doubt. Possibly it is sometimes conveyed by means of money. 
I had a collector under my care, in whom this seemed to have been 

• Lancet^ 1868, vol. v. p. 433. f Ibid., p. 432. 



Communication of Scabies. 321 

the case. Sometimes it seems to be communicated by dirty crossing- 
sweepers opening carriage doors. Mr. Wilson says* it has been 
spreading in this direction ever since the Crimean war, and his prac- 
tice exhibits the startling number of thirty-seven cases of itch out of a 
tliousand cases of all kinds of skin disease. But Dr. Hillier doubts,t 
as I do, if the Crimean war could have had anything to do with it. 
He examined the returns, and found that out of 60,399 cases in 
the hospitals there were only 185 cases of itch. A stafF-surgeon in 
charge of a division saw no scabies during the whole war ; another 
surgeon, in charge of a regiment, did not see one case of the disease, 
and an assistant-surgeon stated to him that scabies was most un- 
common. Hardy tells us (1863) that in Paris it is seen almost 
exclusively among the poorer classes, so that mere importation from 
russian territory cannot be admitted as a cause. Mr. Gay informs 
me that it is largely on the increase among the middle classes, and 
if there be any peculiarity in the eruption of the present day, it is 
that the eruption is more generally diffused over the body, and less 
noticeable on the fingers. 

I really cannot understand on what grounds Mr. Startin has 
arrived at the conclusion that vaccination can transplant the itch, 
impetigo, pityriasis versicolor, and syphilis. % Those who, like 
myself, have always considered him a most careful observer, and 
holding very moderate views, must have been lather surprised to find 
him advocating such an extreme doctrine as that in patients suffering 
under these disorders, the serum of the blood generally^ not the secre- 
tions of the affected parts be it remembered^ becomes so intensely 
infectious that even the lymph of the cow-pock vesicle is sufficiently 
charged with it to convey them. For, unless we suppose an almost 
incredible degree of negligence or stupidity on the part of the 
medical men who vaccinated these patients, — unless we imagine 
them capable of such errors as that of vaccinating patients so covered 
with scabies that the pustules and vesicles of this complaint were 
mixed up with the vesicles of the cow-pock vesicle, there is absolutely 
no other inference to draw. 

Treatment, — Many surgeons consider internal means thrown away 

* An Inquiry into the Relative Frequency ^ &^c., of Skin Diseases^ 1864, p. 21. 
+ Op. cit.y p. 259. 

J On Accidentally Spurious or Impure^ and Effete or Imperfect Vaccination, 
By James Startin, Esq. 

2 T 



322 Treatment of Scabies. 

in the treatment of this complaint, but this belief is not shared by 
some of the most experienced practitioners. No doubt in theory 
the former are right ; if we could apply sulphur properly, medicines 
would be rarely, if ever, called for ; but this is just the very thing 
we cannot always do, and therefore the internal use of sulphur 
becomes an absolute necessity. Common brimstone and treacle 
answers very well with children. For adults, I employ a watery 
infusion of sulphur, made by pouring a gallon of boiling water on an 
ounce of sulphur ; to eight ounces of this an ounce of sulphate of 
magnesia and two drachms of nitrate of potass are added ; two table- 
spoonfuls are given once or twice a day. Mr. Startin gives an 
acidulated saline aperient. Hardy frankly admits that the local 
means used at St. Louis do not always procure immediate relief to 
the itching, while most severe pain is caused by them. 

One of the greatest improvements effected in the treatment of any 
skin disease was the introduction of the penta-sulphite of calcium for 
scabies.* It is cheap, easy of application, cleanly, and painless. For 
adults the solution may be employed undiluted. Women, too, in 
whom the skin is coarse, and many young persons, bear it very well 
of this strength, but generally it requires for them to be mixed with 
an equal bulk of water, and in very young children it can often only 
be employed of the strength of one or two drachms to the ounce. 
When considered advisable, there can be no harm in adding a little 
scent, such as pure spirit of lavender ; or if the surgeon consider it 
necessary to turn hairdresser and adapt his prescriptions to his new 
trade, his genius may find vent in choice and combination of scents 
to any extent. The lotion should be rubbed in with a piece of linen 
every day on each spot, and every papule, pustule, or vesicle should 
be torn open with a stout sewing-needle, so that the fluid may 
penetrate thoroughly. Broken vesications and ulcers may often be 
advantageously dressed with melted zinc ointment. 

Scabies heals rapidly under this treatment, but I may as well state 
that I have never noticed any of those remarkably quick cures of 
which we often read. I have not yet seen vesicular scabies removed 
or even effectually checked in two days or the pustular form in four. 
I should have thought as many weeks more like the time required 
for a cure. 

Dr. Thomas Cattell was, I believe, the first to advocate this plan, 

* For formula see page lo. 



Treatment of Scabies, 323 

having recommended it extensively to the profession twenty-five years 
ago. Dr. Frazer has found it highly successful ; he directs one part 
of quicklime, two of sulphur, and ten of water, to be boiled together. 
The fluid is rubbed in for half an hour with a sponge, a warm bath 
being first given; "a second bath removes the stain left by the friction, 
and leaves the patient quite cured." Hebra attributes the discovery 
to Vlemingkx, of Brussels, who however uses a much weaker 
solution. Hebra entertains a very high opinion of its value, but 
first of all directs the patient to be rubbed all over with potass soap 
(Schmierseife), by means of a cloth, for half an hour, then to be left 
for half an hour in a bath, and then rubbed for the same time with 
the decoction. Another half-hour is spent in the bath, and the cure 
is complete. The artificial eczema, which in some cases follows itch, 
is to be treated with caustic soap and preparations of tar ; excoria- 
tions and ecthyma with cold dressings, wet linen, and lukewarm or 
cold baths ; but it is not disputed that the healing of some of these 
places is a very troublesome process, and I fancy Hebra would find 
the cure of the ecthyma materially hastened by the use of nitric 
acid and quassia internally and benzoated zinc ointment as a 
dressing. 

Dr. McCall Anderson prefers styrax ointment,* or solution of 
chloride of lime, as proposed by Dr. Christison. He advises ladies 
to use a sulphur soap. For large ecthymatous pustules he recom- 
mends t warm baths with a couple of handfuls of potato starch put 
into each bath. Before beginning, the patient should be soaped all 
over. Dr. Spencer, of Oxford, considers iodide of potassium oint- 
ment as trustworthy as that of sulphur. At St. Louis the patient is 
first rubbed all over with black soap, then plunged for half an hour 
into a simple bath, and finally rubbed all over with an ointment 
composed of one part of carbonate of potass, two of sulphur, and 
twelve of lard. This ointment is kept on till next day, and this 
serves to disinfect the clothes. J M. Bazin prefers camomile to 
sulphur. He directs fresh camomile-flowers, lard, and olive oil to be 
heated in a sand bath ; this ointment speedily cures scabies, as it is 
said do stavesacre, iodide of potassium, &c., but I doubt if any of 

* R. Styracis liquidse 5j. 

Adipis 5ij. Melt and strain, 
t The Parasitic Affections of the Skiuy i86i, p. 14 1. 

J Lemons sur les Maladies de la Peau, Par le Docteur Hardy. Deuxi^me 
partie, 1863, p. 205. 



324 Definition of Phthiriasis. 

them will supersede sulphur. Benzine is said to effect the destruc- 
tion of the acarus in a few minutes. Dr. Kempster finds ten grains 
of carbolic acid to an ounce of ointment or glycerine a very effectual 
means of destro)dng the acarus, as also pediculi of every kind. 
Dr. Schulze uses styrax in the following way: two drachms of 
rectified spirit, an ounce of liquid styrax, and a drachm of olive oiL 
This serves for two dressings, and the whole skin is rubbed over, 
not a fold being suffered to escape. 

The clothes should be well fumigated. The best plan I know of 
is to turn them inside out and hang them across a cord in a room ; 
a little chlorate of potass is then put into an old saucer, an iron one 
if possible, half a drachm or so of phosphorus is added, and both are 
covered, except at one spot, with a thick coat of unwashed sulphur. 
The mixture is now fired by touching the phosphorus and potass 
with a red-hot iron or match. Every person must of course leave 
the room, as it quickly becomes filled with sulphurous fumes. As 
much of the lighter furniture as possible, and everything in the shape 
of gilding, such as picture-frames, should be previously removed, 
and the chimneys, windows, and doors closed. Mr. Hooper, of Pall 
Mall, sells these materials all ready prepared, as also the iron saucer. 
Some authors advise that the clothes not in use should be sprinkled 
with sulphur and shut up in a drawer ; also that sulphur should be 
strewed upon the bed. As a good smoking with brimstone does 
the work so very effectually I strongly recommend it I understand 
that the useful system at one time in vogue at some of the public 
baths of providing for the fumigation of clothes has been dis- 
continued. 

B. Phthiri'asis (/i", />, vel eos^ fem.), from 00££f}, a louse. 

Definition. — An irritable, discoloured state of the skin, sometimes 
accompanied by tubercles, pustules, and wheals, occasioned by the 
bites of one or more of the different kinds of lice. 

In a pamphlet reprinted from the Wiener medizin, Fresse, Hebra 
goes at full length into the subject of phthiriasis, and in a spirit of 
downright heresy avows his settled conviction that there never was 
such a disease produced by lice depositing their eggs under the 
human cuticle. Although writers almost without number, from 
Aristotle down to Alibert, have told of the victims of this mysterious 
disease, and related how rebels, anti-popes, blasphemers, heretics, 



Morbus Pedicularis. 325 

simoniacal bishops, persecutors, and, what seems sadly opposed to 
our ideas of even-handed justice, even heroes, poets, and painters 
have been consumed bodily by lice, he clearly does not believe any 
one of them. lie tells the mournful tale of the Portuguese nobleman, 
Tabora, of Lisbon, whose body was so full of lice that two slaves 
had nothing else to do but fill baskets full of them and carry them 
to the sea ; of that murderous devil Philip the Second, who so 
swarmed with them that people could scarcely scrape him clean ; 
of the learned man mentioned by Alibert, who was pursued into the 
very bosom of the Academy, the audacious wretches carrying their 
aggressions so far as to bear off the pen from his hand (! !) ; and of 
M. Laval, spoken of by the same author, who scratched himself for 
twelve years without stopping (!); but then he treats them all as 
fables, and scarcely suppresses his contempt for those who retail such 
legends. 

It must be admitted that all this incredulity is very shocking. 
Nothing is safe if men are to be allowed to go on in this way, and 
insist that every position taken up, every stage in a supposed patho- 
logical process, should be proved before it is admitted. I should 
not be surprised if some sceptic were one day to treat some of our 
favourite doctrines in the same way — blood-poisoning, with its 
intangible process of getting into the blood, and the preposterous 
absurdity of elimination, with other heresies of the day, and many 
other days too— all bound for the one dark bourne. 

While even such men as Devergie and Gibert have believed in 
this phantom of a louse disease, Hebra gives the english surgeons, 
with one exception, the credit of dismissing it to that limbo where 
dwell in cold night the ghosts of so many fables. The exception is 
Mr. Bryant, who mentions the case of a governess in Guy's Hospital 
who could not be freed from the nuisance of these parasites. Some 
of the german physicians, too, Simon, Siebold, and others, have 
honourably distinguished themselves by their exact scientific re- 
searches on this subject. Mr. Bryant is, however, a careful and most 
trustworthy observer, and any statement made by him, however it 
may clash with received views, merits the greatest attention. 

The slightest reflection would have satisfied men long ago that 
these stories could not be true. The louse is an air-breathing animal, 
and could not live under the skin, as some credulous people believe; 
it has no apparatus for boring, so that it could not lay its eggs under 
the skin ; such immense numbers as are spoken of could not have 



326 Morbus Pedicularis. 

lived on the skin, as there is not sufficient surface for them, each 
louse seemingly requiring an area for itself; and if there had been 
space enough on the outside there would not have been blood 
enough inside the body to feed them. Supposing Tabora's slaves 
carried daily two basketfuls of lice to the sea, then a very moderate- 
sized basket would hold a litre. Now computing the size of a louse 
at that of a small barleycorn, a litre measure would hold quite 
10,000. The louse must feed, and judging from the tenuity of its 
food and the quantity of fluid exuded when one is crushed after 
sucking, may be safely assumed to consume at least two minims of 
serum daily. Two litres of lice would therefore require quite 40,000 
minims = 83 ounces of serum. Now, I ask if any person believes 
that the human frame could bear such a strain, or even if it could 
support for any time the exhaustion and irritation which would 
inevitably result from withdrawing the tenth part of this amount ? 

Hebra admits only the usually recognized (three) kinds of lice — 
that infesting the head {pediculus capitis), that in the clothes (/. ves- 
timentorum), and that found on the pubes {phthirius inguinalis, or 
crab). As none of these are furnished with egg-layers, so none of 
them can pierce the cuticle and lay their eggs beneath it. They do 
not breed together, and one species does not invade the domain 
of the other. He totally denies the existence of the variety which 
has been thought by some persons to afflict patients in a state of 
marasmus (/. tabescentium). 

But if lice cannot produce the once dreaded disease (morbus 
pedicularis), they can occasion a great deal of misery, being pro- 
vided with weapons thoroughly adapted for irritating the skin. 
Underneath the snout lies a pair of brown-coloured mandibles, with 
which they bite their way into the skin, while the snout serves to 
pump the serum. When the louse bites, the skin round the puncture 
swells into a fold, which catches the finger nail when scratching, and 
consequently the excoriations .from this source are disproportionately 
large. Boils and carbuncular swellings may result from the prolonged 
scratching thus induced. Certain forms of impetigo (the achor 
mucosus and impetigo granulata of Hebra) are very often accom- 
panied by lice, a fact also noticed by Willan. Swelling of the glands 
of the neck from the itching may proceed to such an extent as to 
induce suspicion of scrofula. Add to this the rapid increase of these 
vermin in numbers, for a louse will bring forth 5,000 young in eight 
weeks, and we have enough real ills resulting from the presence of 



Treatment of Phthiriasis, 327 

these pests, without inventing phthiriasis ; such, at least, is Hebra's 
experience of quite 11,000 patients afflicted with these hateful things. 
Treatment. — In general, lice are very easily disposed of. When 
they get into the hair of children, the small-tooth comb is the best 
remedy, and a weak wash of bichloride of mercury, gr. ss to gr. j., 
in an ounce of rose-water, will effect the destruction of the nits, or 
coculus indicus powder may be blown in with a puff. There can be 
no doubt that in some children lice are much more difficult to 
remove than in others. I saw this in the case of two young ladies, 
sisters, sleeping in the same bed, and nursed by the same person, a 
most careful and exemplary mother. The elder sister was freed from 
them in two or three days ; in the other, notwithstanding the most 
devoted care, they were constantly reappearing for many weeks. 
Stavesacre ointment * answers very well for the irritation set up by 
the body-louse in grown and elderly persons. It should be rubbed 
on every day. In some severe cases no treatment is more service- 
able than that for scabies, especially as regards the fumigation of the 
clothes. Elderly people suffering from this disease are often out of 
health, and are benefited by steel, nitric acid, bitters, and purgatives. 
For the pediculus pubis the lotion of bichloride of mercury, just 
spoken of, answers very well. Dr. Purdon finds oil of santal-wood, 
suspended by means of glycerine and spirit, a very cleanly and 
useful remedy in phthiriasis. The sea worm-wood (absinthium 
maritimum), so highly extolled by Linnaeus as a " pulcifuge," might 
be tried. 

* The best formula for stavesacre ointment that I know of is that recommended 
by Bourgignon. It is — 

R. Staphisagriae sem. ^iij. 
Adipis praep. ^v. 
The materials are to be digested in a sand bath at boiling- water heat for twenty- 
four hours and then strained. It is essential the seeds should be fresh. 



( 328 ) 



CHAPTER XII.— RELIQUIAE. 

Under this head I have ventured to group together, for the sake 
of convenience, all the remaining forms of cutaneous disease which 
I propose to notice. I do not seek to defend this arrangement, 
except on the ground that it saves a great waste of time, which, I 
submit, would be very ill spent in giving all the reasons for sub- 
dividing these disorders into as many groups as there are names. 
This chapter accordingly embraces — 

A, Warts, B, Corns, C. MoUuscum, D. Scleroderma. E, Rank 
Perspiration. F. Leucopathia. G. Ephelis and Lentigo. H. 
Chloasma. I. Bronzing of the Skin. J. Silver-staining. K. 
Ncevus. L. Mucous Tubercle. 



A. Warts — ^Ver'ruca {a, cb, fem.), supposed to be derived from 
verrucare^ to change a thing for the better, though what possible 
connexion there can be between the two ideas, or why warts 
should more than any other disease be distinguished by a 
capacity for change for the better, our commentators do not 
explain. 

Definition. — Clusters of enlarged papillae, covered with thickened 
epidermis, generally nearly circular in form. Fissured. Most fre- 
quently met with on the hands. Those on the face usually pointed. 
Dr. Wilks has described a variety (verruca necrogenica\ which attacks 
the knuckles and wrists of those engaged in post-mortem exami- 
nations. 

Auspitz holds that in homy affections (keratoses) such as ichthyosis. 



Warts. 329 

there is either no change in the form and size of the papillse, or it is 
due to the presence of the hypertrophied homy layer ; while condy- 
lomata, warts, and epithelioma (papillomata) are due to an active 
neo-plastic process in the rete, which process penetrates more or 
less deeply into the connective tissue of the corium, this being also 
hypertrophied. The alterations in size and form of the papillse are 
due simply to changes in the epidermis. There is no anatomical 
difference of any moment between warts, pointed condylomata, and 
cauliflower excrescences. According to Auspitz, epithelioma shows 
remarkably how hypertrophy of the epidermis pierces into the con- 
nective tissue of the corium. According to my observations, 
vascularity and nervous action are not unfrequently augmented in 
these growths. 

There is a form of wart so like lepra, or of lepra so like wart, that 
I am at a loss to know which of the two it is, or if it be a compound 
of the two disorders, that is to say, a form of growth possessing 
characters common to both. I have only seen three well-marked 
cases, and though evidently examples of the same disease, there 
were yet marked differences between them. In one patient, a girl, 
I was able to trace the progress of the complaint, which I could not 
do in the others. She was pale, slightly made, except about the 
legs, which were extraordinarily thick below the knee, and of low 
stature. Just below the knee and on the front part of the one leg 
were six or seven dark-coloured warty-looking growths, varpng in 
size from a sixpence nearly to a halfpenny. On the knee and front 
part of the same leg there were at least twenty or thirty more 
coming. They evidently all began as lepra-spots, none of them 
being at the outset bigger than split peas, and giving to the hand 
when passed over them a sensation like that of spines. When the 
hard summit was removed, the surface below was exactly like a lepra 
patch, red and flat. They soon, however, became conical again. 
All were for a time covered with bright silvery scales, about the 
nature of which there could be no mistake. The other leg was 
similarly affected, but not to so great an extent. This, the mother 
told me, had always been the case. The girl has two sisters, said 
by a gentleman who ought to know, to have lepra. There is no 
history of hereditary disease of any similar kind in the family. 

Arsenic seems undoubtedly to have great power over the simple 
form of warts, especially when seated on the face. Not very long 
ago I prescribed it with entire success, the growth having been 

2 u 



330 Corns ; Molluscum. 

pretty rapid up to the time of beginning with the medicine, and 
being quickly stopped by its use. At the end of some weeks all 
traces of the disease had disappeared. As a local application, I 
prefer the hot iron as the most efficacious, speedy, and least painful 
remedy. It is not necessary to burn the skin in the least ; all that 
is required is to touch the tip of the wart and bum as much each 
time as the patient can easily bear. Dr. Hillier found five-grain 
doses of magnesia and a drachm of cod-liver oil useRil in a case of 
warts in a boy. The growths were seated on the arms, hands, and 
other parts. The girl just spoken of seemed to be very much 
benefited by the same treatment as that laid down for ichthyosis. 

B. Corns — Cla'vi, Clavus {usy /, masc), a nail. 

Definition. — ^An elevation and thickening of the cuticle covering 
a small portion of skin. Generally nearly circular in form ; of 
a brownish-yellow colour, sensible at its base. Central part com- 
posed of harder and more translucent material than the rest. Cells 
arranged obliquely, forming concentric arched laminae with the 
concave side downwards. Thickening, hardening, and increased 
nervous sensibility of the cutis lying imdemeath. 

Treatment — Corns are a more serious matter than warts ; they 
may bring on bunions by pressing on bursas, or make their way into 
joints, causing ulcers, absorption, and exfoliation of the bones. The 
first step towards a cure is to have a last made expressly for the foot, 
with a prominence on it corresponding to each com and rather 
larger. I have seen people suffer martyrdom for want of this simple 
precaution, which insm-es much greater comfort than a loose boot 
If the boot still cause pain, the part over the com should be steeped 
in hot waster till it is quite soft and then stretched over the last 
Amadou plaster should be applied over the com itself, and every 
three or four days the com should be thoroughly softened with very 
hot water, pared or rasped down, and then painted with strong 
tincture of iodine or gently mbbed over with solid nitrate of silver. 
Caustic potass is very useful in refractory cases. 

C. MoLLUs'cuM (urn, i, neut.), firom mollis^ soft 

Definition, — Slowly-forming, slightly lobulated, sometimes pedun- 
culated swellings, apparently due to closure of the mouths .of the 



Molluscum. 331 

sebaceous follicles, generally of the natural colour of the skin* 
Often depressed in the centre of the summit. Chiefly situated on 
the neck, face, and shoulders. 

Divisions. — i. M. contagiosum, answering to the description given 
above. Very possibly contagious in some cases. In a form of this, 
called by some writers molluscus simplex, we find growths of the 
skin, generally pedunculated, varying in size from a pea upwards. 
Growth of both very slow. Texture soft and flabby to the touch. 
2. M. fibrosum, a slow growth of peculiar fibrous tumours, in size 
from a pea to a walnut, or even larger. Painless. Not discoloured. 
Sometimes sessile ; sometimes pedunculated. Often found on skin 
covering ribs and back. 

In the first volume of the Journal of Cutaneous Medicine * there 
is an extraordinary case of fibroid molluscum by Dr. Izett Anderson. 
The tumours were scattered all over the frame from head to foot,^, 
almost the whole of the trunk, fi:ont and back, being studded with 
them. Dr. Anderson examined two of the smaller tumours. The 
section of one revealed a dense, pure white surface, like that of a 
raw turnip or bacon fat. The microscope showed that it consisted 
principally of fibrous tissue, the fibres arranged in large thick bundles, 
inclosing loculi full of plastic matter, apparently being developed 
into cells. When squeezed, a drop or two of glairy fluid exuded, 
containing granules and cells, many of the latter assuming a fusi- 
form condition. There was no appearance of a capsule in the 
tumours, and the skin seemed to be quite incorporated with the 
morbid tissue. In some parts the fibrous tissue of the derma had 
softened and degenerated. 

Dr. Hilton Fagge, in a very able paper f on the anatomy of this 
disease, has arrived at the following conclusions : Each tumour is 
developed round a hair-follicle and its sebaceous gland. The smaller 
tumours consist of a central glandular body surrounding a hair, and 
a quantity of very fine connective tissue with numerous minute oval 
nuclei. These two elements, the glandular body and the connective 
tissue, are present even in the smallest tumours. The glandular 
body itself is a sebaceous gland, enlarged by the sacculi separating 
from each other. Very possibly the sacculi are also increased in 
size and multiplied. Dr. Fagge thinks the connective tissue is 

* Page 60. 

t Anatomy of a Case oj Molluscum fibrosum^ Med. Ckir, Trans., vol. liii. 



332 Treatment of Molluscum; Scleroderma. 

developed from the outer layer of the dermal coat of the hair-follicle 
and sebaceous gland. Some of the tumours in the case he is 
describing were embedded in the cutis, others lay almost entirely in 
the subcutaneous tissue. The hair-sacs were visible in the form 
of greyish dots, and the tumours seemed to consist nearly all of soft 
reddish material. 

Treatment, — In the two first forms (M. contagiosum and simplex) 
removal with the scissors and the application of any mild escharotic 
to the base are generally all that can be considered requisite. In 
children I have seen the use of steel wine, and saccharated car- 
bonate of iron produce falling of the tumours. In one case, that of 
a child, the growths began to drop off rapidly in five or six weeks 
after the steel had been begun with. In another the saccharated 
carbonate of iron produced much the same effect in about the 
same time. Bateman saw arsenic produce a general diminution in 
the tumours, and the experience of other surgeons has confirmed his 
statement I have found it impossible to persuade grown persons 
suflfering from this complaint to attend regularly, so that I could not 
judge properly of the power of arsenic. With one exception, I have 
only seen the contagious form in adults in suckling women, and 
here it is necessary to give arsenic with care. In the fibrous form I 
should not expect any benefit from medicine. I have had only one 
opportunity of fairly trying it, and in that case I gave iodide of 
potassium and liquor potassse for months without producing any 
effect. 

D. Scleroder'ma (a^ atos^ neut), from aKXripdcf hard, and Mp/ia, 

skin, hide. 

Definition, — A slowly-growing hardening of the skin, starting from 
one particular point, usually on the upper part of the body, and 
gradually but irregularly spreading in all directions ; often with bands 
of dense tissue, almost like the cicatrices of a bum in point of hard- 
ness, radiating from it Colour and sensibility of the part not 
affected at the beginning. May, however, be preceded by erythema 
or aching in the skin, and sense of burning. When attacking the 
face, sometimes causes such contraction and stiffness as to require 
the removal of some of the teeth to allow food to be taken. Tongue 
may participate in the disease. Often ascribed to a chill or 
getting wet 



Scleroderma. 333 

It seems quite certain that at least four forms of this disorder must 
be recognized, i. Diffused scleroderma (scleriasis\ corresponding 
to the description just given, and generally recognized as the disease. 
2. Local scleroderma, the keloid of Addison, where the indura- 
tion takes place in the form of roundish white patches from two 
lines up to two inches in diameter, surrounded by a zone of redness 
with a horny spot in the centre. 3. An inflammatory and fatal form 
described by Rasmussen. 4. Rhino-sclerma, described by Hebra. 

Dr. Hilton Fagge showed the Pathological Society * a case of the 
first-mentioned form (diffused scleriasis he calls it), in a woman 
sixty-five years of age. The disease began in the neck and extended 
over the cheek, arms, back, and ch'est. The sensation was not im- 
paired. In front of each elbow there was a band of dense tissue,, 
which when stretched, looked like a cicatrix (the morphea of 
Addison). This gentleman also gives two cases in Gwfs Hospital 
Reporis,\ In one of these, when one of the bands was scraped with 
a knife, the effect was very peculiar; tlie surface creaked beneath the 
blade, and the epidermis brought away looked more like moist, 
dirty sand than anything else. No change in the epidermis was 
detected by the microscope ; some of the cells floating free in the 
liquid had an unnaturally glassy appearance. 

A very severe case of diffused scleroderma is related by Mr. 
Startin in his lectures in the Medical Times,X He calls it ichthyosis 
cornea ; but with all due deference to Mr. Startin's opinion, I think 
it clearly belongs to the disorder I have just attempted to describe. 
The patient was a young lady, and the affection is supposed to have 
had its origin in venaesection, followed by a severe chill. Numerous 
small pustules formed, emptied themselves and healed, leaving a 
homy point or scale at each place. The disease had gone on for 
years, the limbs, body, hands, face, and scalp being affected with 
intense rigidity, in which even the tongue was involved. 

Hebra, in the Wiener medizin, Wochencshrift^ § describes a form 
of this affection, which he calls rhino-sderma, and which is, I believe, 
quite unknown in England. He has only seen nine cases, — ^four in 
men, five in women. It is generally seen only on the nose and 
upper lip, but may attack also the cheek and forehead. It consists 

* Lancet^ 1869, vol. ii. p. 842. f Third Series, voL xv. p. 298. 

X Vol. xiii. p. 371. 

§ Jan. 1870. Translated by Edward Fjraukel, American Journal of SyphilO' 
graphy^ vol. i. p. 146. 



334 Treatment of Scleroderma, 

of flat, hard swellings, projecting as much as a line and a half in 
some parts, with a sharp border and steep edges. The colour varies 
from that of the skin to a deep reddish-brown ; the upper surface is 
smooth but rarely shining. The swellings feel as hard as ivory. The 
growth of the tubercles is exceedingly slow, and they neither 
degenerate, ulcerate, soften, nor do they become absorbed. The 
nose is always implicated, and in one patient the swellings extended 
from the upper lip to the inner canthus, not only filling up the sulcus 
between the nose and the cheek, but overlapping with their edges 
the zygomatic arch on each side. An examination by Dr. Moriz 
Kohn showed the epidermis and Malpighian layer normal, the 
papillae larger than usual, conical or knobby, their external con- 
nective tissue wasted, that of the body of the papillae being merely 
a network of slender fibres, their blood-vessels few and much 
diminished in size, as were the fibres of the connective tissue of the 
vascular stratum. These parts (the network of the vascular layer and 
papillae) were crowded with small cells, which in places extended 
down into the corium. These cells possessed small, little refractive, 
finely-granulated nuclei. They were very slightly attached, being 
easily displaced. The corium was only superficially attacked, the 
deeper parts being free. No sudoriparous or sebaceous glands were 
found in the affected parts examined. Treatment seemed to be of 
no avail, arsenic, iodine, and mercury continued for years, having 
failed to produce any effect. 

In one of Dr. Fagge's cases of the diffused variety * considerable 
improvement took place under the influence of quinine and cod-liver 
oil. Dr. McDonnell, who had previously described this disease, 
speaks of its tendency to spontaneous resolution. A case is related 
in the Medical Press and Circular ^^ in which great benefit resulted 
from the use of grey powder and Dover's powder, chlorate of potass 
with bark, and frictions with mercurial liniment. Warm baths every 
other day, first of simple and then of sea water, with s)rrup of the 
iodide of iron in half-drachm doses, were clearly useful in a case 
treated in the Hamburg Hospital, and reported in the third volume 
of Hat Journal of Cutaneous Medicine, In one case under the care of 
Dr. Addison, Dr. Fagge ascertained that spontaneous disappearance 
of the hardness had taken place. Mr. Sedgwick brought before the 

* Guy^s Hospital Reports, Third Series, vol. xv. p. 298. 
t For 1869. 



Rank Perspiration. 335 

Pathological Society* another case. The patient was a child, who had 
thrown off the disease. As cod-liver oil had been given, this might 
have had some influence. The child sprang from an unhealthy, 
delicate, strumous family. The disease consisted in the formation 
of sclerous patches of skin, which first grew pale, and then of a light 
brown or dirty straw-colour, with a horny plate in the centre. They 
formed below the right jaw, on the front of the body, on the neck, 
behind the right ear, at the outer angle of the right lower eyelid, &c. 
There was also a very well-marked patch on the tongue. At a sub- 
sequent date the skin had almost recovered its healthy appearance. 



E. Rank Perspiration. —Derivation and definition omitted as 

superfluous. 

This is such an offensive affection that it ought to be got rid of at 
any cost. Not the least painful feature of the case is the fact that 
some of those suffering from it are not aware of their infirmity. 
Cleanliness inside as well as outside is one of the first necessities. 
It has been well observed that many people who would be shocked 
at the idea of having a dirty skin, never think how dirty the inside is, 
or how much depends on their own exertions for keeping it clean. 
The great highway of life is left to purify itself 

Arsenic has always appeared to me the most effectual remedy. 
Purgatives given two or three times a week and tonics often do a 
great deal of good, and the same may be said of cod-liver oil and 
a properly-regulated diet, but still a course of arsenic is essential. 
The clothing, stockings, boots, &c., should be of the lightest descrip- 
tion. Many of those patients bring on or develop their complaint by 
a chronic dread of catching cold. When the armpits are affected; the 
hair should be cut short or pulled out ; the latter is by far the most 
efficacious. The armpits, folds of the groin, and feet should be 
washed every day with hot water and soap, and then dusted, after 
well drying, with rice-powder. If any smell linger after this, free use 
should be made of chloride of zinc or permanganate of potass in the 
form of a lotion, or occasional brushing with tincture of iodine may 
be tried. In a case accompanied by offensive breath. Dr. Kempster, 
of Utica, gave two drachms three times a day for two days of a solu- 
tion of carbolic acid, a grain to an ounce j accompanying this by the 

• Transactions of the Pathological Society^ vol. xii. p. 234. 



336 Leucopathia. 

use of a lotion of the same salt, five grains to an ounce, and effectually 
checked the symptoms.* 

Hebra, in the form affecting the feet, recommends t light shoes and 
dusting the skin with lycopodium, alum, or common flour, or cover- 
ing every part with an ointment of equal parts of diachylon plaster 
and olive oil spread on linen. At the end of twelve hours this is 
taken off, the skin is again dusted, and the ointment reappUed. The 
feet are not washed till the old brown epidermis has come away. Mr. 
Stanislas Martin says the smell may be removed by wearing a false 
sole inside, made of gum-arabic and charcoal, fifteen parts of the 
former to forty of the latter. This is moistened, made into a paste, 
and spread on felting or flannel felt After being covered with 
paper it is smoothed with the hand, squeezed for an hour to get 
out the water, and then cut to the shape of the foot. 

For excessive perspiration. Dr. Druitt, in an excellent practical 
paper, % recommends sponging with hot water. When the skin is 
greasy this remedy should also be tried ; active exercise, sleeping 
with the windows open, tonics and aperients, and avoidance of malt 
liquors are often very useful. Astringent lotions of bichloride of 
mercury and washing with juniper tar soap have also been recom- 
mended. When, on the other hand, the skin is pretematurally dry, 
it should be stimulated by free rubbing and sponging. Iodide of 
potassium has here more than once proved useful 

F. Leucopath'ia (ciy as^ fem.), (or Letue^ properly Leuke), from 

XtvKoQy white, and Trafli;, a disease. 

Definition, — Oblong, oval, or circular patches of bleaching of the 
skin, unattended by loss of sensibility or any perceptible change in 
the health. Rare. 

Treatment. — I have very little to say on this part of the subject, 
having only had a chance for a short time of trying medicines. Most 
patients will, I fancy, never submit to what they think a series of 
experiments for a disease which is, after all, only an inconvenience 
or an eyesore. In one case where the stains were seated on the 
backs of the hands, I gave steel and arsenic for between two and 
three months j the patient, who was a highly nervous, rather delicate, 

* jfournal of Cutaneous Medicine^ vol. ii. p. 449. 
t Medical Times and Gazette, 1865, vol ii. p. 265. 
t Ibid.y vol. i. p. 222. 



Case of Acute Leiue. 337 

sparely-built man, then went into the country. His health improved 
under the treatment, but no alteration took place in the patches. 
There seems little doubt that in a rare case or two the natural hue 
of the skin has been restored by means of tonics, shower-baths, and 
stimulating liniments to the affected parts. M. Biett says that blisters 
and the active use of sulphur externally, in the form of ointment and 
douches, are of service. 

The following case may, I think, be considered as an instance of 
acute leuce arrested or cured. 

Annie C , aged 18, living at St. Alban's, entered as out-patient 

September 8th, 187 1, with leuce affecting both feet. ,She had 
hitherto enjoyed very fair health, and to all appearance was exceed- 
ingly healthy, being, though short, very compactly made, with plenty 
of colour and a bright clear complexion. She menstruated pretty 
regularly, but rather too often, and with some degree of pain. She 
looked then, and appeared all through her attendance, one of the last 
persons to be nervous or fanciful. Her account was, that in June 
of the same year she began to feel the left foot sore in the daytime 
and heated at night. She was thus led to examine it, and found, 
under the ball of the great toe, a whitish spot about the size of a 
shilling. This gradually increased in diameter, and shortly before 
she commenced attendance a similar spot formed on the heel of the 
same foot. Subsequently the same appearance made itself visible 
all along the edges and under-sides of the toes and between them, 
and then by patches on thetir upper surfaces, principally, however, 
over the great toe. Very soon after a similar whiteness began to 
attack the right foot, which had also become very sore, starting from 
the plantar surface of the toes, then creeping towards the hollow of 
the foot, and after that stretching more rapidly than before from the 
hollow of the foot to the heel. Next it invaded the insides of the 
toes, and then spread over their distal surfaces for about an inch 
backwards, reckoning from the tips. The progress of the disorder 
had throughout been accompanied by great pain in the affected parts. 
The sensation strongly resembled that of a scald, and was so severe 
that she could scarcely ever stand with comfort, and at times could 
not remain upright at all. 

When I first saw her, September 29th, the skin of the affected 
parts was in a perfectly blanched condition. Except that it was not 
wrinkled, but, on the contrary, firm, plump, and smooth, it looked 
exactly as I have seen the fingers of washerwomen do after a hard 

2 X 



338 Case of Acute Leuce. 

day's work. The edges of the patches were sharply defined, and 
the contrast between the blanched and the healthy portions of skin 
was very striking. 

For two or three years previously she had noticed that the hollow 
of the foot perspired rather freely, but since the bleaching of the 
skin had set in, the perspiration from the affected parts, especially 
from the plantar surface, had been so excessive that she was 
frequently compelled to change her stockings three times a day. 
There was no unpleasant smell connected with the perspiration. 
She has at times felt rather weak since the disorder began, but on 
the whole there does not seem to be any reason for thinking that 
this has much to do with the local complaint. 

From the 8th to the 29th of September she was attended by my 
colleague, Mr. Bowden, who prescribed her salines and ordered her 
to put her feet in salt-and-water. On the 29th she came under my 
care. Not knowing what to do with such a case, I prescribed 
tolerably full doses of arsenic in the form of the solution of de 
Valangin, but, according to her account, the pain and soreness 
increased both rapidly and decidedly under the influence of this 
treatment, and it was therefore exchanged for the saturated solution 
of iron in strong hydrochloric acid ; of this she took three drachms 
weekly up to the 26th of January. 

Owing to her living at such a distance I only saw her at rather 
long intervals, and did not keep any notes of the case at this time, 
but she tells me that during October and November there was littie 
improvement as regards the colour, although the pain had a good 
deal abated. • The diminution in the latter symptom was, however, 
fitful, and at times the morbid sensation returned almost as bad as 
ever. When seen, however, on the 20th of December, there was an 
alteration in the colour for which I was not prepared, and she told 
me that the natural hue had been returning steadily for the last 
three weeks. At her next visit, on the 5th of January, 1872, there 
was scarcely any discoloration, and when she again called, January 
26 th, I was unable to distinguish a single vestige of the disease, and 
a surgeon who was present at the examination was not more fortunate 
than myself in finding any traces of it. She was therefore, at her 
own request, discharged cured. She stated that there was now 
scarcely any abnormal sensation, and that the perspiration had 
diminished in proportion as the bleaching had passed off. She had 
continued the salt-and-water up to the present time. 



Ephelis ; Lentigo; Chloasma. 339 

It seems only a fair conclusion that the remedies had some share 
in bringing about the result. I do not however take any credit to 
myself on this score ; for, as I said before, I was quite at sea as to 
the treatment, and I merely seek to place the facts of the case on 
record without venturing to draw an}1;hing beyond a very guarded 
inference from them. 

G. Ephelis and Lentigo. — Ephe'lis (/>, idos^ fem.), from £iri, on 
account of, and ^Xioc, the sun. Lenti'go (^, iginisy fem.), from 
lensy a lentil. 

Definition, — A deposit of minute patches of brown pigment, 
possibly containing an excess of oxydized iron, in the lower surface 
of the epidermis, seen principally on the face and backs of the 
hands. Lentigo might, I think, very well be omitted, and all 
varieties of the affection embraced under the name of ephelis or 
freckle. 

Treatment, — The perchloride of mercury in almond emulsion, one 
to two grains in four ounces, will, I fancy, remove every case that 
can be cured by treatment. 

H. Chloas'ma ((ty atos, neut.), from x^o«> «c> green herbage, grass. 

Definition, — Deposition of very slowly-forming patches, streaks, 
&c., of yellowish-brown pigment under the surface or in the lower 
side of the epidermis. Often seen on the face, especially the fore- 
head, unaccompanied by brawny desquamation. * 

The reader will see that by chloasma I mean a distinct disease 
from pityriasis versicolor. The disorder, which is much rarer than 
what is usually called chloasma, is not unfrequently seen in married 
women, the patches growing darker with each successive pregnancy. 
I consider Mr. Wilson has committed a grave error in confounding 
two aflfections between which there is such a clear line of demar- 
cation. 

In the first volume oiiht Journal of Cutaneous Medicine there is a 
digest, written by myself, of a paper by Hebra on this subject,* of 
which I now give a very brief abstract. Hebra divides chloasmata 
into idiopathic and S}'Tnptomatic, and the idiopathic into artificial 
and coincident. The symptomatic are a result of sexual, mostly 

* Page 77. 



340 Bronzing of the Skin. 

uterine, disorder, of cancerous diseases, and other general morbid 
conditions. The artificial result from long-continued pressure, as of 
garters, braces, from scratching, as in prurigo, from vesicants, from 
heat and great exposure to light. The brown stains seen on the 
forehead are often due to uterine disturbance and pregnancy. These 
latter may assume the shape of spots and stripes ; they often follow 
the arch of the eyebrow, or may assail the skin of the upper or under 
eyelid. The skin of the concha of the ear, the chin, and the under 
part of the neck always escapes. They disappear with the cessation 
of the functions of the uterus. Maliiria frequently engenders a dark 
brown or yellow chloasma. His treatment is to brush the part with 
tincture of iodine three or four times a day for four days following. 
After the browned epidermis has fallen off, the new scarf skin appears 
of a normal hue. He also recommends bichloride of mercury lotion, 
five grains to an ounce, used as a compress, and white precipitate 
and magist^ry of bismuth in the form of ointment. I never saw 
distinct benefit from anything that I tried. 



I. Bronzing of the Skin {Morbus Addisonit), Derivation and 

definition omitted as superfluous. 

Dr. Greenhow's views, which may be accepted as the most 
advanced and accurate on the pathology of this disease, are as 
follows : — I. Constitutional symptoms invariably co-exist with a 
peculiar degeneration of the capsules, allied to tuberculosis. 2. A 
darkened condition of the skin is almost constantiy associated with 
constitutional symptoms. 3. A stained condition of skin may 
accompany several forms of non-specific disease of the capsules 
independently of constitutional symptoms. Thus there are three 
factors, — the affection of the capsules, the constitutional symptoms, 
and the staining. To constitute true Addison's disease the two first 
must be present, and they are generally accompanied by the third. 

With regard to this somewhat rare complaint, I have little to say. 
Respecting the pathology of it I must refer the reader to the writings 
of Addison, Greenhow, and others. Professor Oppolzer says* that 
Virchow was the first to show that this affection may accompany 

* Wiener med. Wochmschrift, 1866; also Journal of Cutaneous Medieine, 
vol. i. p. 432. 



Treatment of Bronzing of the Skin, 341 

cancerous disease as well as tubercular degeneration; he now inclines 
to Addison's view. The capsules are liable to nearly all forms of 
disease which assail glandular organs. The staining takes place on 
the under surface of the rete Malpighii, and in many places penetrates 
the superficial part of the cutis. It appears in the form of reddish- 
brown pigment-granules, partly scattered in an irregular manner, 
partly deposited in individual cells ; even the brain and outer layer 
of the venous walls may become the seat of this change. Buhl 
found great loss of fibrine in the blood and increase of the white 
corpuscules. Oppolzer thinks there is considerable anaemia of the 
nervous centres, and that dyspepsia is more common than vomiting. 
The cases in which the staining corresponded with some disease of 
the capsules are very much more numerous than those in which 
these bodies were sound. Still several of these have been noticed, 
as by Peacock, Simpson, May, Hutchinson, and Greenhow. On 
the other hand, several instances of disease of the capsules without 
staining have been recorded ; Max Doderlein has alone related four. 
Ogle and Manneret have each contributed one. 

Treatment. — It is very doubtful whether any medicines possess 
influence over this disease, and whether the few instances of re- 
covery or arrest are not purely spontaneous. The prognosis is 
consequently unfavourable in the highest degree. Still I think it 
only fitting to bring forward a few particulars tending, I hope, to 
throw some light on the subject. 

In addition to the case mentioned by Mr. Hutchinson, Professor 
Seitz mentions • one in which the patient, a working man, seemed to 
be benefited by the employment of iodide of potassium and Heilbronn 
waters ; he left the hospital relieved, and did not return. Another 
patient also derived some good from the use of the iodide, but the 
improvement was of short duration. Dr. Greenhow says,t " Treat- 
ment directed toward quieting the gastric irritation and improving 
the patient's powers of taking and digesting food, together with care 
in securing the avoidance of fatigue and of all other causes of depres- 
sion may, and I believe will in many cases, if employed early enough, 
tend to prolong life and to ward off the fatal asthma even after the 
organic disease is confirmed." ,He has found the compound mixture 
of iron and cod-liver oil useful, also nitro-muriatic acid with vegetable 

* Deutsche Klinik^ 1 866. Also Journal of Cutaneous Medicine^ vol. i. p. 433. 
+ On Addison^ s Disease. ByE. M. Greenhow, M.D. 1866, p. 22. 



342 Cases of Morbus Addisonii. 

bitters, dtemated with citrate of iron in tiieeflfei^escmgfo^ Chloric 
ether, brandy, and beef tea have produced temporary rallying. 

In the second volume of Hat Journal cf Ctdaneous Mediant I gave 
the history^ of a case in which, after a course of arsenic, a very decided 
dedine in the staining took place. The patient was a girl twenty 
years of age. Wliep I first saw her the skin of the fece, neck, and 
fi-ont of the chest almost down to the waist, looked of a dirty day- 
colour with a substratum of a pale dirty green, tiie tint at the side^ 
of the waist being much darker. From the waist to about nine inches 
above the knees the colour was, according to her account, for I did 
not examine this part, lighter than anywhere else, but fnom above 
the knees to the foot the colour was again much darker, the s taining 
occurring in the form of patches, which locked like pale raw bacon. 
These patches shaded off into the hue of the surrounding skin, which 
itself was again darker than that on the chest and abdomen. The 
skin of the arms was darker than it ought to be, especially at the 
bend of the elbow ; the colour, however, was far lighter than on 
the legs. Her feet were stiff and painful, but with the exception of 
this and an occasional headache she had nothing to complain of; 
there were a few small patches of lepra on the feet and legs. Her 
tongue was quite dean, and menstruation, which began at an early 
age, was regular in all respects and fi-ee fitmi severe pain. Bowels 
open. She stated that she had perspired Httle or none for two years, 
and thought, though not quite sure, that previous to this time she 
did so. AMien quite young she suffered fix)m what she was told was 
a sluggish Hver, but thought she had quite thrown this offl I never 
saw any symptom of such an affection, and I may here mention that 
the conjunctiva was perfectly dear. At one time a gnawing pain in 
the upper part of the left thighbone gave her a good deal of un- 
easmess, but this too had left her. She never suffered to any extent 
from pain in the region of the kidneys or loms. Her mother said 
tiiat when bom the patient was of a very dark colour, almost black, 
but that m a few days she became light and always remained so. 
There was no history of any mixture of race in the femily. Her 
ocojpation was not laborious and did not confine her to the house. 

rhe treatment consisted of five-minim doses of Hquor ai^enicalis 
^ ce daily, gradually increased till she took two hundred mmims 
rJ^ni ^^ ^^ ^^ exception of about a month when it was sus- 

S^lS^V^"^"^' ""^ ^^""^ ^^ *^ ^"^^ maintained with great 
regulanty fi-om the 9th of November, ,865, up to June, 1866. 



Cases of Morbus Addisonii. 343 

At first the colour darkened, till, on the back of the neck, the 
front and upper part of the bosom, and on the front of the knees 
and feet, it had, at the end of about two months, assumed a dark 
olive hue in some parts and the colour of raw bacon in others. The 
patient remarked that she was turning " bronze-black." The pain 
and stiffness in the feet grew worse. The symptoms then remained 
stationary for a few weeks, and finally began to decline. When I 
last saw her, in the summer of 1868, I found the skin of the face, 
though still very decidedly pale and dark, much brighter and clearer. 
The neck, bosom, and upper part of the back were of a light yellowish 
brown, almost like that seen in some dead leaves. She told me that 
down to a little below the bend of the thigh the colour was much 
lighter, but from considerably above the knee to the foot, the old 
bacon tinge, though very much faded, was still distinctly seen. 
However, even this had become much lighter during the last few 
months. Some of the lepra patches had left slightly reddish stains. 
She represented herself as being in very good health.* 

The following case is the only one of golden staining of the skin 
that I have seen. 

The patient, a physician, otherwise healthy, but of a most ex- 
citable temperament, began to suffer about seven years ago from 
what he at first thought was lumbago, but which he subsequently 
took to be neuralgia of the loins. For this he repeatedly used 
hypodermic injections of morphia and took large quantities of 
medicine. Three years later he fancied he had caught gonorrhoea, 
but there was no discharge beyond a little muco-purulent matter 
and no history of infection. I endeavoured to dissuade him from 
doing anything for it, but instead of that he injected four times in 
rapid succession, within a few hours, a strong solution of nitrate of 
silver, injecting as far as the neck of the bladder. This naturally 
enough set up violent pain in the urethra and bladder, from which 
he was, according to his own account, never again entirely free, and 
he consequently resorted to subcutaneous injections of morphia to 
relieve it. 

Next, the patient fancied he had contracted syphilis ; but here 
again there was no history of infection, nor could I make out any- 

• The address of this patient was, with her free assent, given in the journal 
spoken of, in order that any one who felt so disposed might inquire further into 
the matter. 



344 Cases of Morbus Addisonii. 

thing like chancre. He now consulted at least twenty medical men 
for this complaint, and finding they would not support his view of 
the case, became his own medical adviser, and took an extraordinary 
quantity of mercury for it. I have every reason to believe that he 
often dosed himself seven or eight times a day. On one occasion 
he made his mouth so sore that, according to his own account, he 
could not take any food at all for some days. At last he began to 
fancy he was wrong, and then resorted to sulphur-fume baths, to 
neutralize the effects of the mercury. 

About two years before his death bright golden spots began to 
appear on different parts of his body and limbs, and increased in 
number till there were several hundreds of them. They varied in 
size fi*om a small split pea to a half-sovereign. It must be understood 
that I never measured any, but certainly my impression was that 
some of the largest reached the size mentioned. They were mostly 
of an extraordinarily bright colour ; indeed almost like sections of 
gold leaf, or small coins of this metal, such as the american gold 
dollar, laid upon the skin ; some resembled patches of gamboge. I 
do not mean to say that the colour was as deep and bright as gold, 
neither was it uniform all over the patch as gold would be ; I confine 
myself to stating that the appearance of the spots suggested the 
comparison. This appearance alarmed him seriously, and though, 
after a little while, he threw off his apprehensions and continued for 
the most part to enjoy excellent spirits, they returned at intervals. 
So strong indeed was this feeling that he repeatedly assured his family 
he could not live till the next day, made all arrangements for his 
funeral, and filled up his own certificate of death. With all this he 
shpwed no particular sign of ill-health. Except after the occasional 
attacks of pain in the loins and bladder, when he always seemed 
unwell — partly perhaps owing to the inordinate quantities of medi- 
cine he continued to swallow for every symptom — he was in high 
spirits and extremely active. Though I repeatedly questioned him, 
he assured me that he never suffered from loss of strength, breath- 
lessness, palpitation, weight over the loins, feverishness, or night 
sweats. Nor was , there any coldness beginning at the loins, 
pulsation of the abdominal aorta, tendency to sleep, electric-like 
sensation or action in any part of the frame, sickness or anasarca. 
He was nervous and irritable in the highest degree ; beyond that 
there was nothing particular to report. 

He was, when the spots seemed at their height, ordered citrate of 



Cases of Morbus Addisonii. 345 

quinine and iron, solution of chloride of arsenic, and cod-liver oil. 
His o^vn impression was that these medicines did him a great deal 
of good ; certainly the colour of the spots faded while taking them, 
and unless my observations deceived me, the spots themselves visibly 
contracted in size. He felt so much better that he contemplated 
going for a long voyage, when he returned home one day (in April, 
1872) feeling much as usual (but looking so much worse that his 
family sent, unknown to him, for medical aid) and died quite suddenly 
the next day, being, when near death, so little conscious of his 
approaching end, that he had only an hour previously given direc- 
tions about his dinner, and had refused to let any one be called in to 
see him. He had just completed his sixty-fourth year. 

At the post-mortem examination the first thing noticed was an 
extensive discoloration extending from the loins, over the nates, and 
to about three or four inches down the outer part of the thighs. It 
stretched forwards at its most anterior part over about a third of the 
crest of the ilium ; great part of its surface was more of a mauve hue 
than anything else, the proportion of dark-coloured ecchymosis being 
unusually small. A little higher up than the highest point of the 
crest of the left ilium there was an effusion of blood into the adipose 
tissue ; possibly the results of some recent injection, as there were 
marks of punctures near. The organs of the chest were healthy, 
as were those of the abdomen, except the kidneys, which were 
unusually congested. The fat surrounding them was extremely hard, 
and great part of it, on section, presented a glandular appearance. 
There was a tolerably well limited effusion of blood, almost free 
enough to be spoken of as a clot, about an inch in diameter, in the 
fatty tissue enveloping the right kidney. It lay over the anterior 
surface. Although a very careful search was made by the two gentle- 
men who performed the/^j/ mortem and myself, we did not discover 
the supra-renal capsules. After several incisions in quest of them, 
I cut away all the fat and cellular tissue lying on the upper end and 
inner border of the kidneys, and sent it to a gentleman perfectly 
qualified to give an opinion on the subject. His report was that the 
capsules were not there. As these bodies are so easily found, it be- 
comes a question as to whether they had undergone absorption in 
the present instance, or if, as was suggested by one gentleman, they 
had expanded into the glandular-looking masses incorporated with 
the fat. In this case the outer part of the capsule must have been 
thinned out to an extraordinary extent, as no distinct traces of it were 

2 Y 



346 Silver Staining, 

visible. The head was not examined. The spots had faded much 
since I last saw them, about thirty-three days previously, and seemed 
to have diminished in diameter \ changes which may have been in 
great measure owing to dissolution, but which I think had clearly 
been going on for some time previously. 



J. Silver Staining. 

I need scarcely say that a slaty discoloration of the skin from the 
internal use of filtrate of silver has been repeatedly described. In 
the second volume of the Journal of Cutaneous Medicine^ however, 
I narrated a case of this result from the use of the oxide of silver, a 
preparation considered by many practitioners to be quite innocuous 
in this respect. 

The patient was the mfe of a medical man since dead. Fifteen 
years before, after suffering much from a distressing irritability of 
the stomach and bowels, accompanied by a fearful pain in the 
colon, which generally began at the left end of the transverse portion, 
she was induced to take the iodo-bromine baths at Woodhall, in 
Lincolnshire. These had at first the effect of making her look as if 
she were sunburnt ; by the time she had taken eighteen baths this 
tint had deepened to that of mahogany. Previously she had been 
very fair. The change of colour never passed off, even after many 
years. About six years before I reported the case, the oxide of 
silver was prescribed for the attacks spoken of, and gave very decided 
relief; but, at the lapse of every eight or ten weeks, she was always 
compelled by a return of the pain to resort again to this medicine, 
which was consequently taken at intervals for about four years and a 
half. By the time, however, that she had used it three years she 
began to notice a peculiar discoloration of the skin, which at first 
looked as if it were dirty, and gradually deepened, till now it shows, 
when seen in one light, of a purplish slate-colour, and in another like 
a mingling of french grey and plum-colour, with a lurid tinge inter- 
mixed. The neck and ears are also to a great extent discoloured in 
the same way. The skin of th^ top and front part of the head 
seems to me also similarly affected, but not to any great extent 
Her hands are much darker than the natural hue of the skin, but 
still several stages lighter than the face and neck. Up to the time 
of taking the first notes of the case the hue seemed to be steadily 
deepening, but for the last three or four years it has appeared 



NcBvtis. 347 

stationary. The skin is not discoloured in any other part. The 
patient's pulse is usually under sixty, and always weak. 



K. NiE'vus {us^ /, masc), from ^^genere, to beget, as in gnavusr 

Definition, — An enlarged plexus of vessels, varying in size from a 
few slender threads to a patch covering a large surface. In more 
severe cases texture of vessels becomes spongy, and skin is irregularly 
uplifted. Often congenital. 

Treatment, — ^The most valuable addition to the therapeutics of 
this complaint njade of late years is, supposing always that the ex- 
perience of others should confirm it, that by Mr. Hunt. He con- 
siders the naevus araneus to be constitutional, treats it with arsenic 
as he would lepra, and cures it. As it is always desirable to avoid 
an operation, Mr. Hunt's system should receive a fair trial. Should 
it fail, as I fear it will do, I would suggest gentle applications of the 
acid nitrate of mercury, washing off the acid with plenty of water so 
soon as it is evidently causing pain ; or the plan advocated by Dr. 
Behrend, of Berlin. He applies strong acetic acid to the naevus, and 
after this employs compresses soaked in vinegar. " Under this 
treatment,'' we are told, "the blood is made to coagulate in the 
vessels, the naevus becomes hard and clear, and is throwm off in the 
form of a parchment-like layer by a process of exfoliation." Vac- 
cination seems to have answered very well in some cases, the inflam- 
mation induced by it ending in a very firm cicatrix. 

I have on more than one occasion tried a long course of arsenic 
for naevus, but cannot say that I have noticed any particular benefit 
from it. At the present time, however, there are two girls attending 
at St. John's Hospital, who have now taken this medicine, — one for 
upwards of two years, the other for about a year, — and in whom 
there is a sensible though slight change in the hue. The acid 
nitrate of mercury has been at the same time employed, so that I am 
uncertain to which agent the benefit, supposing it due to treatment 
at all, should be ascribed. The mother of the patient who has 
been longest under my care says there is a very decided improve- 
ment. Injecting should Ije practised with care, as death has followed. 

Virchow recommends that every naevus showing any tendency to 
increase in size should be operated on at once ; superficial ones of 
moderate size, seated on face and neck, to be extirpated; deep- 



34^ Mucous Tubercle. 

S]>reading ones, or those which are difiuse, and lie near large blood- 
vessels, to be treated with the needle or galvano<:aiistic apparatus. 



L. Mucous Tubercle. 

Definition, — A slowly-forming elevation of the mucous membrane. 
Small, conical ; edges sloping off to the ordinary level of the 
membrane. Apparently encysted. Exuding a greyish mucus on 
puncture. Painless. Rare. 

Treatment, — I have only had two cases of this affection under my 
care. In both the tumour was seated on the lower lip and on the 
upper part of its inner surface. In both cases, too, it was exactly in 
the centre. In the first instance, which I saw some years ago, I was 
rather puzzled as to the nature of the complaint Subsequently I 
felt quite convinced that the opinion given by Mr. Wilson, that it 
was mucous tubercle, was correct. The patient was a young man of 
twenty-five. Before I saw him the tumour had been punctured and 
cauterized by two surgeons in succession without any diminution 
of it being effected. Mr. Wilson suggested caustic potass, but as, 
after a fair trial, no change took place in the swelling, I persuaded 
the patient to let me use the actual cautery, which he at once did. 
A skewer was bent about an inch from the point to a right angle, 
made red-hot, and then very gently applied. In a very short time 
the tumour began to shrink, and in the end levelled quite down. 
This was in 1868, and up to the present time I believe he has had 
no return. Two years later I learned that he had remained quite 
free. The other patient was a woman about forty years of age. I 
could neither induce her to let me apply the cautery nor to do it 
herself, and, after coming three or four times, she left dissatisfied on 
my telling her that medicines would never cure her. 



INDEX. 



Page 
Aberration in Growth of Cells. . 54 

Acne, Causes of 226 

„ Definition of 225 

„ Diet in 237 

,, Treatment of 225 

Addison's Disease {see Bronzing of 
the Skin — Morbus Addisonii) . . . 340 

Affusion, cold, in Scarlatina 193 

Air, change of, in Eczema 1 29 

„ „ Lupus 27s 

„ ,, Scrofuloderma.. 284 

,, injurious action of in Lupus... 275 

Aleppo Boil, Definition of 248 

,, Treatment of 248 

Alkalies in Acne £31 

Alopecia, Definition of 52 

„ Treatment of. 63 

Ammonia, Sesquicarbonate of, in 

Scarlatina 194 

Ammonium, Iodide of, in Lupus.. 279 
Anderson, Dr. McCall, on arrest 

of Eczema by Measles 106 

„ „ the pa- 
rasitic nature of Favus 54 

„ „ treat- 
ment of Eczema 155 

„ ,, vesicu- 

larnature of Eczema 83 

Anthrax (see Carbuncle) 244 

Antimonyas a sudorific, formulafor 12 
Antiphlogistic Treatment in 
Eczema 114 



Page 
Antiphlogistic Treatment in 
Erysipelas 176 

79 »> in 

Scarlatina 195 

Aperient Pills, formula for 12 

Aperients in Eczema 117 

Arsenic, Chloride of. Solution of. 6 
,, De Valangin's Solution of 6 
„ ,, formula for 268 

,, Fowler's Solution of 6 

,, Hunt on mode of giving 6-8 
, , internal use of, in Acne ... 23 1 
,, ,, „ Anthrax 246 

,, ,, ,, Eczema.. 124 

„ „ „ Erythema 173 

,, ,, ,, Lepra ... 27 

,, ,, ,, Lichen... 6 

,, ,, ,, Lupus ... 268 

„ „ „ Onychia 246 

„ „ „ Pityriasis 37 

j> „ M Prurigo. 13 

,, ,, ,, RankPer- 

spiration 335 

,, „ „ Sycosis.. 242 

,, ,, „ Urticaria 180 

„ „ „ Warts ... 329 

„ intolerance of 9 

,, mode of giving 6 

,, not a specific in Lupus 

exedens 269 

Asclepias gigantea in Lepra 29 

Astringents in Eczema 119 



350 



Index, 



Page 
Balfocr, Dr., on Tmctme of 
Sesqnichloride of Iron in Erysi- 
pelas 176 

Bandage, best kind of 163 

„ Spiral 165 

Bandaging in Ulcer of the 

L^ 163 

Barium, Chloride of^ in Lnpns .... 265 
Barker, Dr., on abstinence from 

meat in Lepra 31 

Bateman on cold affusion in Scar- 
latina 193 

Bathing in Lupus 275 

Baths in Eczema 136 

„ hot, in Prurigo 14 

„ turkish, in Prurigo 14 

„ vapour^ in L^ra 29 

>* ,f Prurigo 14 

Bazin, M., on the repulsion of 

Eczema 106 

„ „ Treatment of 

Eczema 159 



Favus 73 

Tinea 69 

Beauperthuy, M., on treatment 

of Leprosy 298 

Begbie, Dr., on arsenic in Ich- 
thyosis 49 

Belladonna in Scarlatina 195 

Bennett, Dr. J. Hughes, on ex- 
ternal treatment of Eczema 130 

„ » Favus 73 

Benzoated Oxide of Zinc Ointment, 

formula for 2 

Bichloride of Mercury [see Mer- 
cury, Perchloride of ) 126 

Biesiadecki, M., on Morbid Ana- 
tomy of Eczema 98 

Bismuth, Oxide of, in lotion, 

formula for 22 

Bleeding in Eczema 114 

Boils, Definition of 244 

,, Treatment of 244 

Brandy in Eczema 146 

Bread, best kind of, in Eczema ... 144 



Page 
Brondiitis as a complication of 

Eczema no 

Broozii^of the Skin, Cases of .... 342 

Pathology of 340 
Treatment of 340 

Bnmelliy Dr., cm Leprosy 296 

Burgess, Dr., on Treatment <^ 
Acne rosacea 236 



>• 



>» 



>» 



>» 



Calcium, Pentasulphite of, 

formula for lo 

„ „ value 

of in Scabies 322 

Calomel in Lupus 269 

Cantharides in Baldness 63 

,, Tinea areata and 

decalvans 62 

Carbuncle, Definition of 244 

„ Treatment of 244 

Carter, Dr., on Pathological 

changes in Leprosy 296 

Caustics in Lupus 271, 279 

Cazenave and Schedel on absorp- 
tion of fluid in vesicles of Eczema 87 

Charbon, Definition of. 247 

„ Treatment of 247 

Chelis, Definition of. 313 

„ Treatmentof 313 

Chilblain, Definition of 189 

,, Treatmentof 190 

Children, diet for in Eczema 143 

Chloasma, Definition of 339 

,, Treatmentof 349 

Chloroform Ointment, formida for 22 

Clavi (j^^ Corns) 330 

Cleanliness, want of as a cause of 

Leprosy 293 

Cod-liver oil in Eczema 125 

Favus 71 

Lepra 28 

Lupus 265 

Prurigo 13 

chocolate 126 

Cold-cream 2 

Comedones {see Acne) 225 



»» 



>» 



»» 



») 



)» 



»» 



»> 



f» 



»» 



»> 



Index, 351 






Page 

Contagiousness of Eczema 99 

Favus 58 

Pityriasis versi- 
color 41 

Tinea 58 

Cooke, Mr. Weeden, on lemon- 
juice in Lupus 278 

Copland, Dr., on influence of air 

• in Lupus 276 

,, repulsion of Acne 237 

Corns, Definition of 330 

,, Treatment of 330 

Croton, Tincture of, formula for... 50 
Curgenven, Mr., on Herpes epi- 
zooticus 203 



>» 



>» 



>» 



») 



»» 



Danger of curing Acne contested 237 

Eczema ,, ... 105 
Ulcer „ ... Ill 

De Jongh's cod-liver oil 125 

Delhi Boil, Definition of 248 

,, Treatment of 250 

Depilation in Favus 71 

Sycosis 71 

Tinea 67,78 

De Valangin's solution of arsenic 7 
Devergie, M., on danger of sup- 
pressing Eczema 105 

,, vesicular nature 

of Eczema 76 

Dickinson, Mr., on Pathology of 

Delhi Boil 249 

Diet as a cause of Eczema 143 

„ Leprosy 292 

for children in Eczema 143 

infants in Eczema 146 

in Acne 237 

, Eczema 139 

, Lepra 30 

, Lupus 276 

, Scrofuloderma 282, 283 

, Urticaria , 181 

Donovan's Solution, objections to 7 
Drysdale, Dr., on Tinea areata 
and dccalvans 66 



>» 



)» 



>> 



»> 



»> 



>* 



»> 



Page 

Ecthyma, Definition of 223 

Divisions of 223 

Treatment of 223 

vesicular, case of 224 

Eczema, Acute 83 

anatomical seat of 97 

antiphlogistic Treatment 

of 114 

Aperients in 117 

Causes of. 96 

classed as a vesicular 

disease 75 

Contagiousness of 99 

Cod -liver oil in 125 

Danger of curing ques- 
tioned 105 

Definition of 75 

dependent on mal-nutri- 

tion 95 

Desiccation of Vesicles in 87 

Diagnosis of. 103 

Diet in 139 

Divisions of 87 

external Treatment of ... 129 

Hebra's Divisions of 93 

hereditary nature of loi 

internal Treatment of. 1 1 2 

Iodide of Potassium in ... 1.17 

Mercury in 118 

Nature of. 95 

Nature ofmorbid process in 84 

Ointments in 131 

Origin of from Erythema 92 

Pityriasis 91 

Pustules.. 83 

Tinea ... 91 

Vesicles.. 79 

Pathology of 75 

Prognosis of 104 

siccum 133 

solare 82 

Steel, value of in 123 

Sudorifics in 115 

Treatment of complica- 
tions of 127 

vesicular nature of, ques- 
tioned 79 



»» 



)» 



»* 



»> 



352 



Ifidex. 



Page 

Eczema, ulcerative 89 

Eczemata 75 

Ephelis, Definition of 339 

,, Treatment of 339 

Epithelioma, connexion of with 

horns 315 

Definition of 315 

Development of on 

lupoid patches 316 

,, Treatment of. 317 

Erysipelas, Definition of 1 75 

,, Treatment of 175 

Erythema, Definition of 171 

Divisions of 171 

Prognosis of 172 

Treatment of 172 

Erythemata 171 

Exanthemata 191 

Exercise in Eczema 138 

Lepra 33 

Lupus 275 



»> 



»» 



if 



»> 



)) 



>> 



>f 



Fagge, Dr. Hilton, on Anatomy 

of Molluscum fibrosum 33 1 

,, „ Diagnosis 

of Scabies 320 

), ,, diffused 

Scleriasis 333 

Eat, inunction of, in Scarlatina ... 192 
Eavus, Analogy of, with local 

varieties of Eczema 86 

,, Definition of 52 

,, Treatment of 64, 71 

Fleming, Dr., on Pathology of 

Delhi Boil 248 

Fowler's Solution 7 

Frazer, Dr. W., on Arsenic in 

Carbuncle 246 

M n Cases of Lupus 

of the limbs 254 

n M on Chloride of 

Barium in Lupus 265, 278 

M ,, Pentasul- 

phite of Calcium in Scabies 323 

,, Treatment of Eczema... 150 
a ,i Pityriasis 40 



Page 

Frazer, on Treatment of Tinea ... 68 

„ „ Urticaria 180 

Freckles (j^^ Ephelis) 339 

French, Mr., on subcutaneous 

incision in Carbuncle 245 

Fumigation of infected clothes .... 324 

Fununculi 244 

Furunculus (j^^ Boil) 224 



Galium Aparine in Lepra 18 

Galvanism in treatment of Ulcer... 169 

Gay, Mr., on increase of Scabies.. 321 

,, incurable (arterial) 

Ulcer 167 

Treatment of Ulcer 167 

varicose U leer 1 65 

Grantham, Mr., on lard as an 

application in Erysipelas 1 77 

Greenhow, Dr. E. H., on the 
Pathology of Addison's Disease 340 
Treatment ,. 341 



if 



»> 



ft 



>> 



Hardy on Treatment of Favus ... 70 
,, „ Pityriasis 40 

,, ,, Tinea ... 70 

Health, state of in Eczema 95 

„ „ Lupus 259 

Hebra, M., on Chloasma 339 

Diet in Eczema ... 143 
Divisions of Eczema 93 
Growth of Epithe- 
lioma on lupoid patches 316 

, , Morbus pedicu- 

laris 324 

,, Pathology and 

Classification of Eczema 77 

Pathology of Pru- 



>t 

if 



a 



ngo 



17 



,, peculiar form of 

Scleroderma ( Rhinosclemia) .... 3 33 

,, Repulsion of Ec- 
zema 107 



a 



Treatment of Ec- 
zema 156 

„ „ Lepra 34 



Index, 



353 



Page 
Hebra, on Treatment of Prurigo ... 19 
,, ,, Rank Per- 
spiration 336 

,, ,, Scabies ... 323 

Herpes circinatus buUosus, cases 

of 205 

,, Definition of 202 

„ Divisions of 202 

,, epizobticus 203 

,, Form of confounded with 

Eczema 81 

,, Gestationis 205 

,, perstans, case of 209 

,, Treatment of 204 

H illier on Treatmen t of Eczema ... 1 54 
„ „ Lepra ... 34 

Home, Sir Everard, on mode of 

giving colchicum 179 

Hot local bathing in Eczema 133 

»» )) Lupus .'.274 

Hunt, Mr., on antiphlogistic 

Treatment in Eczema 114 

,, Arsenic in 

Acne 232 

„ Naevus 347 

„ Prurigo 13 

,, Diet in Lepra 32 

, , Exercise in 

Lepra 33 

,, Mode of giv- 
ing arsenic 6, 8 

,, Prognosis and 

Treatment of Prurigo 13 

,. Treatment of 

Ichthyosis 49 

„ (the) turkish 

Bath 15 

Hutchinson, Mr., on communica- 
tion of Tinea 58 

,, the Prurigo of 

Hebra 17 

Ilydrargjrrum c. creta in Eczema.. 119 
Hydrocotyle asiatica in Lepra ... 29 



Ichthyosis, Definition of 42 

,, Divisions of 42 



») 
)» 






Page 
Ichthyosis, hereditary nature of . . . 47 
sebaceou.s, form of . . 48 
„ Dr. Ogle's 

cases of : 49 

simple, Treatment of 42 
spurious or warty, 

Treatment of 42 

Impermeable dressings in Eczema 137 

Impetiginoid Eczema 85 

Impetigo contagiosa 216 

,, Definition of 215 

,, Divisions of 215 

,, rodens 218 

Treatment of 219 

rodens, case of 221 

,, Treatment of ... 221 

Infants, diet of 146 

Iron, acid solution of, formula for 37 

,, in Eczema 123 

red Pityriasis 37 

Scrofuloderma 283 

, , saccharated Carbonate of . . . 1 20 
, , Tincture of Sesquichloride of 

in Acne 230 

,, ,, in Eczema... 130 
„ Preparation of, in Lupus ... 266 
,, ,, Scrofulo- 
derma 282 

Issues, doubtful value of in Eczema 108 
Itching in Eczema, Treatment of.. 133 
Prurigo, Treatment of.. 21 



)) 



»» 



>» 



)> 



»» 



>> 



Kelis (j^^Chelis) 313 

Kerion, Definition of 53 

,, Treatment of 66 



Lard, action of, in Erysipelas ... 177 
„ ,, Scarlatina 192 

Laycock, Professor, on a conta- 
gious Furunculoid 247 

Lead, white, as an application in 
Boil and Carbuncle 244 

Lemon-juice in Eczema 1 40 

,, Lupus 271 

Lentigo (j^^Ephelis) 339 



2 Z 



1 



54 



Index. 



>» 



>» 



»» 



>> 



>» 



>> 



»» 



»» 



»» 



)) 



»» 



Page 

Lepra, Definition of 24 

Diet in 30 

Divisions of 26 

external Treatment of ... 29 
Identity of with Psoriasis. . 24 

internal Treatment of 27 

Pathology of 25 

Prognosis of 26 

Vapour-baths in 29* 

verrucosa (warty) 329 

Leprosy, age at which it appears.. 295 
,, Beauperthuy*s Treatment 

of. 298 

Cases of 3CX3 

Causes of 291 

,, contagious Nature of 

examined 288 

Decline of 290 

Definition of 284 

Divisions of 285 

greater prevalence of 

among Males 295 

different Races 295 
hereditary Nature of, 

examined 287 

Nature of 287 

not due to climate 294 

diet 293 

unwholesome 

state of dwellings 294 

,> want 293 

Pathology of 296 

possible Causes of De- 
cline of 291 

Prognosis of 297 

Remedies recommended 

297 

Report of College of Phy- 
sicians on 285 

State of blood in 296 

„ urine in 305 

structural Changes in 

Nerves in 296 

Treatment of 297 

white, a variety of Leuce 286 
Leucopathia (Leuce), Acute (?), 
Case of 337 



>» 



»» 



>» 



»» 



>» 



»» 



>» 



>> 



»» 



»» 



»» 



»» 



»» 



in.. 



>» 



»» 



)) 



»>. 



>> 



>» 



»» 



»» 



Page 

Leucopathia, Definition of 336 

,, Treatment of. 336 

Lice, kinds of 326 

Lichen, Definition of 4 

Divisions of 4 

Treatment of 4 

Light, influence of on Eczema 138 

** ' n Lepra 33 

,, ,, Small-pox.. 199 

Liquor Plumbi in Lupus 273 

,, Potassae in Acne 231 

Liston, Mr., on destruction caused 

by Lupus 260 

Lotion, stimulating, formula for ... 67 

Lupoid Ulceration from Biles 258 

Lupus, Definition of. 251 

Diet in 277 

Divisions of 251 

er3rthematosus on Hand ... 255 

,, Limbs.. 258 

not S)rphilis 257 

exedens 251 

„ on limbs 253 

external means in 271 

internal means in 264 

non-exedens 251 

on limbs ... 253-7 
not Syphilis.. 255 

Pathology of 252 

Prognosis of 259 

strumous 253 

,, on limbs 258 

Traumatic (?) 258 

Treatment of 263 

verrucosus 258 



>> 



»» 



»> 



*» 



>y 



»» 



>» 



)» 



*) 



>> 



>» 



>> 



)) 



>» 



>» 



»f 



>» 



)) 



»» 



)) 



)) 



Magnesia in Eczema 118 

Mercury, acid nitrate of, in Lupus 274 
,, „ Scrofulo- 
derma 283 

Biniodide of in Eczema.. 126 
Ointment of nitrate of, 

in Eczema 131 

,, ,, nitric oxide 

of, formula for 63 

Perchloride of, in Eczema 126 



a 



ft 



>> 



Index. 



355 



»» 



»> 



Page 
Mercury, Perchloride of, in Lichen lo 
,, ,, Lotion of, 

formula for lo, 22 

preparations of in Eczema 1 1 5 
„ Lupus.. 269 

Miliaria, Definition of 214 

,, Treatment of 214 

Molluscum contagiosum 331 

Definition of 330 

fibrosum 331 

simplex 331 

Treatment of 332 

Morbus Addisonii {see Bronzing of 

the Skin) 340 

,, Cases of. 342 

pedicularis 326 

Mucous Tubercle 348 



>> 



»» 



») 



»> 



>> 



>» 



»> 



»» 



NiEVUS, Definition of 347 

„ Treatment of 347 

Nayler, Mr., on local treatment of 

Prurigo 23 

sulphur in Eczema 116 
Treatment of Ec- 
zema 154 

,, State of urine in 

Ichthyosis 5° 

Neligan, Dr., on Treatment of Acne 

rosacea 239 

Favus ... 72 
Ichthyosis <p 
Pityriasis.. 41 
Urticaria.. 181 
, , Turpentine in Pur- 
pura 1 88 

Nervous exhaustion as a cause of 
Tinea areata and decalvans 60 



Oppenheim, Dr., on a possible 

form of Urticaria 186 

Ogle, Dr., cases of sebaceous 

Ichthyosis by 90 

Ointments, objections to combated 3 

, , valu e of generally 2 

Over-feeding in Eczema 1 40 



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PaPUL/E I 

Parasiticae 319 

Parasitic diseases of the skin 53 

Parasitic growths, vegetable nature 

of. 53 

Pemphigus, communication pos- 
sible of from cow 212 

Definition of 2H 

Divisions of 2H 

Treatment of 212 

Pernio {see Chilblain) 189 

Perspiration, ranjc (offensive) 335 

Phosphates, doubtful value of in 

Eczema 145 

Phthiriasis, Definition of 324 

Hebra on 324 

Treatment of 327 

Phytiform elements, derivation of 

from cells 54 

Pick, Dr., on treatment of Chelis 314 

Pitch-plasters, objections to 63 

Pityriasis rubra, as a starting-point 

• of Eczema 85 

Definitionof 35 

Prognosis of 39 

Treatment of 36 

simplex. Definition of . . . 36 
,, Treatment of .. . 36 
,, versicolor, contagious 

nature of. 41 

,, ,, Definition of... 36 

,, ,, Treatment of... 39 

Plumbe on Eczema solare 82 

Porrigo scutulata 220 

Potassium, iodide of, formula for 267 

in Eczema 117 
Lupus of 

limbs 267 

Pouchet, M., on fungi 61 

Prurigo, Definitionof II 

Divisions of. i i 

external treatment of 21 

,, Form of, described by 

Hebra 17 

internal treatment of ii 

senilis, connexion of with 
lice 18, 22 



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356 



Lidex, 



Page 
Pruritus in Eczema, Treatment of 133 
„ Prurigo, „ 21 
,, Urticaria 181 
Pullar, Dr. Alfred, on imperme- 
able dressings in Eczema 1 37 

Purdon, Dr. H. S., on anatomical 

seat of Eczema 97 

,, cases of Lupus 

of the limbs 255 

,, on moisture as a 

cause of favus, 60 

„ Neuroses of 

the skin 171 

,, ■ Treatment of 

Erythema 174 

Purgatives in Eczema 114, 1 23 

,, Lupus 270 

,, Scrofuloderma 282 

Purpura, Definition of 187 

,, Divisions of 187 

,, Treatment of. 188 

Pustulaj 215 

Pustular origin of Eczema 83 



Quinine, formula for • 12 



Rayer, M., on repulsion of Eczema 106 
„ rest in Eczema .... 138 

Reliquize 328 

Rest in Eczema 138 

„ Ulcer 164 

Rhinosclerma 333 

Richardson, Mr. E., on value of 

fatty frictions in Scarlatina 193 

•Ringworm {see Tineoe) 52 

,, Burmese 91 

Rodent Ulcer, Definition of 3/8 

„ Treatment of 318 

Rosacea (j-^^ Acne) 225 

Roseola, Definition of 197 

,, Divisions of 197 

,, Treatment of 197 

Rowe, Dr. T. Smith, on preven- 
tion of pitting in vSmall-pox 199 

Rubeola, Definition of 197 



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Rubeola, Divisions of 197 

,, Treatment of 197 

Rum and milk in Lupus 276 

Rupia, Definition of 213 

,, Treatment of. 214 



Saline aperients, formula for .... 37 

in Acne 229 

Eczema 117 

red Pityriasis 37 

St. John's Hospital soap 135 

Sarracenia purpurea in Small-pox 200 

Scabies, Communication of 320 

Definition of 319 

Diagnosis of 320 

Treatment of 321 

Scalled head {see Kerion ) 53» 66 

Scarlatina, Definition of 191 

,, Divisions of. 191 

, , Inunction of fat in 1 92 

„ Treatment of 191 

Schneemann, Dr., on inunction of 

fat in Scarlatina 192 

Scleroderma (Scleriasis), Defini- 
tion of 332 

Divisions of.. 333 
Treatment of 334 
Scrofularia nodosa in Pemphigus . 213 

Scrofuloderma, Definition of 280 

,, Treatment of 281 

Scrofulous Lupus, Definition of... 252 

,, ,, on Limbs 258 

Sebaceous Acne {see Acne sim- 
plex) 225 

,, Ichthyosis 49 

Sedatives in Eczema 153 

,, Ulcer 160 

Silver, nitrate of, in Leprosy 299 

„ „ Lupus 273 

„ staining 346 

Sisson, Dr., on complication of 
Scarlatina by acute catarrh of 

stomach 195 

, , Description of Delhi 

Boil by 249 

Soap in Eczema 135 



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Index. 



357 



sacea 

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Soaps 135 

Soda, carbonate of, lotion of, in 

Eczema 130 

,, ,, in mixture, for- 
mula for II 

,, Sulphite of, in Pityriasis 

versicolor 39 

Spender, Dr., on the Treatment 

of Eczema 156 

Squamae 24 

Squire, Mr. Balmanno, on con- 

* nexion of Prurigo with lice 22 

Startin on communication of Sca- 
bies, &c 321 

Treatment of Acne ro- 

238 

Area ... 68 

Eczema . 147 

Faviis ... 72 

Ichthyosis 49 

Impetigo 220 

Lepra ... 33 

Lichen . 10 

Pityriasis 40 

Prurigo . 16 

Roseola . 54 

,, ,, Strophulus 3 

Starvation in Eczema 141 

Statistics of Eczema 10 

Stavesacre ointment in Phthiri- 

asis 327 

Steel (j-^^ Iron) 120 

,, wine in Eczema of children 120 
Stokes, Dr., on Treatment of Epi- 
demic Pemphigus 213 

Strophulus, Definition of I 

Divisions of i 

Treatment of i 

Strychnia, value of, in Prurigo ... 13 

Sudorifics in Eczema 115 

,, Prurigo 12 

Sulphur in Eczema 116 

„ Prurigo II 

,, bath as a means of Dia- 
gnosis 139 

,, ,, in Pityriasis versi- 
color 39 



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Sulphur, ointment of hypochloride 
of, in Acne 233 

Swift, Dr., on the Treatment of 
Eczema 156 

Sycosis, Definition of 240 

,, Prognosis of 241 

„ sometimes a form of 

Lupus 240 

,, Treatment of 241 

Tanner, Dr., on the Treatment of 
Eczema 152 

Tar in Acne 232 

,, Eczema 136 

,, Prurigo 16 

Tarragona wine in skin diseases ... 38 

Thompson, Dr. A. T., on Treat- 
ment of Lupus 277 

Tinea areata {see Tineae) 52 

, , circinata {see Tineae) 52 

,, „ as a starting-point 

of Eczema 91 

, , decalvans {see Tineae) 52 

„ favosa „ 52 

,, tonsurans ,, 52 

Tineae 52 

,, Definition of 52 

„ Diagnosis of 6i 

,, Divisions of 52 

,, parasitic nature of. 53 

,, Prognosis of 62 

,, Treatment of 62 

Tuberculae 251 



Ulcer of Leg, arterial, Gay on ... 167 
,, ,, dependence of, on 

Eczema 89 

„ Divisions of 1 68 

,, Varicose 165 

Ulcerative Eczema 89 

Unguentum,stimulous, formula for 67 
Urea, deficiency of, in Inveterate 

. Eczema 96 

„ „ Leprosy.. 305 

Urine in Eczema, Dr. Frank 

Smith on 95 

„ Leprosy 305, 311 






358 



Index. 



Page 

, Urticaria, Definition of 178 • 

„ Dependence of, on the 

Acarus Scabiei 178 

Diet in 181 

Divisions of. 178 

Treatment of 179 

unusual form of 182 



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Vaccination of Children suffer- 
ing from Eczema ICX) 

„ as a means of com- 
municating Scabies 198 

Variola, Definition of 198 

,, Divisions of 199 

,, pathological changes in . 199 

„ Treatment of I99 

Veins, Varicose, as a cause of 

Ulcer 165 

„ „ Treatment of ... 165 

Verruca, Definition of 328 

,, Treatment of 329 

Vesiculse 202 

Vesicular Eruptions, unusual forms 
of {see Herpes gestationis and 
perstans, and Vesicular Ec- 
thyma) 205 

Vinum ferri {see Steel Wine) 120 

with Arsenic, formula 

33 



for 



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Wallace on external Treatment 

of Eczema 130 

Warts (j^dsf Verruca) 328 

Weisse, Dr., on acetate of zinc in 

Lupus 273 

Willshire, Dr., on Treatment of 

Lepra 34 

Wilson, Dr. Marris, on sedatives 

in Eczema 273 

,, Mr. Erasmus, on Acne 

rosacea 239 

I>iet 141 
,. I^ivi- 
sions of Elczema 92 

» „ »> p^^yti- 

form nature of Tinea 54 

„ „ „ Treat- 
ment of Eczema 149 

Pni- 

16 

„ „ „ Tineae 67 
Wine in Eczema 140 



Zinc, acetate of, in Lupus 273 

„ Chloride ofi in Eczema 131 

LeP"^ 30 

„ ,, lotion of, for- 
mula for 30 

„ „ Lupus. 271, 272 
„ Ointment of oxide of, for- 
mula for 2 



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