No. 1037.

, SATURDAY, JULY 15, 1843.

COURSE OF LECTURES

ON

DISEASES OF THE SKIN;THEIR

HISTORY, PATHOLOGY, AND TREATMENT.

Delivered in the Middlesex Hospital, duringthe Summer Session, 1842, byERASMUS WILSON, Esq.,

Consulting Surgeon to the St. Pancras Infir-mary ; Lecturer on Anatomy and Physio-logy in the Middlesex Hospital School.

LECTURE XXV

DIAGNOSIS OF ECZEMA.

ECZEMA is an eruption that is easily dis-tinguished ; and yet I have seen it mis.taken. It is one of three vesicular diseases.the others being herpes and sudamina. Now.the vesicles of herpes are recognised by theirlarge size, their disseminated distribution,and frequently by their annular arrangement.The vesicles called sudamina are associatedwith profuse perspirations ; they also are

larger than the vesicles of eczema ; they areisolated, scattered, and unattended withredness of the skin. The vesicles of eczema,on the other hand, are recognised by theirsmall and oftentimes minute size, their aggre-gation in clusters, their frequent confluence,and the large quantity of discharge whichthe excoriations which follow them pour out.There is, however, a form of eczema inwhich the vesicles are scattered, single, andfew in number, and in this state the eruptionbears a close resemblance to scabies, scabiesin point of fact being an eczematous eruptionoccasioned by, and superadded to, the irrita-tion caused by parasitic animalcules inhabit-ing the epidermis. I have already describedthis form of eruption, and need not advertto it again. The diagnosis between it andscabies is founded on the presence or absenceof the acarus scabiei.Eczema simplex and eczema rubrum, in

their most distinctive forms, are widely differ-ent from each other; but as they are simplydegrees of inflammation, there is a broadneutral ground on which they merge imper-

ceptibly the one into the other. The sameremarks are applicable to eczema impetigo-nodes ; in one spot the appearances are thoseof eczema simplex; in another, eczema rubrumis perfect; while in a third appearances are sohybrid as to lead to an uncertainty, whetherthe characters of eczema or of impetigo pre-ponderate,-hence the designation of this formof disease. Oftentimes I have had occasion,when I have seen this disorder in its crustedstage upon the face, to ask myself, Is it aneczema? Or is it an impetigo? Again, forsimilar reasons to those I have alreadystated, an eczema simplex may, by an ill-crease of inflammation or by mismanagement,become an eczema rubrum or eczema impe-tiginodes.Chronic eczema may be mistaken for

lichen agrius, or for psoriasis ; but this errorwill be avoided by recollecting the elemen-tary form of the three diseases. In eczemachronicum there are generally some traces ofvesicles. In lichen agrius there are alwaysindications of papulae. In psoriasis thesquamae consist of altered epidermis, andare not scabs formed by desiccated secre-tions, or mere exfoliations of desquamatingepidermis. Again, the cracks and chaps ofboth eczema and lichen are moist and

ichorous ; while those of psoriasis are alwaysdry, and as though dusted by a minutefurfur.Eczema capitis, the humid scall, consti-

tutes a considerable proportion of the ring-worms of popular report ; eczema, the moist

scall ; impetigo or the crusted scall ; a scalydisease termed pityriasis ; and the true ring-worm, or favus, are the four principal dis-

eases of the scalp, of which the two last arethe least frequent. The two first are thescalled heads so frequently met with in

practice; they are distinguished, to a certainextent, by the appearances conveyed in theirdesignations, moist and crusted, but both arein their latter stage crusted. Better termsthan these would be vesicular scall and pustu-lar scall, for their elementary form can gene-rally be ascertained, excepting when the dis-ease has assumed the chronic character. Itis not uncommon to find the two forms ofscall combined, and in that case the diseaseis an eczema impetiginodes; or it may be

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that the impetigo predominates, and theeczema is superadded, a state that might bedenominated impetigo eczematosa ; but theseare points of insignifleant importance in

diagnosis and none in practice. The objectshould be to determine the preponderatingform. From all the three other affections ofthe scalp eczema is distinguished by thepresence of vesicles; in impetigo the eruptionconsists of pustules; in pityriasis there is no 1eruption, but a superabundant formation ofepidermic scales, while the yellow cup-like icrusts of favus are dissimilar to all. It istrue that herpes sometimes occurs on thescalp, but by no means frequently, and whenit does its characters are very different fromthose of eczema.Some of the local forms of eczema, as, for

instance, eczema aurium et mamillarum,bear a close resemblance to erythema inter-trigo, in the inflammation of the skin, and theeffusion of an abundant ichorous or puriformdischarge ; but they differ from the latter,when more carefully examined, by presentingeither vesicles or the remains of vesicles inthe neighbourhood of the disease. Whensuch indications of vesicles are absent thecase must be regarded as an undoubted ery-thema. But so far as practice is concerned,the distinction is unimportant, for the treat-ment is the same in both cases.

Causes.-The causes of eczema may bereferred to two heads, constitutional andlocal. The former embrace all those abnor-mal states of the system, which may be re-ferred to hygienic influence, such as altera-tions of season, temperature, and the hygro-metric condition of the atmosphere. Othercauses belonging to the same group are suchas depend upon disturbance of the nutritiveor nervous functions; for instance, irritationof the alimentary canal, disorder of the kid-neys, uterine irritation in its various forms,dentition, mental depression, anxiety, &c.Bad and improper food, again, is not anuncommon cause of this eruption, particu-larly in persons of scrofulous habit.As respects period of life, eczema is most

frequently met with in children, and in them,in the greater number of cases, is developed ’,,on the face and scalp, and it occurs morecommonly in the female than it does in themale.

Besides the general causes which occasionthis disease, there are numerous local excit-ants, such as heat and cold, friction, and irri-tating substances of every kind. A well-known vesicular eruption occurring on thebacks of the hands, in females particularly,has been denominated by Willan, for an obvi-ous reason, eczema solare. Another form ofvesicular disease appearing about the wristsand on the backs of the hands of grocers, andoccasioned by the prolonged contact of sugar,has been termed the grocer’s itch. Dry andpowdery substances of different kinds pro-duce a similar effect. The eczematous

eruption developed around the seat of ablister on delicate skins is well known; asis that also, which occurs beneath and arounda Burgundy-pitch plaster in persons of ex-citable nervous system. I have seen a

copious eruption of eczema follow the appli-cation of the compound sulphur ointment, ami (iI am in the habit of explaining the occasionaltransmission of this disorder from one personto another by reference to the irritationcaused by the contact of the morbid secretiollwith the skin of a sound person.Prognosis.-Eczema is a disease so wholly

dependent on the nature of the cause thatproduces it, that our deductions as to itscurability must be entirely determined bythe latter. It is frequently obstinate, becausethe cause is one not easily removed ; often itceases spontaneously, as soon as the primarydisorder is cured. Sometimes eczema per-forms the part of a derivative, and protectsthe system against a disposition to diseasethat might otherwise burst forth in a moreimportant part; and at other times the dio-

charge, maintained for a considerable period,becomes a necessary part of the sources ofwaste to the economy, and must be checkedguardedly.

Treatment.-The treatment of eczema

should be antiphlogistic, apportioning the

energy of the remedies to the activity of thedisease and taking into consideration the

particular causes which may be excitant ofthe disease. When the eruption assumes amild form and the local inflammation is

moderate, diluents and laxatives of neutralsalts will be all the general treatment re-quired. But when it assumes the exaltedcharacters of eczema rubrurn or eczema im-

petiginodes, it will be necessary to act uponthe alimentary canal more freely, and, if thestrength of the patient permit, to withdraw afew ounces of blood from the arm.The symptomatic forms of the disease re-

quire medication of the organ which is theexciting cause of the disease. It may be thealimentary canal or liver. The kidneys arenot unfrequently the source of the morbid

action ; or it may be necessary to direct yourtreatment to the uterus. In each of thesecases you would employ the remedies whichare applicable to disease in these organs.Eczema in its chronic form exhausts our

trials, conducted on general antiphlogisticprinciples; and it becomes necessary to halcrecourse to alteratives and endeavour tomodify the state of constitution by variousmeans. The medicines best calculated toeffect these objects are, the hydriodate ofpotash, mercury, liquor arsenicalis, tinc-ture of cantharides, &c. The two lattermedicines require to be watched with care,and intermitted or stopped the instant thatany unpleasant symptoms appear to resultfrom their use. The best formula for theexhibition of the tincture of cantharides is

one in which that medicine is combined

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with tincture of camphor and tincture ofbark.

In cases, where the powers of the constitu-tion are reduced, a tonic plan of treatmentmust be substituted for the antiphlogistic,and a more generous diet and regimen em-ployed.

In the local treatment of eczema it may besometimes useful to remove blood by leechesor puncture ; the bleeding being encouragedby warm fomentations or water-dressing.The local warm bath or vapour bath is alsovery serviceable in these cases. After theinflammation is reduced, you may employsome gentle stimulant, such as a lotion of

zinc, a weak solution of nitrate of silver, analkaline lotion, or one of sulphuret of potash.A pleasant application to the surface at allperiods of the course of the local disease isthe liquor plumbi ointment ; it relieves thepruritus which attends the eruption, andproduces a sedative effect on the excitednerves of the part. For the same purposethe emulsion of bitter almonds, the hydro-cyanic-acid lotion, an opiate lotion, camphormixture, chlorate of potash lotion, or an infu-sion ofdulcamara, are useful.In the chronic state of eczema a variety of

local remedies have been applied withvarious results. The chief of them are, theoxide of zinc ointment, ointment of nitrate ofsilver, calamine ointment, sulphate of copperointment, tannin ointment, and ointments ofwhite and red precipitate, calomel, carbonateof lead, tar, sulphur, iodine, and mercury.A weak lotion of the bichloride of mercuryor lime-water is also occasionally useful.In cases of long standing it is sometimes

necessary to set up a new action in the dis-eased part, either by the application of ablister upon the surface or by means of asaturated solution of bichloride of mercurypencilled on the disease. In these eases,moreover, it is often judicious to prevent anyill effects resulting from the sudden cure ofa long-standing disease by the application ofcounter-irritants, such as the croton oil, to a

neighbouring surface of skin.Two new remedies have been lately intro-

duced into continental practice for the treat-ment of chronic diseases of the skin, andparticularly of eczema, They are compoundsof potash, with coal and soot, the formerbeing termed anthracokali, and the latterfuJi::Bokali. Anthracokali was originallyadministered internally, but was found to

give rise to unpleasant symptoms ; it is nowemployed as an ointment, and appears to benothing more than a common stimulant of themilder sort, owing, probably, all its powers Ito the potash which it contains. Soot pos-sesses more numerous ingredients than coal,and has been long used as an empiricalremedy in some diseases of the skin. Ac-cording to Gibert, the ointment of fuligokaliis resolutive, detersive, and stimulant, and it

is certainly a more efficient remedy thananthrakokali.

Fuligokali is made by boiling together 100parts of soot, with 20 parts of caustic potashin solution in water. The fluid is evaporatedand filtered, and the salt dried and collected.The ointment of fuligokali should containfrom twenty to thirty grains of the salt to anounce of lard.

6UDAMINA; MILIARY VESICLES.

Sudamina are small vesicles developedon the skin, under the influence of an ele-vated temperature of the system, but with-out inflammation. They have been com-

pared, in point of size, to millet-seeds, andhence have been termed miliary vesicles, andthe disorder miliaria. When first developedthey are transparent, and filled with a limpidserous fluid. In this state the congesteddermis shining through the colourless fluidgives them a pinkish hue, and occasions thedistinction implied in the term miliaria rubra.In the course of twenty-four hours, how-ever, the fluid becomes milky and opake,and then the vesicles have received thedesignation of miliaria alba. Sudamina

occur, for the most part, on the trunk of thebody, particularly on its under side, or

beneath a flannel covering, if such have beenworn. They run a course of three or fourdays, and terminate either by disruption anddesiccation, and so form a thin scab, whichspeedily falls, or by absorption of the con-tained fluid. The vesicles vary very con-siderably in point of number, but are alwaysdiscreet, and more or less disseminated overthe surface.The term sudamina applied to these vesi-

cles has reference to their production undera state of elevated temperature of the skin,a state which is usually associated withcopious perspirations; hence we find themvery frequently developed in fevers andacute rheumatism. They sometimes accom-pany diseases in which there is considerablecongestion of the skin, such as rubeola,scarlatina, and small-pox; and one form oferythema, erythema miliare, is distinguishedby the presence of these vesicles. Theagency of heat in the production of sudaminaexplains their more frequent occurrence inthe summer than the winter season, and inpersons possessing a high degree of suscep-tibility in the skin.

During the latter half of the seventeenthand nearly the whole of the eighteenth cen-tury, we read much of miliaria or miliaryfever in the medical writings of the period ;and we are informed that this disease pre-vailed epidemically, and was dangerous andfatal in its consequences. De Haen, of

Vienna, about the middle of the last century,endeavoured to prove, that there was no spe-

I cific fever accompanied by an eruption ofvesicles, and that these and the severe symp-toms which the fever assumed at that period

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were the direct consequences of the heating regard to it, that" among the various circum-system of treatment which was employed, stances under which the miliaria was

For the complete disabuse of the public formerly excited, the puerperal state appearsmind, however, with regard to this fever we to have been most frequently the source ofare indebted to the improved principles of it, insomuch that it was first described astreatment introduced into medical practice an epidemic among puerperal womn." Thisby Sydenham,-the substitution of the is sufficiently accounted for by the treatment,cooling antiphlogistic method for the heating which was unhappily pursued during theand exciting plan which was previously in confinement after childbirth, and of whichuse. Miliary fever has altogether disap- an impressive description is given by Mr.peared before the enlightened doctrines of White. "For not only was the mother imme-modern medicine, and the disease is at the diately loaded with bedclothes, from whichpresent day unknown. Sudamina,itis true, she was not allowed to put out even herappear from time to time, and must continue nose,’ and supplied with heating liquorsto be seen in association with febrile dis- from the spout of a teapot; but to her room,eases ; but the fever of invasion, eruption, heated by a crowd of visitor3 and a fire, alland maturation of miliaria can exist no access of air was denied, even through amore. keyhole. From these causes fever was

Among writers on skin diseases miliaria almost necessarily induced, with the mosthas continued to obtain a description almost profuse sweats, oppression, anxiety, andto the present time. Wilson gives the usual fainting ; and these, again, were aggravatedaccount of the chills, heats, anxiety, sighings, by spicy caudles, spirits, opiates, and am.profuse sweats of a sour scent, with pricking moniacal medicines. That numbers shouldsensations preceding the littleround vesicles. perish under such management, with everyWillan describes a summer fever, in the symptom of malignity, and that many whocourse of which vesicles are developed on survived it should escape with broken con-the surface of the skin, but regards the stitutions, will surprise no person who is

symptom as the disease. Bateman, how- acquainted with the baneful influence of over-ever, views the eruption in its true light, and excitement in febrile complaints."looks upon miliary vesicles as "invariably In a note appended to this account we

symptomatic" of some feverish state of the find the following:-Mr. White observes

body. The duration of the eruption is that a woman in childbed is so much ex-

necessarily dependent on the state of the hausted by the mode of treatment before

system and the treatment pursued; for when, described, "that the highest cordials haveas Sir Richard Blackmore remarks, the pa- been necessary to support her; nay, I havetient lay " drowning in sweats," it was by been credibly informed (he adds) that underno means uncommon to find the eruption these circumstances a patient has sometimesrepeated several times successively, and the drunk a gallon of wine in a single day, ex-disease lasting for nearly fifty days, clusive of brandy, and of the cordials from"It is scarcely necessary now," writes the apothecary’s shop, and all this, too,

Bateman in his Synopsis, " to enter into any without intoxication."detail of proofs, that the miliary eruption is Diagnosis.-The distinction of sudaminathe result of a highly heated and per- from other vesicular eruptions is by no meansspiring state of the skin; and that, in its difficult. They are larger than the vesiclessevere and fatal degree, it is solely the effect of eczema, and smaller than those of herpes,of a stimulating regimen in a confined atmo- and at the same time differ from both in thesphere. The almost total annihilation of the absence of inflammation of the skin. Otherdisease of late years, since the general characters which distinguish sudamina areadoption of a better practice, is of itself un- their occurrence on the trunk of the body,equivocal evidence of its origin." 11 hippo- their disseminatiou, and their separate loca-crates, whose mode of treatment in febrile tion, however numerous they may chance todiseases was not calculated to produce ex- be. You must recollect, too, that sudaminacitement, has once or twice but casually are, for the most part, developed in personsmentioned the miliary eruption. And again, occupying their beds from pre-existing dis-at the latter part of the seventeenth century, ease ; in those too warmly covered withwhen, in the practice of the majority of phy- bedclothes ; in the summer season ; or in

sicians, the miliary fever was a frequent and patients suffering from disease, in whichfatal occurrence, Sydenham witnessed no there is considerable perspiration from thesuch fever, but mentions the occasional skin.

appearance only of miliary vesicles, which C<MMg.&mdash;Concerning the cause of sudaminahe ascribes to their proper cause." medical authorities are now decided ; they

But it is in the puerperal state more than are the consequence of an unusually heatedalmost any other, that we find the conditions state of the skin in persons whose nervous

which, if abused, are calculated to be pro- system is debilitated by the presence or con-ductive of the eruption of miliary vesicles. tinuance of disease, The latter condition.This is the febris puerperarum miliaris of namely, debility or exhaustion of the peri-the older writers, Bateman remarks with pheral nerves, exists more frequently as a

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predisposing cause of cutaneous eruptionsthan we are perhaps aware. This beliefhas in many instances served to modify mytreatment in these disorders, and with de-cided benefit. Sudamina are sometimesoccasioned by a draught of cold water whenthe surface is warm.

PI’ognosis,-From the description whichI have just given you of sudamina it is clearthat your opinion as to its issue must be de,termined solely by the nature of its cause.It is at all times a symptom merely, andnever rises to the importance of a disease.When the cause is not immediately apparent,it might perchance by mistake be consideredas an eruptive disease, and fatality of thecause might, improperly, be referred to theeffect.

Tt’t/tMK&mdash;The treatment of sudaminamust be directed to the disease of whichthey are symptomatic. The general princi-ples which should guide us in our treatmentuf them, when the primary disease is tinim-

portant, are a cooling regimen, gentle laxa-tives, ventilation of the apartment, reductionin the coverings of the body, and spongingthe surface with tepid water.

CHANGES OF MERCURIALS IN THE SYSTEM.

THE fact that calomel could be convertedinto corrosive sublimate, in the system, waskuown many years ago. But the exact cir-cumstauces of this transformation were not

sufficiently understood. Mialhe, in an ela-

borate set of experiments on the subject(Ann. de Chimie, v. 160), says, the actionoccurs when calomel is brought in contactwith a solution of an alkaline chloride, thatthe quantity of sublimate formed is in pro-portion to the amount of alkaline chloride

present, and the action increases in propor-tion to the concentration of the alkalinechloride. His experiments were made withcommon salt and sal-ammoniac. The actionis much increased by the presence of airand dextrine, but is retarded by fat andgum. By simply boiling calomel in distilledwater, sublimate is formed. Mialhe ex-tended his observations to all the compoundsof mercury, and obtained similar results.He concludes that it is corrosive sublimatev/hich is the active agent in medicine. Ifthis idea should be confirmed, it should leadto the substitution of this form of mercuryfor all the others. The same chemist recom-mends the hydrated proto-sulphuret of ironas a complete antidote to corrosive subli-mate. To prepare it, copperas is to be pre-cipitated with hydrosulphuret of sodium, theprecipitate washed and preserved in an air-tight bottle.&mdash;-Df. R. D. Thoinsoit in Pna- iccederr;s of Glasgow Plailosophicul Society, IKo. 4.

CLINICAL LECTURESON CASES OF

DISEASES OF THE NERVOUSSYSTEM;

DELIVERED AT KING’S COLLEGE HOSPITAL

(During the Summer Session, 1843).BY

R. B. TODD, M.D., F.R.S.,Physician to the Hospital.

LECTURE IV.

LOCAL HYSTERIA.

IN many women the characters of thehysterical state of constitution are manifestlypresent; but the hysterical paroxysm rarely,or never, breaks out. The patient is moreor less troubled with globus ; she may havethreatenings of a paroxysm, and, perhaps,her strength of mind may be sufficient toenable her to ward it off. It is a popularnotion, that it would be better for such apatient to let the fit pass off and have donewith it-to give free vent to her feelings, andso to gain complete relief-than to go onfrom time to time opposing their outbreak,thereby keeping up a state of general excite-ment, which, like one of continual watching,must have a most debilitating influence uponthe system. I am not sure that this view isnot the correct one; certain it is, that there isfrequently great difficulty in finding properremedies for the peculiar symptoms whichatise in women who are thus circumstanced.It is in such women that hysteria is

frequently apt to show itself by affectingsome limited portion of the body ; it becomes,as it were, localised to some particular spot;and hence it may not be inappropriately dis-tinguished as local hysteria. This form ofhysteria, however, often occurs in womenwho are liable to the paroxysms.

It is difiicult to assign a cause for thefixation of the hysterical phenomena in par-ticular localities. We have, indeed, verymuch the same difficulty here, as in explain-ing other examples of general or constitu-tional disease exhibiting local symptoms.It may be that, in many cases at least, thelocal symptoms should be regarded as

reflected nervous phenomena, either of sen-sation or motion ; some part of the greatgastro-intestinal surface, or some internal

viscus, being the seat of a primary disturb.ance, which creates an irritation of a por-tion of the nervous centre, and this affectssome sentient or motor fibres connected withit, which propagate their irritation to some

peripheral region. Or, again (and this, per-haps, is of rare occurrence), there may besome immediate irritation of a part of anervous centre, not propagated from anysentient surface, but caused by some localdisturbance of the circulation, and, conse-quently, of nutrition. Or, lastly (and this