No. 1031.

SATURDAY, JUNE 3, 1843.

COURSE OF LECTURES

ON

DISEASES OF THE SKIN;THEIR

HISTORY, PATHOLOGY, AND TREATMENT.Delivered in the Middlesex Hospital, during

the 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 XXII.PEMPHIGUS.

PEMPHIGUS, a term derived from theGreek word 7, a bubble, is sufficientlyapplicable to the form of cutaueous diseasewhich it is employed to designate, andwhich consists in the evolution of bladdersformed by the epidermis, and containing aserous fluid. The bladders, or bullse, pre-sent every variety of size, from the merestvesicle to that of the size of a walnut, or pul-let’s egg; they are developed on a patch ofinflamed and erythematous skin, and theyoccur either partially or generally on anypart of the surface of the body. Pemphigusis always associated with disorder of thesystem, and the extent of that disorder influ-ences the appearance of the contents of thebu!i:e; under a moderate degree of consti-tutional disturbance the serous fluid is trans-parent and colourless, or simply yellowish ;but in a more severe state of disorder thefluid may be more or less purple, from ad-mixture with blood, or it may be turbid andpuriform. The bullae arise on the surfacein a remarkably short space of time ; a spotperfectly free at night may be covered withbladders by the morning, and their declineis in some instances equally speedy. Theyterminate usually by rupture of the bullioand dessication of the epidermis into a thinbrownish scab ; in other instances the serousfluid evaporates, and a scab is similarlyformed, the scabs leaving at their fall a con. I

gestion of the dermis, which lasts for severalweeks, and denotes the character of the pre-

vious affection. Pemphigus frequently en-dures for a very considerable period indespite of all the remedies employed for itstreatment, lasting for months, and sometimesfor years.The varieties of pemphigus indicated by

different authors, are, from their number,truly ludicrous, and convey a merited sar-casm on the inventive genius of cutaneouswriters ; thus, we have a pemphigus conge-nitus ; p. infantilis ; p. simultaneus ; p. suc-cessivus ; p. solitarius ; p. confluens ; p.acutus ; p. chronicus ; p. pyreticus ; p. apy-reticus, &c. Willan has a pemphigus in.fantilis; p. vulgaris ; together with a pom.pholyx benignus; p. solitarius ; and pom-pholyx diutinus. But, in the first place,there exists no legitimate distinction betweenpemphigus- and pompholyx (1roj1poÀv;, a

water-bubble), and in the second all the va-rieties of the disorder may be considered intheir two states of acute and chronic, theformer of these states including the pemphi-gus vulgaris, pompholyx benignus, and pom-pholyx solitarius of Willan, and the latter hispompholyx diutinus.

PEMPHIGUS ACUTUS.

Acute pemphigus is characterised by thebrevity of its course rather than by the seve-rity of its symptoms. It occurs mostly inchildren and young persons, is accompaniedby a moderate degree of constitutional dis-turbance, and terminates within a periodvarying from one to four weeks. The con-stitutional symptoms of acute pemphigusvary very much in their intensity, in one casebeing so trifling as scarcely to excite atten-tion, and in another rising to serious disorderof the nervous and vascular systems, andeven to delirium. Irritation of the gastro-pulmonary and urino-sexual mucous mem-branes is a common concurrent symptom.The cutaneous eruption is usually pre-

ceded by some degree of languor and list-lessness, by loss of appetite, nausea, and

quickened circulation ; it is first apparent inthe form of small red spots, which increaseto the size of circular patches, and in thecentre of these patches the epidermis gradu-ally arises distended with a serous fluid.The bullae present considerable variety in

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regard to distribution; in some instances

they are disseminated regularly over the sur-face, in others they are scattered, or collectedinto patches of small dimensions ; and in

others, again, as in the kind termed by Wil-lan pompholyx solitarius, the bulla is single,and attains an inordinate bulk. The bulla;also vary in relation to the size of the patchon which they are seated ; in some instancesthe bulla covers completely the erythema-tous patch, while in others the bulla ismuch smaller than the patch, and the latterforms around its base an areola of variabledimensions. The after progress of the bullaalso presents the varieties which I have in-dicated in the general definition of the dis-ease ; usually the bullse burst, and give riseto excoriations, upon which a thin brownishscab is subsequently formed; in other in-stances the effused fluid dries up, and, toge-ther with the including epidermis, forms atemporary scab ; while in other cases, pre-viously to these changes, the fluid is altered,-from being limpid it becomes turbid, andfrom being colourless it becomes either san-guineous or purulent. The eruption issometimes consentaneous, at others it is suc-cessive, and consequently liable to be pro-longed in its duration.An extremely rare modification of pemphi-

gus acutu-4, termed by Willan pompholyxsolitarius, is remarkable for its limitation toa single bulla, and for the large size of thelatter, which has been found to contain se-

veral ounces of serous fluid. From its greatbulk and the necessarily extensive surfaceexposed on the rupture of the epidermis, it isusually followed by superficial ulceration.At the end of one or two days after the rup-ture of this bulla, another appears in its

neighbourhood, and, like the preceding,runs a course of two days, and bursts in thesame manner ; and this may be followed byfive or six successive bullas, each pursuing asimilar course. Willan remarks, with re-

gard to this variety of pemphigus, that " itis a disease which rarely occurs, and seemsonly to affect women. I have," he says," seen three cases of it ; in one the left arm ’,was affected, in the other two the breasts. I,The excoriations occasioned pain and irrita-tion, with partial hardness in the substanceof the breast."

PEMPHIGUS CHRONICUS.

Pemphigus chronicus corresponds withthe pompholyx diutinus of Willan, and, asthe latter term implies, is remarkable for thelength of time during which it continues tovex the patient in despite of the treatmentemployed for ita relief. The symptoms bywhich it is accompanied are less active thanthose which attend the acute form of the dis-

order, and are limited to some slight degreeof nausea, headach, and lassitude. The co-

existing disorder of the mucous membranesis more evident; thus, there are not unfre-

quently aphthas developed on the mucousmembrane of the mouth, the intestinal irri.tation is considerable, and occasionally thereis dysuria and haematuria. I have also seenchronic pemphigus associated with obstinatebronchial disorder. Chronic pemphigussometimes recurs for several successive

years, appearing at certain seasons, as inthe spring or autumn ; at other times it con-tinues with little variation for many months ;it is more painful than the acute variety, andoccurs in the persons of those who are

weakly, and reduced in powers of constitu-tion.The local eruption pursues the same course

with that of the acute variety, but is some.what more tardy in its progress ; the bul],Tmay generally be seen in all their stages atthe same time, and they are frequently de.veloped in small confluent clusters, partiru,larly on the face.

Chronic pemphigus is occasionally compli-cated with prurigo, and in old persons thecomplication may prove fatal.

Diagnosis.-Pemphigus is one of thosediseases which is very easily distinguished,-the bulla, with intervals of unaffectedskin, at once indicate its nature. Thesebullse, mounted on small circular erythema-tons patches, are widely different from thebuliae on the highly inflamed and tumid sur-face of erysipelas. They are less strikinglycontrasted with the smaller, flattened, andsparingly disseminated bulloe of rupia, butthe after characters of the two diseases arewidely opposite. The bullse oJ rupia arefollowed by deep and foul ulcerations, andby scabs of remarkable structure and magni.tude.

Causes.-Acute pemphigus is chiefly re-ferrible to irritation of the mucous surfaces;in some instances it appears to depend ondentition, in others on disorder of the ali.

mentary system, and in a third series on

irritation of the uterine mucous membrane.

Occasionally it is seen as a complication ofvaccinia, and it has also been found to ac.

company intermittent fever. Cases are onrecord showing its prevalence as an epi-demic disorder, and a variety of this disease;described by Sauvages under the name ofpemphigus indicus, occurs as a symptom ofdysentery.The causes of chronic pemphigus are all

such as tend to reduce the powers of thesystem ; it is, therefore, met with in the oldand infirm, and less frequently in childrenthan the acute form. Among the excitingagencies in the production of chronicpemphigus may be enumerated bad anddeficient food, intemperance, cold, residencein an unhealthy localty, fatigue, anxiety, &c.I have seen this disease a sequela of scar-latina, and the reduced state of the powersof the system in which it occurs may beinferred from the observation of Biett, that

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he had frequently found a fatty liver in thosewho had died with chronic pemphigus.Pg-MMM.—Pemphigus is always a dis-

ease of unfavourable augury, from its fre-quent association with depression of thepowers of the constitution. In the chronic

form, as I have already observed, it is

obstinate, and frequently fatal. Rayeralludes to a case in which the eruption ap-peared to act beneficially in relieving a

patient who had suffered from repeatedattacks of haemoptysis.

rtMmemr.—Where the patient is of fullhabit and sufficiently strong, and the feveracute, great benefit may be derived from amoderate general bleeding, seconded by anactive purgative and antiphlogistic regimen.But this plan requires to be practised withcare, for symptoms of debility speedily suc-ceed to the acute stage, and call for the em-ployment of tonics. When the symptomsare less severe, moderate purgatives, withthe usual anti-febrile remedies and diluents,are all that will be needed.Chronic pemphigus requires a tonic plan

of treatment, with generous diet. Themineral acids, combined with bitters or

with bark, are well suited to these cases.I have also seen much benefit result fromthe use of the hydriodate of potass ; andthe shower-bath, when the patient can bearit, I regard as a remedy of the first impor-tance. After all medicines had proved in-effectual in one case of this troublesome

disease, the patient was cured by settingthem aside at my request and using the Ishower-bath daily. Rayer, I should imaginein despair, had recourse to the arseniate of Isoda in an obstinate case of pemphigus.When the indications of the disease point

to any of the viscera or mucous membranesas the exciting causes of the local disorder,your remedies must necessarily be directedtowards them ; to the alimentary system, forinstance, or to the uterine system.

I have derived much advantage in someinstances of cutaneous eruption, of obscureorigin, by seconding, as it appeared to me, theefforts of nature in evolving a cutaneousexanthem. I have recently met with a re-markable instance of severe bronchial dis-order, of years’ standing, which was entirelycured by effecting that which nature seemedto aim at in vain ; and I believe that casesof chronic pemphigus might be much bene-fited by such a plan. 1 use for this pur-pose a liniment of croton oil, containing adrachm to the ounce of olive oil, and ap-plied by means of friction to the whole sur-face of the sound skin, or baths containingmustard.In regulating the local management of the

bul1ae of pemphigus your object should beto prevent the formation of excoriations.This is best effected by opening them early,and pressing the epidermis gently on theparts beneath. When excoriations have

formed, the surface should be dusted withsome absorbent and moderately astringentpowder. These form a crust upon thedenuded dermis, beneath which the excoria-tion heals. Sometimes you may deriveadvantage from an astringent lotion, or fromone containing sulphate of zinc, or nitrateof silver, or from the application of tinctureof catechu or benjamin. When the localdisorder is inflamed and irritable it may be

necessary to employ emollient and anodynefomentations. As an ordinary therapeuticapplication, the calamine ointment is all

useful medicine.

RUPIA.-ATONIC ULCERS.

Rupia may be regarded as a modificationof pemphigus occurring in weakly andcachectic constitutions. It is known by theproduction of bulla: of smaller size andflatter than those of pemphigus, the bul]Eebeing few in number and dispersed at irregu-lar distances on the skin. Like thebullas of pemphigus, they are developed ona patch of erythema, which sometimesscarcely exceeds in size the base of thebladder, and at other times extends to somedistance around it, so as to form a consider-able areola. The contents of the bu1Jae are,for the most part, limpid and colourless atfirst; frequently, however, they are sangui-nolent and dark-coloured, and occasionallypuriform and opake. When the bulla bursts,a copious secretion, poured out by the ex-coriated surface, concretes and dessicates intoa moderately thick crust, which becomeslaminated by the successive addition of newlayers of dessicated matter at its base, andthus attains considerable thickness. Thecrusts of rupia, being composed of a purulentichor more or less discoloured with blood,are generally of a dark-brown colour, some-times, in parts, approaching to black. Theform of the crust is also subject to variation,at one time being nearly uniform in thick-ness, and resembling an oyster-shell ; atanother being conical in its shape, muchthicker in the centre than at the circum-ference, and resembling the shell of thelimpet. On the fall of the crusts the dermisbeneath is found deeply ulcerated, theappearance of the ulcers being foul and

unhealthy, burrowing beneath the adjacentskin, and pouring out an ichorous and fetiddischarge. These ulcerations are exceed-ingly obstinate, resisting the means adoptedfor their cure, and continuing for several

weeks, and even months.The varieties of rupia are three in num-

ber, namely,Rupia simplex," prominens," escharotica.

RUPIA SIMPLEX.

The simplest form of rupia is that inwhich the disease possesses, in the most

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moderate degree, the general characterswhich I have just described. The bullaare circular in their form, and vary in sizefrom that of a sixpenny to a sliilling- piece ;they are developed without any markedalteration of the skin preceding their appear-ance, and the ulcerations they leave behindthem are superficial, aud less troublesomethan those of rupia prominens. I observedto you, on my first mention of rupia, thatthe disease is invariably dependent on acachectic state of constitution in the sufferer;hence the local disorder maintains the

ordinary characters of atony and debility,the edges of the ulcer are purplish and livid,the areola, if there be one, surrounding theulceration is also livid and purplish, andthe congested patch which it leaves behindit presents the same appearance. This livorof the tissues affected with rupia, with thetransudation of the biliary elements of theblood, the consequence of tardy circulation,into the areolar textures around, gives oftento the seat of this disease the coppery hueso generally regarded as an evidence of

syphilitic disease ; and this error has spreadso far that the unfortunate subject of rupiais frequently made to bear a stigma on hismoral character in addition to the miseryentailed by his physical disorder. I haveheard a surgeon of eminence assert that

rupia was always a disease of syphiliticorigin. Such an opinion is altogether anti-physiological, and consequently erroneous.And I have no hesitation in declaring that amajority of the cases of diseases of the skinpronounced to be syphilitic have no con-

nection whatever with syphilis, either proxi-mately or remotely. Rupia is undoubtedlya disease of cachexia ; cachexia is inducedby a variety of causes, and one, amongmany, is syphilis and the mercurial treatmentof syphilis. In syphilitic cachexia wemay have rupia, consequently syphiliticrupia ; but this surely aftords no groundsfor attaching suspicion to all those who mayhave the misfortune to be the subject of thisdisease. The more frequent seat of rupiasimplex is the lower extremities.

RUPIA PROMINENS.

Rupia prominens is more severe than thesimpler variety; it is preceded by an erythe-matous redness of the skin, in the form of

patches ; the bullae are of greater extent ;the contents of the bullae darker coloured ;the ulcerations deeper and widely burrowed;and the crusts thicker, darker, and harder.Indeed, it is the thickness of the crusts thathas gained for the disease its appellative,prominens, the term rupia, derived from

PV1rOÇ, sordes, having relation to the filthyconcretions which, without cleanliness, col-lect upon and around these sores.

I have before remarked that the crusts ofrupia prominens are conical in shape andlaminated in structure. This peculiarity of

form and structure of the crust has referenceto the mode of its production; for instance,after the formation of the first crust, theeffusive and ulcerative action continuingbeneath it, the epidermis becomes raisedaround its base, and a fresh deposit is madeto the under surface of the crust, extendingas far as the limit of the newly-raised epi-dermis. The effusive and ulcerative processstill remaining unchecked, and again ad-

vancing beneath the adjacent epidermis,another addition is made to the base of thecrust, and the same process is continued

progressively until by successive deposits thecrust attains its remarkable form, a formthat has been aptly compared to a limpetshell. The process of formation of the crust

usually advances for some days and thenstops, but the crust often remains adherentfor a week or more afterwards. At its fall,a deep, foul, ulcer, with thin livid excavatededges and an inflamed areola, is discoveredbeneath. The ulcer sometimes secretes anew crust, but at other times, and more fre.quently, remains open, pouring out a quantityof fetid ichorous discharge, and obstinatelyresisting treatment.Rupia prominens is usually developed

on the extremities, and more frequently onthe lower than the upper. The bultae areusually two or three in number, and the dis-ease may be seen in every stage of its pro.gress at the same time: on one spot, theerythematous patch ; on another, the bulla

advancing in distention, and filled eitherwith transparent and limpid, or turbid andpurulent fluid; in a third place is the deepfoul ulcer ; and in a fourth, perchance, thecicatrix of a healed ulcer surrounded by acongested and purplish stain. The con-

gested stain of rupia remains visible forseveral months.

RUPIA ESCHAROTICA.

Rupia escharotica, in some respects, bearsresemblance to pemphigus, particularly inthe absence of the thick rough crusts whichare so conspicuous in rupia ; hence it hasbeen described by some authors under thename of pemphigus gangrenosa. That formof disease which is termed by Willan

pemphigus infantilis, is also identical withrupia escharotica, the essential character bywhich rupia diflers from pemphigus beingthe deep and foul ulcerations, which accom-pany the former and are rarely met with inthe latter.Rupia escharotica is developed in the

form of bull pe, which are raised on spots of apurplish or livid hue. The bullse are smallerthan those of pemphigus or of the othervarieties of rupia; they are irregular i)itheir form ; they contain a sanguinolentserous fluid, which becomes turbid and verydark-coloured, and they are surrounded bya purplish areola. When the bullas burst

they leave behind them small ulcers, which

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are foul and excavated, irregular in their

form, and have thin undermined edges.Sometimes the parts beneath the bulias arein a state of gangrene, and the dead skin isthrown off by sloughing. The ulcers pourout an abundance of sanious discharge, andare troublesome and tedious under treatment.The bullae of rupia escharotica usuallyappear in successive crops, and the diseaseis prolonged for a considerable period. Thelocal disorder is accompanied by feverish-ness and nervous irritability, and the patientis often worn out by the irritation inducedby the continuance of the disease. Rupiaescharotica is most frequently met with onthe lower limbs, it also occurs on the trunkof the body, the neck, and organs of genera-tion ; on the face it is less common.Diag’HMM.—Rupia bears considerable

analogy to pemphigus, but, as I haveendeavoured to show you, there are several

sinking differences between them. Thesmaller size, flatness, and irregularity ofthe bullae; their ftequently sanguinolentand turbid contents; the thick, laminated,dai-k-coloured and rugous crusts; and thedeep ulcerations which succeed, are charac-teristic of rupia, while the characters of

pemphigus are the very reverse of these :the buHae are large, full, and regular ; theircontents are mostly limpid and transparent;their scabs are thin and pellicular, andthere are either no ulcerations nr the latterare very su perficial.There is one other disorder which might

be confounded with rupia, it is ecthyma ;but ecthyma is a pustular disease ; the

puatules are not elevated above the surfaceto the same extent with the bullae of rupia ;they are surrounded by a highly inflamedareola, and the scabs, though hard, thick,rugous, and dark-coloured, are set in theskin so as scarcely to rise above its level.Causes.-Rupia is a disease of cachexia,

and may occur in debilitated constitutionsfrom any cause that shall have the power ofreducing the powers of the system, such aslong-continued illness, want of food, mentaldepression, intemperance, absence of cleanli-ness, &c. It has been observed as an after

consequence of measles, small-pox, andscarlatina. It has been seen, also, inassociation with purpura hasmorrhagica.Bateman, Biett, and Plum be, consider rupiato bear some analogy to ecthyma, and casesare recorded in which these diseases havebeen seen combined. The escharotic varietyof rupia is occasionally seen in weaklyinfants and sometimes in aged persons.

yreaCKt.—That which is most essentinlin the treatment of rupia is attention to thegeneral health, and the employment of thosemeasures which are best calculated to restorethe powers of the system and remove thecachexia. For this purpose you must haverecourse to tonic medicines and a generousdiet, aided by exercise and by the warm and

cold bath. The best tonics for rupia arewine ; honest beer, if it can be found ; barkwith mineral acids and bitter infusions, suchas hops, wormwood, and gentian. As soonas the strength permits, the shower-bath,with dry frictions, will be found veryserviceable.The local treatment of rupia consists in

opening the bu]Jae at an early period andpressing the epidermis gently with a pieceof dry lint, keeping the lint applied bymeans of a light bandage. Water-dressing,also, is sometimes efficacious. More fre..

quently, however, it will be found that thesesimpler means have no influence on theulcerations which follow, at least, not untilthe system becomes atrected by the generaltreatment; we must then employ stimulatingapplications, beginning with the milder kindand proceeding to the more active. Thebest of these stimulating medicaments arelime-water, sulphates of copper, alumina,and zinc, nitrate of silver, nitric acid, &e. ;there are, besides, numerous others whichthe mind of each practitioner will suggest.Rayer recommends that the ulcers should bedusted with cream of tartar, while a favoriteapplication of Biett is an ointment of theproto or deuto-ioduret of mercury. In a veryobstinate case of rupia promineiis of the

upper extremity, I succeeded in healing theulcers, after divers applications had failed,by injecting a strong solution of alumbeneath the undermined edges. Whateverthe medicinal substance employed, however,the loose edges of the sores should be com-pressed against the surface beneath, eitherby plasters or bandage.

POISONING BY COMMON CERATE.-Thefollowing circumstances suggest the neces-sity of extreme caution in the manufactureand use of common cerate, which may beequally liable to become injurious in thiscountry as in any other from the cause aboutto be specified. A French practitionerhaving ordered one of his patients, a manfifty-five years of age, to apply plain cerateto heal some blisters on his arms, the patientpurchased some of a druggist for the pur-pose. Next day he was restless ; the armswere inflamed and painful; tongue red anddry ; thirst intense ; pulse small, irregular,and frequent; headach, gripingo, involun-tary contractions of the muscles of the legsand back, &c., were present, and the patientdied. Similar symptoms manifested them-selves a few days afterwards in anotherpatient, a little girl, who had had occasionto use cerate purchased of the same druggist;but this case did not terminate fatally. Thepractitioner now inquired narrowly respect-ing the manufacture of the cerate, and foundthat it had been composed of the ends of :t’f’candles, in making which arsenic had beenemployed.- Gazette des Hôpitaux.