No. 346.

LONDON, SATURDAY, APRIL 17. [1829-30.

LECTURES ON SURGERY,MEDICAL AND OPERATIVE,

DELIVERED AT

St. Bartholomew’s Hospital;BY MR. LAWRENCE.

LECTURE XXXVIII.

,4affections of the Skin continued.- PO1’rigo,its variousforms.-Tubercular Diseasei.Lupus-.Noli me tangere.

jPorro.&mdash;Gentlemen, the terms tinea andporoigo are employed technically, to desig-nate some affections of the hairy scalp whichare called, popularly, scalledhead, and some-times 7*<Kg:o)’Mt. Porrigl&THORN;is the term em-ployed by Drs. Willan and Bateman, andhence it has been generally adopted as thescientific name for those affections. The Eng-lish term of " scalled head," is not meant toindicate that the affection is connected withthe application of heat, or of its being at alllike the effect of scalding ; but it is a namederived from an old English word, which, Ibelieve, may be considered nearly as equiva-lent in sound to the word scald; and scalledhead, in this sense, means scabby head. Theterm ringworm is applied to a particularform of eruption ; sometimes to what I havementioned under the name of her pel/. In oneform of herpes the vesicles assume a circularappearance, and are called herpes eirci7zaties;they have the appearance of rings-hencethe term ringworm. In one form of psoriasisthe inflamed and scaly state of the skin re-sembles a narrowish line, it hasa sort of spinalappearance; and the ringworm or scalledhead,is an affection of the scalp in which the in-flamed and pustular part exists in circularpatches. Now, under the term porrigo Drs.Willan and Bateman include some other af-fections of the hairy scalp, besides those towhich our familiar name of scalled head isapplicable. They include some other affec-tions, which, in fact, have very little resem-blance in their nature ta scalled head ; and

probably when these affections shall havebeen more minutely investigated, some ofthe complaints which they include under thatterm will be separated.

Porrigo, or tinea capitis, is an inflamma-tion of the hairy scalp, originally commenc-ing in patches, and seen in groups of minutepustules, pustules which are situated on theskin of the scalp. Now these pustulesgenerally assume apeculiar appearance ; theyare very small in size ; they produce a pecu-liar kind of secretion; they are such kindsof pustules as nosologists have distinguishedby the terms achores and favi. The affec-tion achor, of which achores is the plural, isparticularly distinguished by its circular

form ; it is minute in point of size, embeddedin the skin, and produces a thick, and, atthe same time, nearly transparent secretion,which has been compared to honey, which,when it exudes from the pustule, incrusts intoa scab upon the surface. The term fazlusis applied to a pustular affection of the scalpwhich is larger in extent, but which pro-duces a similar kind of secretion, a secretionsimilar in its obvious qualities, and resem-bling it also by terminating in nrm yellow-ish crusts. The secretion, which takes placefrom the groups of pustules that constitutethe state of porrigo, forms thin scabs, vary-ing in size and in figure. In proportion asthe disease proceeds, the continued exuda-tion from these pustules adds to the thick-ness of the incrustations, which consequentlyenlarge in size, and become considerablyelevated above the surface of the skin. Theseaffections, if they are not well attended to,go on for several years; and thus you fre-

quently see an individual whose head is co-vered over with irregular bumps, which giveit a very singular appearance, these massesof incrustations rising considerably above thesurface of the head, and presenting a verystrange figure. In some instances, the scabswhich form from those pustules have an in-dentation upon their surfaces-a cup-likeindentation. When they have increased insize, and formed the elevated masses 1 havementioned, they have been compared to

various objects, and thus different nameshave been given to different forms of the

complaint, according to the appearances

66

which the incrustations exhibit. Where Porrigo is considered to be a contagiousthere is a number of these cup-like indenta- affection, and it is supposed that the mattertions, they have been compared to the which is secreted by the pustules of the in-honey-comb ; hence the term porrigo favosa. flamed scalp, when applied to that of a soundSometimes the disease has been compared to person, is capable of producing the disease.the lupine, and it has been called porrigo Tlius,very often,itisfound tbatacliild affectedlupinosa. Sometimes the disease is seen with this complaint, on going into a school, willwithout the incrustations rising so high, but communicate the disease to many others, andforming regular scabs, and that has been that often the disease runs through the wholetermed porrigo scutulata. Now, I do not of the inmates of the establishment. I believeapprehend that these different terms denote it is not ascertained that all forms of the dis-any thing different in the nature of the af- ease possess this contagious property ; it isfections ; they are merely applied to modified however agreed, that the form which 1 haveforms of them. In the first instance, the pus- called porrigo scutulata, in which there aretules appear to form in the intervals between certain regular circular forms of pustules, atthe hairs and the scalp ; but as the affection all events is contagious. I suppose we

proceeds, the bulbs of the hair become in- could not very safely trust to the non-con-volved, and are destroyed by the ulcerative tagious nature of other forms of porrigo,process ; so that when the complaint has so that I should be inclined, practicallyexisted for a long time, and you come to speaking, to say that all cases of this pustu-loosen from the head those firm indentations lar disease of the hairy scalp are capable ofand scabs which I have described, you will being communicated to others.find that the greater proportion of the bulbs It has been represented by some of thoseof the hair are destroyed, and that, in fact, who have had extensive experience in thesethe hair never grows again there under these affections, that one form of porrigo in an in-circumstances ; so that when the disease has dividual, will produce different forms of thebeen of long duration, you will find the complaint in other individuals&mdash;that is, sup-head, even of a young subject, left ultimately posing one to have the porrigo seutulata,in the state of that of an old person who has contagion from-that disease, will produce onelost all his hair ; the hair is unnaturally re- form of the disease in one person, anotherinoved by the complaint. The progress of in a second, and another in a third ; so that itthis affe&eacute;tion is of course much favoured by would seem that the particular modificationsthe neglect of cleanliness. Thus you find of the disease do not so much depend on thethat some of the worst cases occur in the exact nature of the matter communicated, ormiddle and lower classes of society, in the the part affected, as on some circumstanceslatter particularly, where proper attention respecting’the state of constitution of theis not paid to cleanliness. Frequently the individual by whom the disease is caught.irritation which is produced on the scalp by This is a point, however, not very accu-

the pustular disease is materially aggravated rately ascertained.by the addition of numerous vermin, which Now, inasmuch as this disease very oftenseem to breed and propagate most excellent- arises from contagion, of course you do notly under this state of the head. It frequently always see circumstances in the state of thehappens in this disease that the lymphatic health of the individual capable of givingglands, those to which the absorbent vessels rise to it. You find, perhaps, that thisof the scalp pass, become enlarged. Thus affection of the scalp arises and exists, for ayou will have enlargement of the lymphatic great length of time, in children who areglands situated behind the ear and along the perfectly healthy; children who have goodneck. This affection generally commences appetites, with regular performance of theon, and is confined to, the hairy scalp, but digestive functions, and in whom all partsit may extend to the neighbouring skin, and, of the economy seem in a natural andin fact, over the whole body ; so that you healthy state. The question has arisen,frequently find, not perhaps exactly the same whether porrigo must actually originate inkind of appearance over the whole of the contagion, or whether it may be developedbody, which characterises the disease when under some particular combination of cir-it is seated on the scalp, but appearances cumstances with which contagion has BO-somewhat similar in nature. The extension thing to do. Now I do not know any factsof the disease over the whole body is said to capable of elucidating this point; but I find,be produced by a kind of inoculation ; that from the experience of others, that the statethe patient by scratching the head, the of the health is a sufficient cause-that

original seat of the disease, and afterwards the affection may originate independentlyapplying the matter to various parts of the of the actual communication of infectiou!

body when scratching them also, inoculates matter.

himself with the disease. Whether it arises Treatment.&mdash;Now the treatment of thisin this way or from the prevalence of other disease cannot be conducted upon one and

causes it is rather difficult to determine, the same plan in every stage. You have,

67

in the first instance, an active inflammatory adopted a plan in France, of applying whatcomplaint; the period of inflammation passes are called depilatory substances to the scalpby, and you have then a long chronic stage ,-substances which have the effect of re-of the disease. You would not find the moving the hair, the active portion of whichsame treatment advantageous both in the consists of lime&mdash;quick lime. The mode in

period of active inflammation and in the which these depilatories are used is, in thelong chronic stage. In the early inflamma- first place, to apply linseed, or other poul-tory course, you must employ an antiphio- tices, to the surface of the head, and then togistic treatment; you may find the applica- wash the part very carefully with soft soaption of leeches necessary on the inflamed and water every day, to get rid of all scabsskin behind the ear, or on some parts of the and incrustations. Then having got theinflamed scalp ; you may employ cold appli- head dry, you apply the depilatory sub-cations, saturnine or spirituous lotions, in stance. Here is a formula of this kind byorder to diminish the temperature; soothing Rayer : take one ounce of lime, and withapplications, tepid ablutions, or warm things this combine two drachms ;of the subear.of an emollient kind, such as warm bread bonate of potash, and one drachm of char-and water, or bran and water, or milk and coal; mix them with as much lard as willwater,, and mild unctuous applications; make an ointment; apply this ointment topoultices, generally-bread-and-water poul- the head, and you will find, upon washing ittices ; these are the means applicable to off, that a certain part of the hair will comethe stage of inflammation; and with them away also. This is to be repeated till theyou will combine such mild internal reme- surface of the head is completely denuded.dies as are calculated to keep the digestive Another form consists of twelve drachms oforgans in a proper state. It is a matter of quick lime, ten drachms of starch, and onegreat importance to keep the affected part drachm of the sulphuret of arsenic. This isclean and dry from the discharge produced. to be employed in the same way. I haveThere is some difficulty in accomplish- not seen these depilatory applications used ;ing this, on account of the hair becoming but 1 should conceive that, if they are ca-knotted, incrustations forming, in conse- pable of removing the hair, they are muchquence, with great facility. Now it has more eligible than the plan of drawing off,been often said, that you should have the or tearing out, the hair, by pitch or the for-hairy scalp regularly shaved and cleansed. ceps. Of course they are only to be usedBut you cannot have the scalp of a child, where the state of the scalp prevents youwhen active inflammation exists, shaved ; from removing the hair by the shorter opera-the irritation of such an operation would tion of shaving.materially aggravate the complaint. You When the complaint is in its chronicmust be content, therefore, with having the stage, we can safely employ those active andhair cut short with scissors, and you will stimulating substances of which I have al-thus, probably, bring the scalp into a state ready had occasion to speak to you ; thein which a thorough cleansing can be ao- sulpliur, the tar, the nitrate of silver, andcomplished. When you come to the chronic the mercurial ointments, are the most com-stage of the inflammation, however, when mon ; any two of them may be corn-

the skin is no longer in so tender a state, bined ; they should be applied pretty abun-the regular operation of shaving is very ad- dantly on the diseased surface, after thevantageous, though it may still be a ques- parts have been cleansed, and then the headtion whether the state of the skin is such as should be covered with a light linen cap.to admit of shaving ; for the skin may yet be The plan which is generally adopted ofso sensitive, that the slight wounds and irri- covering the head with an oil-skin cap istation, consequent on the operation, may objectionable ; the perspiration is confined,.actually produce greater mischief, than the and the head is heated by doing so. Theentire removal of the hair will accomplish tar ointment is not ucfrequently employed,benefit. Under such circumstances, you and with considerable advantage, the ex-

must be contented simply to cut the hair tent of which may sometimes be increasedshort with scissors. Mow, very rough mea- by the combination of the sulphate of cop-sures have been recommended to get rid of per; two drachms of the sulphate with anthe hair of the scalp. It has been suggested ounce of the tar ointment. Then among theto cover the hair with linen spread over with lotions that may be used, I may mentionointment, chiefly made of pitch ; which, after the acetic acid lotion, the pat ts being lightlybecoming warm and adherent to the hair, is sponged over with this, before the tar andto be dragged off with the hair attached. sulphate of copper ointment is applied ; theThis, however, is too rough and unscientific ointment, if put on tolerably thick, may bea mode to be recommended. It has been left there for two or three days, but you willndvised, again, to take a pair of forceps, and probably have occasion again to apply thedraw the hairs out by the roots ; but this acetic acid when you remove the old, andis equally objectionable. They have lately apply fresh ointment. The nitrate of silver

68

is very useful in these. cases ; from two to I do not know that you can do more hereten grains in an ounce of distilled water may than keep the part clean, and then npplybe made into a lotion. The part is to be the local stimuli. But in respect to the

cleansed ; apply this solution, and then branny state of desquamation which is con.spread the ointment over that. The com- sequent on the pustular disease, the affec-plaint of which I am now speaking has pre- tion may be kept up too long by the appli.vailed very extensively in a neighbouring cations you have been using. If you sus-institution, that is, in Christ’s Hospital. A pect that to be the case, you must confinegreat number of individuals have suffered your treatment to cleanliness merely, andthere under different forms of the disease; the application of simple soft ointment.they have very frequently employed a lotion Then these authors mention another affec-of an astringent kind with considerable tion of the scalp which is very singular, andbenefit. The lotion, which is not very un- I think nat at all allied to the preceding,like ink, is composed of four ounces of the although the name of porrigo is given todecoction of galls, half an ounce of distilled this also. I think the one is totally differ-vinegar, .two drachms of the sulphate of ent from the other. This affection is theiron, and one drachm of the acetate of cop- Porrigo decalvans, and consists in a fall-per, and this is used as a lotion to the spots. ing off of the hair; no inflammation, noSuch, then, are the means that may be em- formation of pustules, but a gradual loss ofployed in the chronic stage of tinea or por- the hair, and, ultimately, the portion of scalprigo. The complaint is a very obstinate and thus affected becomes of a bright shiningtroublesome one, and a great deal will de- white, the bulbs of the hairs themselves

pend on the careful application of the local completely disappearing, and the head re-means that are used in the treatment. In a sembiing the top of the head of an old baldgreat many instances you can do no good person. Perhaps in the early stage of thisby the general remedies that are employed. affection, by shaving and keeping the partsYou will find the disease existing in chil- clean, we may stop the complaint, but whe-dren where you can gain no ground by at. ther we have any influence at all over thetention to diet and other circumstances, the progress of the disease is rather a doubtful-children being already perfectly healthy, question.Much, therefore, will depend on the careful There is another affection mentioned un.administration and application of local mea- der the head of porrigo, which begins on,sures. Take care that the surface is tho- and principally affects, the face, on whichroughly cleansed, that the hair is ’not suf- part the characteristic appearances are simi-fered to grow so as to assist in retaining the lar to the pustules arising in the porrigomorbid secretion, and add to the accumula- scutulata ; I mean thetion of the crusts. Ascertain that the appli- Porrigo larvalis, or crusta lactea. Now,cations of the lotions are very carefully at- the crusta lactea, or porrigo larvalis, is mark-tended to, and if you follow up this system ed by two things ; first, its production of in-of rigid attention, you will generally succeed crustations, and next, its appearing duringin getting the part inte a tolerably good the period of suckling; hence the term

state ; but the complete and radical removal milky crusts. This is an inflammation ofof the disease is often attended with great the skin, commencing about the chin anddifficulty, notwithstanding all the care you face, leading speedily to the development ofmay take, and all the pains you can bestow. small minute pustules, called achores, the

Drs. Willan and Bateman mention a por- discharge from which forms thin, yellowrigo furfurans, which means a branny, or scabs ; but the discharge is not so thick in

scaly porrigo. Now, a simply scaly state of this case as in porrigo ; it is more fluid, andthe hairy scalp is an affection of a totally hence the French writers call this the tineadifferent form from one with pustules ; por- niucosa. The discharge continuing after

ligo furfurans, therefore, if attended with the incrustations are formed, exudes at thebranny desquamations, must be very differ- margins of the incrustations, these latterent from the pustular affection. We may themselves becoming thicker and larger.observe, however, that as the pustular affec- The affection extends from its original situa-tion advances towards cure, a condition of tion on the cheeks and neck to the forehead,the scalp remains in which there is some forearm, and very often to all parts of theunnatural hardness, and in which a state of body, occurring not uncommonly in chil-extensive exfoliation lasts for a long time. dren of a gross habit, in children that areThe part appears perfectly healthy, but over-fed, children in whom marks of reple-when rubhed a number of branny scales will tion and an unhealthy state of the digestivebe raised. But, I believe, independently organs are obvious. Sometimes this affec-of that which originally is pustular, there is tion is produced as a direct effect of locala chronic inflammation affecting the scalp, irritation ; thus it will occur as an effect ofwhich occasions these branny desquama- strumous ophthalmia, where there is a co-tions. pious stimulating discharge of the tears

69

1t’hicIl produces an irritation of the palpebrx, lactea, when in an inflammatory stage, with-occasions heating, irritation, and itching, out adopting measures to prevent the recur-and leads the child to rub and scratch those rence of other diseases. I should say, from

parts ; the disease; in consequence, extends the state of constitution out of which thisfrom the palpebr&aelig; to the cheek and face, complaint arises, that if suddenly stopped,and then the incrustations form on the in- there would be considerable risk of disease

teguments, which produce the porrigo lar- occurring elsewhere, and so in other cases.valis. Now, in instances whete this con- But when diseases of the skin are treated ontinues, and where the treatment has been the principles I have mentioned to you,neglected, you will find nearly the whole that is, when you endeavour in the first in-surface of the face become covered with a yel- stance to remove the state of constitutionlow scab ; hence it is called larvalis. Larva which produces them, when you employmeans a mask; and the term larvalis is given antiphlogistic treatment in the inflammatoryfrom the face being covered with a scab like stage, you may then safely take any men-a mask. A case of this sort, though appa- sures that are proper for removing the local

rently very fO1midable, is not so in reality, disease. When you have got the. systembut may easily be removed. I should men- into a healthy state by these measures, yoution, that this is not, like the porrigo or need not apprehend any evil consequencestinea capitis, possessed of contagious qua- from the disease being stopped. There are,lities. however, certain forms of cutaneous affec-

In the inflammatory stage you must, in tions, particularly some of the scaly&mdash;thethe first place, clear out the alimentary ca- lepra, for instance-which exist for a greatnal, if that be loaded, by active apericits, length of time, being more active at one pe-and then administer such mild medicine, as nod of the year than at another, and where,will keep the stomach and bowels in a pro- probably, the individuals in whom they existper state: regulate the diet also. You derive adiantage, in consequence of theshould employ, at this period, soothing, local general state of their health, from such exist-applications. Perhaps, if there is consider- ence ; therefore, if we have the power, Iable heat, you may find saturnine lotions think it would not beat all wise to remove

useful; or, at all events, you may bathe the those affections, while the local complaintsparts with emollient fluids, milk and water, remain in a state not very inconvenient toor other things of that kind. Apply mrlcl the patient. They may he the means of

ointment, spermaceti, or the cidcr-nower keeping off some more serious affections. I

ointment, and the like. When the inilam- think, therefore, that these notions, althoughmation is put a stop to, vou can very speedily not to be carried to an extreme, are foundedcure the complaint by applications of an in truth, and ought not to be lost sight of.astringent kind ; and I think there is one of Tubercles.&mdash;I have next to speak to youthis sort, which pretty well supersedes all of the tubercular diseases of the skin, notthe rest, that is, the oxyde of zinc; one considering them exactly as affections of artdrachm to an ounce of distilled water, will inflammatory nature, but rather as changesanswer the purpose very well. The zinc of structuie, with chronic thickening anddoes not dissolve in the water, but you shake development of tubercles. All affections inthe mixture before you dab the part over: which there is organic change in a part, areby this application, you find the pustules more seiious than those which consist sim-very speedily dry up, and the complaint be- ply in inflammation of that part. In inflam-comes cured. This remedy is sometimes mation there is a serious disturbance, butused in the form of an ointment, but it is not that is of a temporary nature. We knowin that form so useful as the zinc lotion. The that innammatoiv disease will go through aunguentum hydrargyri nitratis in a mild certain process, and then come to an end;form may be used ; that is, one part of the but when you arrive at an actual alte-ointment to four or five or six parts of the ration of structure, you have very littlespermaceti ointment or lard, may be applied power of repairing that; such is the case infor the same purpose. the tubercular state of cutaneous nosolo-Some have entertained a great apprehen- gists as I have already had occasion fre-

sion of the ill consequences from speedily quentiv to mention to you. The first of

removing or drying up an eruption of this these to which I shall draw your attention.nature. They have said that hydrocephalus, ! is,-or other internal diseases, may be thus pro- Elephantiasis,&mdash;A disease which doesduced. The same kind of apprehension has not belong to this climate, but which weexisted respecting the speedy cure of other have occasion to see in individuals whoforms of cutaneous disease. Nw these ap- are either natives of countries in which theprehensions are not altogether without disease is not unfrequent, or who haveground. I should say that it would be a actually brought it into this country fromvery imprudent thing suddenly to stop, if thence. The complaint is chronic, and lastsyou had the power, the progress of crusta’ a great number of years. Elephantiasis oc’

70

curs inhot countries; and patients generally air-passages. In Other cases, this affection

bring the complaibt itself, or at least a is attended with considerable depression ofdisposition to it, from the East or West In- the general powers ; with that state whichdies. In its first development, this com- nosologists have called cachexia. The pulseplaint is inflammatory. There is consider- is small and feeble ; the functions in generalable febrile disturbance of the system, and are irregularly exercised ; the individual istin inflamed state of some part of the skin, languid, and, in fact, falls into a state ofge-although not riiarked by the ordinary cha- neral decay. The continuation of the dis-racters of high inflammation; and in that ease, the recurrence of fresh attacks of in-

portion of the skin, tubercular enlargements flammation, and the development of newarise, varying in size from that of a large sets of tubercles-these continue to depresspin’s head, to that of a large horse-bean, the powers, and the patient sinks under theThese soon change from the slight redness complaint ; such sinking, however, not tak-they have in the commencement, to a deeper ing place until after the complaint has lastedcolour than that of the natural skin. They for a great length of time.form hard, shining, smooth knots of the Treatment.&mdash;In the inflammatory stateskin. After existing for a certain length of of this affection, you must of course

time, they form an unhealthy kind of ulcer, employ such means as are necessary tofrom which a discharge slowly issues, and check the inflammation ; but in theforms thin brown crustations on the surface chronic stage, as far as 1 have seen theof the sore. A kind of indolent languid complaint in this country, I think there,ulceration is produced, which remains for a is very little to be done by medicine.long time nearly in the same state, and then Arsenic, mercury, and some other powerfulslowly cicatrises. Fresh tubercles arise, means, have been supposed to possess a cer-which go through the same process-tuber- tain degree of efficacy in arrestmg the ailec-cular elevation, induration, ulceration, and tion ; but, according to my experience, allcicatrisation. Thus you will see on a part these remedies do more harm than good.of the body affected with elephantiasis, some The only plan that I have seen advanta-tubercles in their original state, consisting geous in the chronic state, has been that ofof mere simple, pale, shining, elevations of allowing the patients good diet,-good nou.the skin ; others in a condition of ulceration, rishment, keeping them quiet, and not giv.and, mixed with these, cicatrisations and in- ing them more medicine than may be ne-crusfat,ions. This affection first shows itself cessary to regulate the bowels. Underon the face, affecting the forehead, eye- such a course of treatment, I have seen

brows, eye-lids, the nose, particularly the them for a time get tolerably well. But,al&aelig;, the lips, the cheeks, the ears, then the unfortunately, though the ulcerations mayupper, and, afterwards, the lower extremi- heal up, and the tubercles get well for aties of the body, showing itself first upon time, persons thus affected, I believe, in thethe fingers, the skin of which becomes so end die of the disease.beset with those tubercles, that their forms Lupus.&mdash;The next affection of the tu-are very much altered; the tubercles spread bercular kind I have to mention is thaton the backs of the fingers, by which they which is called lupus,&mdash;occurring in theare enlarged, and rendered rough and irre- face. This is also known by the name ofgular. In the lower extremities the tuber- Noli me tangere, which I need not informcles first appear on the toes, and next occu- you is equivalent to the expression, "Touchpy the feet. They do not arise much on the me not,"-an indication of the intractablelegs, nor do they, perhaps, reach the upper nature of the affection. It commences witharm. Great deformity is produced by the inflammatory swelling about the nose or

complaint attacking the face ; the also nasi cheeks, or some part of the face, and theare enlarged, fissured, and quite altered in elevation of bright, red, and pretty activelyform ; the lips are thickened and rendered inflamed tubercles of the skin, which thenirregular in shape, and, in fact, such altera- proceed into a state of foul ulceration. Wetions take place in the features, that you do not always, however, observe a tubercu-would not recognise the individual affected, lar state of the skin. We see the nose, forThe disease is not confined to these parts, example, assume a deep livid, inflammatorybut extends to the mucous membrane lining tint, and go into a kind of unhealthy ulcera-the mouth, which becomes ulcerated ; tu- tion, without exhibiting the tubercular cha-bercles form upon the palate ; the entrance racter. The instances in which there is ato the fances is beset with them, and the previous appearance of bright-red spots,affection sometimes extends along the lining seem to be rather indicative of a scrofulousof the air-passages to the lungs. One or tendency in the patient, and in such casestwo cases that I have seen, have ended fa- might be regarded as scrofula affecting thetally, in consequence of inflammation of the skin; this form of the disease occurs in young-lungs, apparently produced by the extension subjects. But the form of lupus, which isof the tubercular disease to them along the perhaps the most intractable, is that which

71

occurs in adults, when inflammation of the generally, for these corroding affections ofskin takes place, a foul ulceration ensues, the face have been considered cancerous,and the process tends to destroy the parts although they have nothing whatever can-in which it is seated, spreading with a vivid- cerous in their nature. Then the liquorly red, inflamed border. In this way we not arsenicalis, of the London Pharmacopoeia, isunfrequently find a considerable part of the used as a remedy for this complaint; but,al&aelig; of the nose become affected, and, in under some circumstances, this must be di-course of time, all the cartilaginous part of luted with distilled water; under others,the nose is destroyed. The ulceration is you may apply the liquor arsenicalis in itsdeveloped principally in the septum of the full strength, and that will frequently pro-nose, and that part, or a considerable por- duce a superficial slough of the part. Thetion, is frequently destroyed before the ala arsenical remedy has been used of variousbecomes affected. In the case of the tu- degrees of strength in different countries.bercular disease, it not uncommonly happens Dupuytren uses it very frequently, but in athat there is affection of the cheeks near the very mild form ; he employs the arsenicalnose itself; in some, the affection generaily preparation with calomel-one hundred andextends from the nose to the upper lip. ninety-nine parts of calomel with one ofThe continued discharge from the nose over white arsenic, sprinkled, in the form of pow-1 should mention to you that this disease has der, copiously, over the part, renewing thesometimes been spoken of under the form application frequently. There is a popularof herpes exedens nasi, though the term French powder, which consists of ten grainsthe upper lip, seems to give rise to the of white arsenic, two scruples of cinnabar,propagation of the disease in that direction, and one pinch (between the finger and

herpes is usually employed with reference to thumb) of the ashes of old shoes. (laughter.)an affection running a certain course and I suppose any inert substance would do justthen coming to an end, totally different as well as that. This is to be made into atherefore to this corroding attack of the paste with saliva, and spread on the surfacnose, this lupus, or noli me tangere. of the sore ; but the remedy is active, and

. Of course you will conclude that this dis- capable of producing a slough; and arsenic,ease cannot take place except in individuals thus applied, completely destroys, to a cer-in whom there is some very unhealthy state tain extent, the parts affected, convertingof the system. I have mentioned to you the surface into a dirty brownish substance,that, amongst young subjects, the scrofulous which separates and, perhaps, leaves a

are those usually attacked. The lupus that healing surface. Professor Dubois uses thetakes place in adults, is generally traceable following formula:-half a drachm of ar-

to some derangement of the system, and is senie, an ounce of French vermilion, andhardly to be found in persons who live tem.. half an ounce of dragon’s blood ; this is toperately and properly. Your first object, be applied in the form of paste, mixed alsothen, in the treatment must be to remove with saliva or some other moisture. Nowthose causes which have given rise to the this strong form of arsenic produces actualaffection. You sometimes find a condition decomposition of the parts to which it isof constitution which renders bleeding from applied, and causes sloughs. In the milderthe arm, and pretty active measures, neces- forms the application is little more than an

sary, with purgatives, regulation of the diet, actual stimulus. The white arsenic may beand abstinence from direct stimuli, or arti- used locally in the form of ointment, beingcles of food of an exciting nature, whether mixed with the ordinary ceratum cetacei;fluid or solid. While you are rectifying or one scruple of white arsenic, with half anremoving the causes that produce the afiec- ounce of spermaceti ointment, will make antion, you must adopt mild and soothing local ointment capable of producing a slough.measures; the application of soft poultices, There can be no doubt that this is a verytepid ablutions, and mild unctuous applica- powerful remedy, and you will recollect thattions. But when you have accomplished all arsenic, either when applied to a recent

you can by these means, then you should wound or to an ulceration, is capable of pro-employ rather more active local-measures, to dueing the same powerful effects as when

put a stop to the foul and unhealthy state of introduced into the stomach ; you must notthe part from which the discharge keeps therefore apply an active form of the re-exuding. The nitrate of silver, in solution, medy to any considerable extent of surface.is very useful for this purpose, and may be If you have a large surface, apply the mildapplied by means pflint under a bread-and- form : if you have a small surface, you maywater poultice. Then, also, long expert- apply a stronger ; be very much on yourence has established the efficacy ot arsenical guard in using it. By these and other simi-applications. From the good that has been lar applications, the ulcerations of lupusproduced in corroding ulcers of the face from are very often put a stop to, though it verythese, the reputation has arisen which ar- commonly happens that considerable de-senic has acquired in caurcrous affections struction of the parts is produced before this

72

object is accomplished. The ulcerations Idestroy sometimes one side of the nose,

frequently the septtim, and not uncom-

monly the nose entirely. The complaint ishowever by no means cancerous, .or neces-sarily malignant ; its worst effects consist inthe deformity which is occasioned by thedestructive progress of the ulceration.

EDINBURGH UNIVERSITY.

CLINICAL LECTURES IN MEDICINE,

BY

DR. DUNCAN.

February, 1830.

NEURALGIA OF THE SACRO-ISCHIATIC NERVE.ON the 26th, Dr. Duncan noticed the case

of Elizabeth Ilood, eetat. 37, married, wholaxesented herself with severe symptoms of (neuralgia of the sacro-ischiatic nerve ; in-tense pain was felt along the course of thatnerve, from its exit beneath the glut&aelig;us!Imuscle, to its division in the popliteal space ; Ithe painful line was also considerably tender Bto the touch. The pain was occasionally’aggravated, and occasionally also suffered Ia remission ; but in this case, as in ischiaticneuralgia in general, a decidedly markedperiod or interval was not seen, though itfrequently occurs in the painful affectionsof the portio dura of the 7th pair. The dis-ease was of some weeks’ duration, and waspreceded by a sensation of pricking in par-ticulat points along the course of the nerve.In this patient, the general functions werescarcely deranged at .a!!, notwithstanding-the very painful character of the affection,a circumstance which is usually remarkedin this species of neuralgia. As to thetiiag-nosis, the only disease with which it couldbe confounded, was morbus coxae, or in-flammation or ulceration of the ligamentsand soft parts of the hip-joint ; here, how-ever, the distinction was perfectly evident;there was no wasting of the nates, no painoil rotation of the limb, or on sudden pres-sure applied to the knee; all which indicate

hip-disease, and are wanting in neuralgiaof the sacro-ischiatic nerve.The pathology of this affection, Dr. Dun-

can continued, was yet obscure, nor had itreceived any light from morbid investiga-tions after death. The only fact bearing onthe point, which he, at the moment, remem-bered, occurred in his own practice, in apatient who had long complained of greatpain in the right lumbar region, when after

’ death by another disease, the nerve enter:ing the kidney of that side, was found en-larged to double its usual diameter. Whe-ther this enlargement was the consequence ofhypertrophy of the nervous structure itself,or interstitial deposition between the fibrill&aelig;,he could not positively state. A questionhad been raised, whether neuralgia depend-ed on inflammation or not, as the pain, andsome other circumstances, seemed to indi.cate that it did, while the usual tranquillitvof the pulse during its attacks, and the diffi-culty with which it was cured by ordinaryantiphlogistic measures, denoted, on theother hand, that the natute of the diseasewas not inflammatory.

Various methods of treatment have beenrecommended by different authors on thissubject. Dr. i)uncan commenced here witlithe use of the extract of stramonium, whichhe now tried for the first time in this dis-ease ; he had often used the extract ofaconite with good effect. Should the stra-monium fail, lie said he would try the car.

bonate of iron, which had been found to

possess a very remarkable influence over

these painful diseases, its mode of operationbeing quite specific-or, in other words, notat all understood. Should the iron be alsoused without success, he would next em.ploy the moxa, applied as closely as mightbe to the site of the pain. This remedy hehad often found of the most siDnal benefit insuch cases. The first patient to whom he everapplied it, attorded an excellent example ofthe sudden relief it occasionally afforded.The man had been almost paralysed-atleast, deprived of the power of moving theaffected limb for some months. The first

day after his admission, a moxa was applied,and the day after he was actively engagedin his occupation as a barber, shaving thepatients in the ward, and he begged foranother application, in order to confirm hiscure.

SEVERE PECTORAL AFFECTION&mdash;TRIAL OF

VARIOUS REMEDIES.

The first patient dismissed since the pre-ceding lecture was Jane Clarkson, with apectoral affection of considerable severity.She seemed to be of a consumptive habit,and stated that her mother had died of con-sumption, from which circumstance she ex-pressed great alarm for the event of her ill-ness. It appeared, indeed, from the historyof the case, and the phenomena it exhibited,that some organic alieration had taken placein her lungs ; there were, urgent dyspnoea,cough, wheezing sound, and copious expec-toration, remaining after an acute inflamma-tory attack, which had occurred sometimebaelt, as to the wheezing sound, however,generally speaking, it rather denotes some