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Archive: Lectures On Acne, Acne Rosacea, Lichen and Prurigo — Dr. Tom Robinson

Archive: Lectures On Acne, Acne Rosacea, Lichen and Prurigo — Dr. Tom Robinson>

From the Archives: Lectures On Acne, Acne Rosacea, Lichen and Prurigo — Dr. Tom Robinson, 1884.

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LECTUEES

ON

ACNE, ACNE KOSACEA, LICHEN AND

PKUKIGO.

BY

TOM ROBINSON, M.D.,

PnYSICIAN TO ST. JOHN'S HOSPITAI. FOB SKIN DISEASES.

IDonbon :

HENRY KIMPTON, 82, HIGH HOLBORN.

1884.

mif. e. ^z c

rOv

JOHN WRIGHT AND CO , PRINTERB, BRISTOL.

PKEFACE.

After delivering the Lectures which form

the pages of this book, I was requested by

some of those who honoured me with their

presence to pubhsh them in book form.

This request I now comply with, — hoping

they may be received with due consideration

for the manner in which they were delivered,

and an apology for the almost conversational

style in which they are composed.

9, Pkinces Street,

Cavendish Square, W

ACNE.

A GREAT deal of discussion has taken place

respecting the word Acne ; some have

asserted tliat the word is a coiruption of the

Greek noun Acme, or highest point of manhood

and woraanliood ; according to my own opinion

and that of many others the word is from the

Greek Acne, that is bloom or efflorescence.

Be this as it may, we mean now by acne, a

disease wliich is most usiially found on the face,

shoulders, and chest, which, histologically, is

an abnormal condition of the sebaceous glands,

their secretion, and the surrounding cellular

tissue. We apply the noun with an adjective

when we speak of Acne rosacea; and for the

purposes of descnption it is best to retain

these names, which convey a definite signi-

ficance, and have been used for so many

years.

ACNE.

I should join issue with many of the varie-

ties of acne, which are described by all

dermatologists, because many are simply the

result of a fancy of the author. 1 allude to

such compound phrases as Acne indui-ata,

Aene punctata, Acne conformis. These

varieties are commonly found on the same

siibject, and the retention of their use in our

vocabulary is only confusing and unscientific.

In the two lectures which I have the plea-

sure of delivering, I shall divide the disease

into three varieties.

Firstly, Physiological Acne.

Secondli/, Climacteeic Acne.

Tfdrdhj, Rose Acne.

But before proceeding to these \'arieties,

let us glance at the histology and physiology

of the sebaceous follicles, which will be found

to be intimately associated with the hair sacs,

and it will be necessary for me to allude to

this relationship many times in these lec-

tures. I consider, by bearing in mind this

relationship, we are enabled to comprehend

raany of the phenomena which we meet

with in these very common and troublesome

maladies.

The sebaceous glands are found in every

situation of the cutaneous surface, with the

exception of the palms of the hands, the

soles of the feet, the last phalanges of tlie

toes and lingers, and tliey are absent on

the glans penis. They are the only secret-

ing glands which are found on the cutaneous

surface, excepting the sweat ducts, and they

have their analogue in the mucous glands

in the interior of the body. The sebaceous

glands are sometimes composed of two or

three gland lobules, which have an excre-

tory duet, which duct rarely opens im-

mediately upon the surface, but as a rule

into the hair follicle. There is an excep-

tion in the case of the long hairs, such as we

see on the head, pubis, or axUlee; in these

situations the reverse is the case, whilst in

the pubescent haire the small hair follicles

open into tlie wide excretory duct of the

gland.

The gland sac is always situated in the

cerium, and never reaches into the sub-

cutaneous connective tissue. This is why a

molluscum contagiosum tubercle rises so

distinctly from the plane of the skin.

ACNE. ,

Tlie interior of the gland lobules is occupied

by an araorpbous mass of fatty matter, and

the debris of numerous cells.

The development of the sebaceous g'laiids

commence at the third month in man. By

remembering this fact we ai'e enabled to f^usp

the reason that some children are born with a

hard inelastic skin, which constitutes the

disease known as Ichthyosis, which is always

congenital, and always incurable; because this

gland formation is abolished by an inflamma-

tion of the skin, which attacks the fcetus in

utero.

The function of the sebaceous secretion is

to give to the hairs an oleaginous food, and to

make the skin supple, and also for the pur-

pose of protecting it from external irritation.

We see this well exemplified in coal poi-tei-s

and others ; the constant contact of dust

iixitates the sebaceous follicles, and their

secretion is increased in quantity to such an

extent that the faces of these men Eire quite

greasy.

The hair sac ami the sebaceous gland form

together a most ingenious contrivance ; but

like so many other ingenious contrivances

they are put out of order by a multiplicity of 1

causes. The way in which the gi-owiiig hair |

creeps upwards in its growth until it receives, I

before it makes its exit on the skin, an oiling

to protect it agaiust advei-ee influences

wondei-fiilly cunning : but so many iniluencesi I

are at woik that ? this process is checked in

very many ways, and it is to these that I must

ask your attentiou. I am met on the very

threshold of my stibject with this difliculty.

How can I separate Lichen from Acne ? And

let me here state that I would not separate

them cluiically. So intimate is the patho-

logical states that it would be far better if

we were to group both these maladies as

Folliculitis, or, in other woixls, inflammation

of the follicles of the skin ; hut I am loth to

abolish names which we have used for years.

We may get out of the difficulty in this

way. By Lichen we mean a pajiule, which

consists of an imprisoned hair without an

adequate secretion of sebaceous matter, and

by an Acne spot we mean a condition in which

the sebaceous matter is plus and the hair

minus. I am aware that this is a new way

to look at the maladies ; but let any candid

r strip a case of lichen, and he will in

a good light find the lichen spots to occupy J

the position of a hair, but he will find these I

spots do not occur in the ordinary acne situa-

tions. Let me be clear on this point. Lichen

is usually found on the limbs, outer aspects,

sometimes on the chest and back, or, in other

words, it is found where the pubescent hairaJ

grow abortively; but in such situations as thei

axillas, the pubis, or the whisker regions, I

where the hairs grow luxuriantly, we never J

find lichen, whilst acne is found on theii

nose, cheeks, forehead, and chin, or, in otheir]

words, it is found where hairs do not grow.

1 must say here that I look upon the fol-1

lowing definition of lichen as the only oneM

which we can use. It is a papule which i

always umbilicated, which has never an in- 1

flamed base, and which is always a lichen I

spot ; it never becomes vesicular or suppurates, 1

Having cleared the gi'ound as well as I antfl

able of this difiiculty, let us ask ourselves!

what it is which stops the mouth of

sebaceous follicle. In the greater number of I

cases the over-secretion of the gland is only 1

an expression of general disorder of the wholoj

organism, in M-Iiicli this secretion takes its

part. Pei-sons whose akins aie thick and

greasy, whose liair and whose nails gi'ow fast,

whose heads are scurfy, who are sleepy and

stupid, wlio look muddy, and are often the

subjects of stomach dei-angements ; these are

the subjects of acne.

Believing tliat this over-secretion does occui',

we must follow out the effect of this bloated

gland. The first stage is an elevated spot

with a black head, which can easily be raised

from its bed, and as we all know if squeezed

a column of sebaceous matter bulges up like

a maggot ; hence the name (Comedo) with a

black head. This black head is simply due to

dirt blocking up the orifice of the gland.

If we place this secretion on a slide, we

find nothing beyond epidermic scales and oil

globules. According to Gustaf Simon a six-

legged para-site with a long belly is common

in these sacs. I have never seen it, although

I have looked for it many times.

If the over-secretion of the gland occurs

in sebaceous follicles without an excretoiy

duct, we have the round pearly white bodies,

which are so common about the eyelids, and

ACXE.

in the linea of a cut, where these ducts would

be severed. These white spots are called

Milium, or better still white acne.

We pass by an easy transition to true Acne.

The first stage of Comedo is so common

that it is really a normal condition of all

adult skins, but, where owing to other causes,

this distended sebaceous follicle be

flamed, we anive at a pathological procee

which will attract so much of our attentioiij

and task us severely in subduing.

The first process is a congestion around the

sebaceous iblhcle, which congestion soon runs

into an inflammatory action. The source of

irritation is due to decomposition in the secre-

tion, and is not a ]ieri-follicular inflammation

set up by a distended sac. You can ascertain

the tmtli of this by smelling the contents of

a large sebaceous cyst of the scalp, which has

become inflamed ; the sun'ouudiiig tissue may

be free from any sympathetic process, and the

contents of such a cyst are most oftensive. And

many suppui-ating sebaceous follicles of the

face and elsewhere do not give rise to the

formation of pus in the neighbourhood of

gland ; it is essentially an inflammation in

m

fiac. Tliis In tiie siiii]ile farm of acne. Wliere

the suri'ounding tissue becomes inflamed, we

have other factors at work, such as scrofula

or syphiHs, and these are tlie cases wliich go

tin for so manv vears, and which cause such

frightful disfigurement.

I have luider my care at the present time

several cases where the history is as follows ;

— The patients were the subjects of acne

commencing in youth, they have contracted

syphilis, and in addition have lived freely and

drank heavily. These eases came to me at

intervals with lai'ge bosses of inflamed tissue,

especially on the forehead ; this tissue, as a

rule, suppurates, and I have in some instances

let out as mueli as half-an-ounee of pus from

one cyst. These are the cases whicli are

designated Acne indurata.

There is one kind of cyst whicli I have not

yet found described, hut of which I have now

seen three examples. The cases which I have

met with have all been women, and they

have hat! several semi-ti-ansparent cysts in

the free edges of the eyelids, which looked

like boiled sago. I have experienced some

difficulty In puncturing these cysts, because of

14 AVNJC.

the density of theii- walls. 1 allude to them

in this lecture hecause I have not been able

to assign them to any other malady but acne.

Similar cysts are seen behind the eai'.

If we are to recognize every altered state

of the sebaceous secretion as acne, which I for

one would encourage, we nmst take many

diseases into the group. In eai'ly infancy we

find the fostus covered with a layer of greasy

matter, which is the sebaceoiis secretion that

has been accumulating in the child during its

intra-uteiine life, and we know how much

this secretion varies in quantity and consist-

ence ; sometimes it is so tenacious that the

nurse has difficulty in ?v\'aHhiiig it off, in

otliers, it is absent, then the skin will be

found dry and inelastic.

When the hair is develojjing iiii tlie crown,

we often find the sebaceous matter accumu-

lated on the summit, in a thick, dirty cake,

which gives much trouble, and in those who

have an eczematous proclivity, this crust

begins an eczemji. In fact, tlie eczema of in-

fants has its origin, I believe, in all cases in

the uTitation induced by an altered sebaceous

secretion ; it is too dense, and that is why cod-

liver oil inside, and applied locally, Is of such

signal service in these cases. It supplies fat

to tlie secretion.

Again, during cold weather, when the seha-

ceons matter is partially frozen like any other

oily substance, we sluiU irequently find round

patches of skin dry and scaly, especially on

the face, and when this occura we have what

the laity call chapped lianda and face, which

in jetiological phraseology is due to a too

thick sebaceous secretion, which is not poured

out in sufficient quantity upon the cuta-

neous surface. We remedy this condition

by oil or glyceniie, and by avoiding soap,

which is an in'itant in these cases, because it

actually saponifies the secretion, which is

already too scanty, and \\e prevent its recui-

rence by warmth.

We might reasonably include in our group

ichthyosis, which as you doubtless know, is an

absence of sebaceous follicles, either on the

whole or a part of the cutaneous surface.

When the contents of a sebaceous gland

become so fii'm that its constituent elements

coalesce, we have horn; in point of fact, the

horns of tlie lower animals are simply oft-

shoots of epithelial secretion, and in our own

species we find the horns of the skin are

neither more nor less than dense sebaceous

matter protruding from the orifice of a skin

gland.

The common boils are always due to re-

tained secretion in a hair and sebaceous

follicle. The retention may be due to special

callings, such as working amongst tar, which

plugs up the orifices, or we find friction pro-

ducing the same efiect. That is why boils

are so common in the buttocks of an oarsman,

or a rider, and that is wliy we find them

around the neck, and the outer aspects of

the limbs, where there is the most friction.

Carbuncles are again due to inflammation

of a group of sebaceous glands, occurring in

those whose general health is feeble firom

some exhausting cause, such as old age or

diabetes. The number of orifices seen oozing

on a cai'buncle, represents the number of

sebaceous glands involved in the procesF,

The slough which comes away represents the

gland itself and its contents.

There is one other condition which I must

allude to, that is " moUuscum contagiosum."

We, in this country, do not doubt that this

is a contagious disease ; on the continent

they dispute the fact, but thei'e is so much

chnical testimony to support the aecui-acy of

the contagious view, tliat it is impossible not

to accept it, although the actual contagion

has not yet been discovered. That this hi-

teresting disease is due to the invasion of a

sebaceous gland by a parasite, I do not doubt.

The button holes in the pearl button-lite

tumours ai'e the orifices of sebaceous glands.

I might also aUude to tiie Meibomian cysts

of the eyelids, to the steatoma of the head,

and of other regions, as maladies which are

due to an abnormal state of the sebaceous

glands. The varieties of balanitis and of

pruritus vulva;, ai'e many of them simply due

to a want of integrity in the sebaceous secre-

tion.

After this very wide digressioii allow- me to

go back to what is accepted as acne, Acne

\ailgaris, if you like.

Young men and women come before us at

about the age of thirteen or fourteen for spots

on their faces. You find these spots are

situated in the situations where good hairs

18

ACNK

are not produced ; such positions as the fore-

head, cheeks, nose ; the inner surface of thel

external ear is a very common situation for 1

them. These spots consist of black headed. I

pimples, some of wliich may be in several I

degrees of inflammation ; and if we strip ourJ

patients we sliall find other and similar spotafJ

on the shoulders, over the sternum, and ve

often on the outer aspects of the anns a

legs, and commonly on the buttocks, but t

grouping is exaggerated on the face and

shoulders. They often itch consideinbly when!

they first appear ; it is this itching whicl

caused Mr. Hutchinson to write a paper

what he called " Prurigo ajstivulJa," or " Pi-u-

rigo adolescentura. "

The prominent features of this condition J

were a collection of abortive pustules, occur-

ring by preference on the face and up

extremities, and commencing usually at the I

age of puberty.

Are not these tendencies exactly what we I

find in acne ? I should have liked the words J

Prurigenous acne better. Be tliat as it may,.J

we have to recognize a form of acne whichj

does itch a great deal.

AGNB.

I am anxious to impress this fact, because

it has been disputed whether acne does ever

itch.

I will now enter into the subject of tliese

constitutional conditions which lend a local

colour to the progi'ess of acne, and in the

first instance, I should select scrofula as the

most common cause of the exaggeration and

pronounced of these influences. It is a pecu-

liarity in all scrofulous manifestations that

the process of inflammation is slow ; and as a

consequence not associated with very high con-

stitutional disturbance. We often meet with

large collections of jjus i]i the scrofulous,

which ai'O almost painless, and which are not

attended by any elevation of temperature.

We see this in the abscesses about lymphatic

glands, and it is for this reason that we use the

term " cold abscess." Scrofula is again a dia-

thesis which, as a nile, is developed durmg the

period of life when the functions ai'e the most

active, that Is to say, in the period of gi-owth.

We speak of senile scrofula, a well marked

series of manifestations, wliich we meet with

ui advanced life. We owe Sii' James Paget a

tribute of gi'atitude for having been tlie fii^st

20 ACKE.

to isolate these conditions. Now, do we not

find in patients with a skin which is thick

and greasy {two conditions essential for the

production of acne), and who have a scrofu-

lous tendency, the most pronounced case of

what is known as Acne tuberosa ? In such

cases we shall find masses of slowly progi'essive

inflamed tissue ai"ound the sebaceous follicle,

inflammation which is tedious in its progresK.

and most obstinate to treab, and we shall find

this state most commonly at that portion of

life when we most frequently meet with acne,

that is, from fourteen to twenty-five. But

we shall also find later on in life some cases

which are precisely the same, only they are

not so general in their distribution.

Syphilis lends its characteristic colour and

progi'ess to acne, and it is most impoi-tant in

any case of skin disease to remember this

fact. The constitutional forms of skin disease

when crossed with syphilis form a group,

which are more difiicult to diagnose and treat

tlian any other condition of the cutaneous

surface. Acne is in no way an exception;

freciuently you will meet with an acne patient

who has contracted syphilis, and in additioi^^j

i

to the \isual course of the disease, you will

be baffled by a stain, which is left behind

when the acute local disturbance has passed

away. I have a gentleman under ray care at

the present time, who has copper coloured

staining of the skm, which staining has ex-

isted now for two yeai'S.

I have some notes bearing upon the ques-

tion of the influence of inherited syphilis upon

the coui'se of physiological acne, and I ain

1 to believe that the influence of the

in this form has a most important

influence upoii the progress of many cases of

acne.

You are doubtless aware, that a disease

has been described as lupoid Acne, or seba-

ceous Acne, and I have seeii several cases

where the sebaceous folhcles have been i-aised

above the surface of the skin ; these follicles

have occurred in patches, which have spread

from their centres, and sometimes attained

great size, and caused mucli disfigurement.

The persistence of this form of emption, the

manner in which it advances, and the rough

follicular surface of the mass (it looks like

the under surface of a nutmeg grater), stamp

it at once as a new growth, invading the

sebaceous follicles, and being a veiy near

relation of Lupus erythematosis and Acne

But by far the majority of cases of acne

are not associated with either of these dia-

theses. I have stated before in my lecture,

and I must again repeat, that three factoi-s

are essential to the production of acne.

I. A thickness and greasiness of the skin.

II, Activity in the sebaceous and hair

follicles.

Ill, An abnormal state of the glandular

secretions.

The thickness and greasiness of the skin

indicate that we have a lai-ge development

of the sebaceous glands ; we find these condi-

tions in the greater number of cases in those

with dark sallow skins, hut there are some

fair-haired people with thick and greasy

skins. Mr. Hutchinson has in his work on

the " Pedigree of Disease," a work which

came as a revelation to me, a paragraph on

acne, as a revealing symptom, and in answer

to the question —

What does acne in its various forms imply t .

he has these suggestive woi"ds : — " We should,

" I think, have to reply that in the first

" place, it denotes original and heritable

" peculiarity in the structure of the skin ;

" next, that its common form in young per-

" sons usually implies greater or less dis-

" turbance of tone in connexion with the

" sexual system."

But does not acne imply still more ? Do

we not find in all our cases of physiological

acne a laziness (if I may be allowed the ex-

pression) on tlie part of every secretion of the

body, and an altered character in this secre-

tion ?

These patients are often the subjects of

indigestion, are, as they say, bilious ; or in

otlier words, the secreting glands of the

stomach are slow in action. The feebleness

of the action of the liver modifies the glyco-

genic process. Are they not again consti-

pated, and does not this constipatiou point to

an altered state of tlie secretion from the

intestinal mucous membi'ane ?

If tlie patients are women we find the

meustmal secretion is scanty, and often much

changed in character.

24 ACJ!{B.

Again, very many of these patients complain

of sexual debility manifesting itself in many

degi'ees, at times even amounting to impo-

tence. If we take a higher flight we shall, if

we know them intimately, discover that they

are slow of perception, very often unusually

lazy, and intolerable sleepers ; and not a few

from the want of activity in the excreting

organs, glide into gout as they become older.

Let us ask ourselves one other question.

What is it that determines the introduc-

tion of acne and what its decline ?

We know as a matter of imi^'ereal observa-

tion that as the sexual life of tlie organism

ai»proacbes, the human being develops a

second crop of hair on the pubis, axillae and

limbs; and in the male sex un the cheeks,

chin, and upper lip. And where this activity

spends itself in the production of vigorous

hair, the condition is a natural one; but where

this process is spent in such situations as the

cheeks, the nose, forehead, and chin, where

hairs ai'e not produced, we find acne spots

appear. In women you will find the situa-

tions where the hair grows on the male sex

very often occupied by acne, and in our sex

ACNE.

where the facial hairs are not developed from

some inherited peculiarity acne may occur in

tlie whisker regions. I am supposing in these

cases that the skins ai'e tliick and greasy.

Tiiere are happily many hundreds of human

heings who cannot produce acne.

When once this acne is established it

undergoes veiy many changes. If we watch

our cases attentively we shall find any cause

which depresses the vitality of the patient,

causes the acne to become more pronounced.

In women it is very common for a few acne

sjiots to appeal" on the face during each men-

stiTjal period. In men excessive sexual in-

dulgence has the same eflect, and masturbation

may produce precisely the same result. It is

tliis latter fact \vhicli has induced some to

attribute (without any data I should say) all

cases of acne to mastui'bation. The changes

under the lower eyelid, which we see occuning

at each successive menstrual period, are due

to the increased pallor of the skin of the face

owing to the loss of blood, and ai'e not in any

way increased pigmentation ; it disappeai's too

quickly for such to be the case.

The association of the advent of sexual

26 ACN'K

potency and acne has induced the laity to

attribute these spots to chastity, and I have

even heard this view supported by our o^\-n

hretin-en.

But there are manifold dehiUtating in-

fluences other than these which foster acne

spots. The exhaustion induced by study, by

late hours, by bad living, by too close con-

finement, by want of exercise in the fresh air ;

each one of these will occur to us all as being

more general in their influence upon acne

spots than the exhaustion induced by sexual

indulgences or bad practices.

It is veiy interestuig to note in passing

how dennatologists have looked upon the

causes of acne from diflerent standpoints ;

those who are disposed to view tlie human

race from a gloomy view attribute the disease

to sexual excess or masturbation, whilst the

optimists attribute it to excessive chastity and

over-continence.

I have one other form of acne to bring

before your notice this evening, that is the

second on my list. "The acne of the Climac-

teric period of life." I have made a separate

group of tliese cases because they stand out

ACNE.

27

in many ways as a distinct pictm-e. ThLs is

the story. Women who had during their age

of adolescence, acne, arrive at the period of

Hfe when the menstmal function ceases, or in

other words when their functions as women

come to an end ; and at this period of life

they very often gi-ow a crop of hair, of varia-

ble lengths, on the upper lip, or cheeks, but

more commonly on the chm, and we find in

those who have thick, follicular skins, a crop

of acne differing neither in fetiological or

pathological nature from the acne of youth.

The common occun^ence of this form of acne

on the chin has given rise to the teim " chin

acne," and it produces a great deal of dis-

figurement, and is a common condition.

Before proceeding to the question of ti-eat-

ment, I will recapitulate the views which I

have expressed.

I look upon acne as a disease which is due

to activity in the life of a hair and sebaceous

foUiele, which activity in the form of the

disease we are considering to-night occurs at

the age of puberty, and in women at the

meso-pause, that this activity is due to the

evolution of hair.

L

28 ACNE.

That we have great difficulty in sepai'ating

acne and lichen.

That acne is not by any means confined to

the face, shoulders, and chest, but makes its

appearance with less abundance, but still in

all cases to a gi'eater or less extent, on the

trunk and limbs, especially the arms.

That for the production of acne a thick

skin and great development oi' sebaceous

glands ai'e essential factors in its production.

That the usual adjectival denominations

ai'e unscientific.

That syphilis and scrofula uifluence the

course of acne in very many cases.

That masturbation and menstruation may

in some cases determine the advent of an

acne spot, but they only act as debilitating

influences and not in any special manner.

That the acne of women advanced in life is

due to activity in the hair follicles of the

chin, lip, and cheeks.

I am anxious to enter on the subject of

treatment, with a reference to the cause, and

I should like to enter my protest against the

vigorous treatment of this disease as is gene-

rally advocated. Imagine what we do. We

rub into the seljaeeous folli

pi,

? lotic

strong sul-

th a tooth brush

ointment

sometimes, and, as if to irritate a gland in a

liigli state of inflammation, we scrub vigor-

ously these spots with a piece of flannel a.nd

soft soap. Do we wonder that under such

a line of treatment our patients pass fi'om one

consulting room to another ? Such vigorous

treatment may open out the orifice of the

gland and let out the secretion, but some-

times it does more ; it peneti"ates tlie gland,

sets up inflammatory action in its interior and

obliterates the gland eiitirely. With what

residt ? that an area of skin lubricated by that

gland becomes di-y and scaly. I know of one

instance of a gentleman fi'ora Devonshu-e who

had simply obstructed sebaceous follicles on

his no3e, and he mbbed in from his own pre-

scribing a strong sulphur ointment, which set

up an acute erythema of his nose, oblitei"atLng

a great many of the sebaceous follicles, and

for a long time he had to supply this defici-

ency by applying grease. I watched the

case for twelve months but he made no pro-

gress towards improvement.

If we think for a moment of the indications

30 ACNE.

for treatment, we shall not commit this error.

In the Comedones you will improve the con-

dition of the sebaceous gland by washing the

face with a good soap and luin-water every

night. Cold water is best because it stimu-

lates the gland and makes it contract ; and in

the morning let the face be gently sponged

with a very mdd stimulating lotion. The

following recipe is a veiy excellent one :

R Hj'drargii perchloridii gr. ii,

Tinct. Benzoin. Co jii.

Emulsio Amygdalir iid 5^. mix.

and give the patient internally a medicine

with the double acids in iniusion of gentian

three times a day, and a claret glass of Pullna

water every morning.

The selection of food is of importance. Cut

out of the dietai-y pork and veal, and haslies

and stews, pastiy, and an excess of sugar.

Make your patients eat wholesome bread and

good butter, meat tlu'ee times a day, and

some good, sound, red wine, and, what is most

important, plenty of salt. Ask them to stimu-

late their skin by cold spongings, to sleep in

a pure air and oxygenate their blood, by

advocating several hours a day in the fresh air.

AC^'E. 31

Where your patients liave a family history

of scrofula or other signs denoting the malady,

let them have, in addition to the above re-

medies, cod-liver oil. Where there is a

syphilitic tendency, mercury must be used

and iodide of potassium forbidden ; the

latter remedy will induce acne, as will bro-

mide.

Tlie local condition often requires veiy care-

ful management. Where a sebaceous follicle is

siippurating, encourage the pus-fonning pro-

cess by hot applications, and as soon as you

are sure it is present let it out ; but make a

veiy small opening or you leave sears.

In some acne spots the collection is in a

?closed foUicle, a blind boil as people say, and

your remedy here is to puncture,

Wliere the Inflammatoiy gi-owth is lieaped

u]i aixiund a sebaceous follicle, the following

sort.ion as tlie

circulation is more active ; thus the circula-

tion is very active in the pulji of the fingers

and toes, the lohule of the eare, and the

tip of the nose, and these parts are so

readily frozen, and are the seat of chil-

blains, and on the eai-s and nose and (.-lieekK

we usually find EiythenuitoHS lupus. And

these are the situations whicli become cold

as dissolution takes place.

What singular depth and power is shown

in Shakespeare's description of Falstaffs

death.

So abade me lay roore clotheR on his feet ; I put niy

hand into the bed and felt them, and they were as cold

as any stone ; then I felt on his knees, and they were aa

cold aa any stone, and so upward and npwai'd. and all ikva

cotd OS any Btanc.

I am almost tempted to give Shakespeare's

word painting of Bardolph's nose. And

ACKK ROSACEA. 37

amongst my own friends I often speak of

advanced stages of Acne Rosacea as " Bar-

dolphian nossH."

The word Acne is miquestionably derived

from the Greek ajevrj (Acne), one of its

meanings being bloom or efflorescence. The

ei-uption on tlie face accompanied by pim-

ples was also called by the Greeks lavBa

(iantlios) i.e. of a violet colour, Tlie Romans

called these punples vari cuperosi, which is

held to be a conoiption of gouthei-ous, or rose-

like drops.

"Jolly noses" must have existed at all

times, but as they did not interfere with the

health, they did not claim the attention of

the physician or surgeon, but aftbrded material

for the satu'ist and the poets, as we find in

the works of the ancients. The red nose

was then, as now, Siscribed either to the

votaiies of Venus or Bacchus. It remained

for modern dermatologists to classify them,

Hebra distinguislied them, so to speak, into

beer noses, bmndy noses, wine noses, &c.,

a classification wbicli is not adajited to

actual experience.

Celsus, Paulus ^ilgineta, Actius, Femelius,

38 ACNE MOSACEA.

Ambrose Pare, Guido de Chauliac, Nicholas

Florentinua, Daniel Turner and Lony, Iia^'e

each described face eruptions, which evidently

include Acne rosacea. A translation of

Celsus, lib. vi. cap. v. De varis ct lenti-

culis, et ephelidv, ft corimn ciirantiorihun,

is all I will quote.

" It is almost a folly to ti-eat of pimples

and lentils and ephelides, yet the anxiety

of women concerning their beauty cannot be

overcome ; of such as I have already men-

tioned vari and lentils are commonly kno^vn,

while that species the Greeks called semion,

being of a more ruddy colour, and more

unequal on the surface. But the ephelides

is known by few, being nothing more than

a certain asperity and hardness of a liad

colour. The others (pimples and ephelides)

appear only on the face ; the lentils appear

sometimes in other parts."

Turner (Dfi Morbus Cntaneis, London,

1721, 3rd edition), was evidently well ac-

quainted with the disease. In the fourth

chapter of his work be treats of diseases

incident to the skin of the face, and he ob-

ACNE ROSACEA. 39

" If I have given instructions how to

abate the fieiy red com]>Iexion8 of the face,

with other bi'eakinga out that so disfigure

it, I cannot think the task below the duty

of a physician. It is certam {says Turner),

that the redness does not always owe its

origin to hard drinking ; since it is some-

times observed to attend the most teni-

pei-ate and aljstemious. However, for the

most part, the constant tipplers of strong

beers and wines, especially the first, ai-e

the most obnoxious to tlie malady."

Sir Theodore Mayem (Observationes vol, 25),

in his regimen for my lord Maxwell, subject

to these exanthemata Faciei cum naso rubi-

dtiw, after taking notice tliat it was here-

rlitary to the faniiJy, the brothers and sisters

being subject thereunto, lays the fault chiefly

in the liver.

I might quote the observations of Plumbe,

Hunt, Burgess, and many other keen ob-

servers of skin affections, but without gain-

ing any other result than great respect for

their work.

I would define Acne llosacea as a disease

which is seen almost exclusively on the

ACXA' JtOSACh'A.

nose, cheeks, chin, and brow. It will some-

times attack the scalp, hut only in the bald,

and I have once seen it on the sternum.

It is a disease which is found about

equal in l>oth sexes, but is never met

with before the age of puberty, and seldom

before 25 years of age. It occui's in women

with much greater fi-equency at the climac-

teric jieriod of life than at any other age,

but it is not by any means limited to this

epoch.

It is always lievakled in by flushings of

the regions attacked, which flushings are

much bicreased after food, or by an in-

judicious diet. These flushings then x^ln into

suflused red patches, witli permanent dilata-

tion of the blood vessels; afterwards pimples

form, these may go on to suppuration, and

the parts then become the seat of a chronic

inflammatory process. Wlien the inflamma-

tion has continued for -some time large

bosses of lead coloured tissue will form, and

the sebaceous follicles may, and frequently

do, become involved; but they in no way

form an essential pait in the aetiology of

Acne rosacea.

ACXE ROSACEA.

My chief object in Introducing the subject

this evening is to endeavour to sliow that

the gi-eater number of cases of Acne rosacea

are associated with an ii'ritable state of the

mucous membrane, especially that of the

stomach ; or, in otiier words, that gastric

catarrh is the foreininner of Acne rosacea.

I should eliminate from this proposition

those cases which we find as a sequel of

smallpox, or any other inflammatory process

which has occuiTed in and aromid the

sebaceous follicles of the face. Neither do

I wish It to he understood that I in any

way postulate that every case of gastritis

is associated with rose-coloured ]iapules on

the face; but I do wish to emphasize my

belief that In all cases (excepting those just

referred to) -it will be found that these

patients have flushings after food; and lest

this statement should appear unsupported

by other testimony, let me draw attention

to the red faces which we see after a dinner.

To the blanching of the face in those who

are sea sick.

To tlie pinclied face of cholera.

To the abdominal fiice, as it is callei

42 ACXK liOSACh'A.

which we see m wounds of tlie intestines,

or perforation from ulcers.

These point to a sympathy hetween the

circulation of the face and the condition of

the abdominal or^ns, whicli every student

knows.

Again the sympathy is evidenced in the

pigmentation, which occurs in Addison's

disease, which commences in the face and

neck ; also the yellow eyehds, which cul-

minates in Xanthelasma palpebrarum, as

found in those who, in common pln-aseology,

are bilious.

The pigmented brow, or uterine chloasma

of pregnant and suckling women, is another

instance of distant and common sympathy.

I might point to the changes in tlie joints

wliich we find occur in some cases of loco-

motor ataxy, to the ulcei^ation of fingers,

which takes place in divisions of nerves, aa

illustrations of the same law.

No doubt it is through the nervous system

that this sympathy is made evident. One of

the chief offices of the nervous system is to

control and i*egnlate the vascular system, and

in no part of the body is the capillaiy system

ACNK ROSAffiA. 4:t

more liable to be influenced by disturbed

nerve force than is the face.

Again, it appears that there is a quicker

sensibility In the face ; in fact, the stimulant

that atti-acts the blood to this pai-t does not

act with the same force elsewhere ; for in-

stance, a blow upon the ear wUl redden the

cheeks more than a similar blow elsewhere.

The blood is withdrawn fix)m the capillary

system of the face with the same rapidity as

it flows to it. In the space of a moment

passions will alternately impress upon the

features, either the fiery complexion of fever,

or the pallor of syiicojie. This applies espe-

cially to the young;. The aged blush not

We must also notice the singular proneness

which some forms of skin diseases have to

appear on the face. With few exceptions, we

may say acne rosacea, lupus erytheniatosis,

rodent ulcer, sycosis, and the other lupoid

process have to appear on the face. I am

not stating this as an absolute tniism, in

iact, I may say I have seen every skin dis-

ease appear on the face, excepting chloasma

and itch. Doubtless this proclivity is due in

AC^e ROSACEA.

a gi-eat measm-e to structural jieculiarities, buffl

more especially to the sources of iiTitatioft]

which influence so much the location of t

skin diseases. In the male the use of the|

i-azor, and in all the influence of wind, su]

soap, haixl water and dirt, have to be recog-

nized as factore in determining the seat (

an J disease of the skin,

I should like to include in my descrip-

tion of acne rosacea, other conditions whicl

have been desciil^ed under a multiplicity i

names. I refer to the cases where the j

of the bridge of the nose, and over

molar bones often becomes the seat of

acute eiythenia, often vesicular, and alwayi

fugitive, leaving behind traces of its visi

such as increased density of the subcutaneoui

tissue. Other cases occur where the rednei

attacks an area of skin in other portions (

the face. It comes when the sufferer i

of health ; it occm-a on exposure to ceitj

forms of u'litation. It is surprising how tei

libly sensitive the skin of the face hecomaS

in some individuals. I know a lady whoai

iace is brought out into a copious vesicul

rash, whenever she is exposed to the dayi

ACKE ROSAVICA. 4.)

light ; others get degi"ees of iiiflaniiiiatioii on

a repetition of the exciting cause.

I have for some time past been dii-ecting

my attention to the very close relationship

which exists hetween acne rosacea and lupus

erythematosis. We find both conditions

occun-ing after the age of puberty, attacking

as a mle, the same regionSj and that these re-

sist witli parallel obstinacy our endeavours to

cure them. I must also mention the prone-

ness to relapses, which spread over some years

ill these diseases. I liave now under observa-

tion cases of erythematous lupus, and also of

acne i-osacea (without organization of tissue),

which have been apparently quite well, but

which have come back to me with the malady

returned.

Again you will find these case.s of lupus

are like rose acne, mtenslfied by an iiritable

state of the digestive organs, also by the

efl'ects of sun, wind, or soap, and they are

worse always after eating.

In some of my cases I have not been able

to distinguish by any outward signs the dif-

ference between the two conditions. I am

aware of the care ^vith ^\'hicb we recognize

46 ACNE ROSACEA.

eryttiematous lupus, wlieii the disease is pro-

nounced by its well defined edge, its colour,

and its adherent scale. But our difficulty

exists at the commencement of the two dis-

eas3s, and I should be disposed to classify

this form of lupus with the uiflammatoiy skin

diseases, and not as ii new gi-owth.

I may be permitted to inti'oduce a piece of

personal pathology to indicate my theory. I

get at intervals a condition .of health which

has the following train of symptoms. A suc-

cession of chills across my shouldei-s and up

my spine, a slight frontal headache, a feeling

"of depression, and a slightly yellow skin ;

tliis continues for two or three days ; then a

patch of herpes comes out at the angle of

my mouth. Tlie patch comes in precisely

the same spot each time. I introduce this

to show that tissue once damaged by inflam-

mation is prone to re-inflame when the exci-

ting cause again aris&s. We see many in-

stances in botli medicine and surgeiy, which

illustrate the same law, but in the dominion

of cutaneous diseases we find our best ex-

amples, and there we can the moat I'eadily

watch them. The local forms of eczema.

i

ACXE ROSACEA.

47

notably about the wrist, occur ovei' and over

again in precisely the same spots. Many

patients will tell us.that herpes 2JcejJH(ia?i'.i

attacks them in the same situation each time

The forms of relapsing chancre, the revivify-

ing of old syijiiilitic and inflammation are

pai'allel examples, I might illustrate the

tendency by showing how gout and rheu-

matism attack the same joint at intervals.

Sir James Paget has given us instances in his

own personal experience of the same observa-

tion, and Mr. Hutchinson has the following

pregnant words in his last work : — " We

" need not feel much difficulty in interpreting

" the phenomena which we witness in recur-

" ring erysipelas and persistent elephantiasis.

" They are doubtless examples of the patho-

" logical power of habit and indulgence. Just

" as a man who has yielded to intemperance

" is in danger of becoming a drunkard, so it

" is with his tissues. The oftener they have

" yielded to any special process of inflanima-

" tion the more prone are they to yield

" again."

I have introduced this digression to bring

me to its appHeation to atne rosacea. If we

4S ACNK ROSACEA.

watcK attentively the victims of this malady,

we shall notice that precisely the same spots

become inflamed over and over again, until

the intervals between the attacks grow less

and less, and the disease becomes permanent.

It is an error to describe acne rosacea as a

papular disease, as much as it is to designate

it a pustular eruption. We meet with in-

stances which in some skins are eczematous,

and we rarely meet with it in individuals

who have not other evidence of an uiistable

skin. Only last week I saw a yoimg lady

with the following history : —

" Her giTindfather had eczema of the arms,

her father a,iid brother had chloasma,

another brother has, at the present time,

vivid coloured papules on the nose and

cheeks with conspicuously dilated blood

vessels at the aire of the nose. Another

brother has lichen jtlamts on the right arm.

My patient tells me she had an exception-

ally thin skin at birth ; at two yeara of

age she had an eniption on her neck, which

was called erytliema. Soon afterwaixls a

peculiar hardness of the skin of the hands

commenced, which hr.s continued ever since.

AC^'^e ROSACEA.

49

" This condition is worse in the winter than

" it is in the summer, Slie scarcely ever

" sweats, and she is liable to colds and coughs.

" She had erythema of the legs at eighteen,

" and was unable to walk for three weeks.

" For the last four years she has had an

" eruption of the face, which is worse after

" food."

I will not detain tlie Society with my

notes, but I briefly state that she had common

psoriasis spots on the elbows and knees.

Her soles and palms were covered liy a hard

tlense mass of hypertrophied papillse ; and

where the pressure was gi-eatest these papillie

formed a close homogeneous mass, which she

kept down by rubbing with pumice stone.

She had typical rose-coloured spots on her face.

I introduce this ease to show tlrnt acne

rosacea is frequently associated witli other

skin diseases.

Personally,! object, whenever practicable, to

the elaboration of definitions, believing as I

do that the hard and fast lines which have

been introduced into the nomenclature of

skin diseases, have made a subject, which of

aU others ought to be as cleai' as noonday,

so ACNS ROSACEA.

singularly embarrassing and confusing. But

for the purposes of description, I would dis-

tribute all the cases of acne rosacea into the

following classes : —

I. Those cases which we might conve-

niently call congestive acne rosacea, which

generally commence by reddish patches espe-

cially occupying limited spaces on the cheeks,

the forehead, and the sides of the nose,

whence the I'edness in some cases spreads over

the whole face, and even to the ears, the shoul-

ders and the chest, appearing usually in an

unsymmetrical manner. Tiie red patches

appear at first, for some moments only, gene-

rally during, or after dinner, and towai-ds

evening rather than in the morning, being

more evident in very hot rooms. The red-

ness in the fii-st instance is veiy fugitive, Irat

afterwards becomes deeper in solour and more

g, and is not uncommonly followed by

A precisely similai' condition is met with

amongst huntsmen, gamekeepere, farm la-

bourers, and others who live much in the

open air, but it is only found in those who

have thin skins.

ACA^e ROSACEA.

II. Those cases where in addition to the

congested state of the integument, papules

develop, which iji the first instance are not

red ; but afterwards they become vividly so,

and sometimes they suppurate at their apices.

Tliese spots come out in successive crops, and

in women ai'e more marked about the men-

strual period, and are intensitied in colour by

improper food or hot di'inks. I should include

in tills group all the cases of relapsing ery-

thema, and so-called relapsing erysipelas,

because I believe these are only degi-ees of

the same prochvity.

III. " The joUy or bottle noses " as they

are called, i.e., those cases where in addi-

tion to the varicose condition of vessels and

papules, we find at times enormous hyper-

trophy of the cellular tissue, giving rise to

the most grotesque disfigurements. A care-

ful examination of these cases will enable us

to see the whole glandular system is involved.

The sebaceous glands are in every stage of

inflammation. The blood vessels stand out

in bold relief This state in no way differs

from elephantiasis of the legs, which we see

in the wake of varicose ulcers.

52 ACNE ROSACEA.

I should like to include a fourth variety

which ia common in women at the climac-

teric period of life. It has been noticed from

the time of Shakespeare, that old women

grow Ijeards, and it ia a well-known fact, that

gradually, as menstruation ceases, women

often become fat, and many of them grow a

crop of hair on their upper lip,* but chiefly on

the chin, and it is in this physiological activity

in the hak follicles {which in many instances,

especially in tiiose who had the acne of youth),

that the process transgresses the boundaries of

health, and we have papules developed un-

sightly which are most obstinate to cure.

This condition, more accurately speaking,

should not be classified with acne rosacea,

but rather with the acne of puberty, but in

so many instances I have not been able to

find the spots were in any sense umbUicated, .

that I have placed it with the disease which

we are considering this evening.

I by no means wish it to be understood

that different degrees of acne rosacea have a

a distinct line of demarcation. Nature does

  • TUb condition is also alluded to in my Lecture o»

" Physiological acne"

ACNE ROSACEA. 53

not draw for us clear lines, especially in der-

matology, rather do we find the diseases shade

into each other gradually.

I must say in treating any case of acne

rosacea, how essential it always is to estimate

any superadded influence, such as syphilis,

scrofula, or gout; each will give a local colour

to the disease, and embarrass a great deal

' both our diagnosis and our treatment.

A few words respecting the Etiology

and Pathology of acne rosacea. It appears

clear that any portion of the body which

is the subject of repeated congestion, will

eventually be the seat of inflammatoiy

action, and in this disease we have a good

illustration of the law.

We must believe there are some skins

which will not, under any circumstances,

. take on a diseased condition ; but given a

cutaneous area with an inherited tendency

to become inflamed under provocation, which

tendency is most often found in the face,

because of its pre-eminent blood supply, and

its close sympathy with the digestive pro-

cess ; which association is conveyed from the

solar plexus up the great splanchnic nerves

54 ACA'E ROSACEA.

to the lower middle and upper cervical

ganglia to the nerves of the face, become

congested in cases of difficult digestion.

This exaltation tends to a temporary con-

gestion of the blood vessels ; the congestion

becomes stasis, the papillae becoming con-

gested and afterwards inflamed. Sometimes

suppuration alters the nutrition of the por-

tion of the skin which it governs, so that

the surrounding tissues become inflamed and

eventually hypertrophied. The inflammation

and new growths select those situations which

are the richest in blood supply and glands,

i.e., the alte nasi, the cheeks and the chin.

The an-angement of the papillfe in excess

around the hair follicles accounts for the fre-

quency with which we find follicular acne

associated with acne rosacea.

A few words also as to the influence of

alcohol upon acne rosacea. That alcohol

does produce in some skins all the degi'ees

of acne rosacea is undoubtedly true, but to

associate all cases of the disease with exces-

sive drinking is unscientific and unfair. I

know very many most rigidly careful people

afflicted with the malady, and the popular

AGNE ROSACEA.

55

name for these red spots being " grog

blossoms," in no way diminishes their suf-

fering.

The treatment may be summed up in a few

sentences. It is essential that all those who

are afflicted with acne rosacea should ab-

stain from all food which is difficult to

digest, such as pork, veal, hashes, stews, and

uncooked vegetables, and as a general rule

wine, beer, and spii'its. The face should not

be in'itated by common soap, and care shoxild

be exercised aa regards exposure to the wind

and sun. The meals should be slowly eaten

at regular hours, and fluid put into the

Ktoraach at the end of the meal.

In the tirst degree of the disease it will

only lie necessary to prevent the develop-

ment of the papules by applying a lotion

made witli bismuth and the glycerine of

starch of the Phai'macopceia, diminishing the

starch by three fourths.

Where the papules are developed nothing

answers so well as a lotion made with

two gi'ains of the bisulphuret of mercury in

one ounce of almond emulsion or glycerine

of starch, used every night.

56 ACXE ROSACEA.

Where the mflammation is acute and sup-

puration is going on, we must, in the first

instance, foment the face with hot water

(placing a hot sponge over any troublesome

spot is a simple and useftil plan), when

the acuteness of the inflammation has sub-

sided, rub in an ointment made with 20

grains of the yellow oxide of mercury in

loz, of laitl, and continue this treatment

until the inflammatoiy pi-ocess has stopped,

after which the bismuth and starch lotion

answer well.

Internally I always rely upon a mixture

made with an alkalme cai-honate ; soda 1

think is best; if there is much inflammatory

thickening I add the solution of per -

chloride of mercury, or if there be a

syphilitic tendency to grapple with, I add

the Donovan's solution, if scrofula, cod liver

oil, but internal and external remedies are

useless, where organization of tissue has

taken place. I have never seen an opera-

tion performed upon the advanced cases of

Acne rosacea.

This hi'ings me to the conclusion of my

lectures. I liad some misgivings when I

ACXE ROSACEA.

commenced the study as to the most simple

manner combined with clinical accuracy, in

w]iich I could treat this subject of Acne.

Had I followed my own inclination, I

should have introduced my remarks under

the denomination of folliculitis, and I shoxdd

liave embmced many maladies which may

at the first glance appear to be in no way

akin. 1 allude to Lichen, many forms of

Eczema and non-parasitic Sycosis ; this

would have eliminated acne rosacea. Had I

doTie so the matter was so extensive that I

should have delayed you too long, but

very gi'eat advantages would have followed.

It is embarrassing to di'aw a distinction be-

tween diseases of the hair follicles and

diseases of the sebaceous glands ; and it

would clear the ground immensely if we

were to be bold and abolish much of the

noinenelatui'e which cumbers so markedly

this subject. All skin diseases might with

advantage be divided into eight classes.

I. Those due to atrophy of the skin,

such as many forms of baldness

and gi'eyness.

II. Those due to hypertrophy, such as

ACX'E ROSACEA.

all the forms of mother's mark]

naevi, come, and elephantiasis.

III, Those due to congestion, or stasias

of the blood in the skin, suchil

as the firet stage of

rosacea, or chilblains when not|

ulcerated.

IV. Those due to inflammation of thoJ

skin, such as chilblains, when, |

there is destruction of tissue, i

eczema, or Pityriasis rubra, andl

all tlie constitutional forms

cutaneous diseases.

Those due to a new growth, such E

Lupus, rodent ulcer, or cancer.

Those due to nei-vous disturbancf

such as Herpes or Morphcea.

Those due to an abnonnal state of I

the glandular structures of the J

skin, such as Acne or Lichen.

VIII. Those due to the invasion of thft

body by an animal or vegetable

parasite, such as Prurigo, firomi

lice, or the various forms of ring-fl

worm,Favus, or parasitic Sycosis.

Taking these as the basis for classificationjl

VL

VII.

ACNE ROSACEA.

you would find a great assistance in your work ;

and what is quite as important, aid in guiding

you as to treatment.

I should detain you much too long if I

were to glance at the adaptation of these

simple divisions. They have assisted me

materially in my study of dennatology.

Bear with me please, until I go a step

further, and tell you how I apply these rules

to treatment.

Where the skin is ansemic I give iron, I

increase the quantity of food, and I advo-

cate fresh air.

Where the skin is too full of blood, T

purge and diminish the quantity of food.

Where there is local congestion I remove

the cause of that congestion, and I rest the

skin ; thus In the erythematous group I

cover the skin with a dusting powder, and

[ remove any source of irritation.

Where inflammatory action has arisen,

and if that inflammation is unilateral, I

rely on the ordlnaiy jneans of subduing

that inflammation, and if possible I use

absorbent remedies, such as mercury, to

dissolve fresh inflammatory gi'owth.

ACNE ROSACEA.

Where .1 new growth exists, as in Luput

I use the knife, the actual cautery

escharotics.

In the sistli variety I leave the

alone, knowing that time will remedy th«

evil. An exception occurs in Uiiicaria;

such cases you must find out the caus<

which is always food, and abolish the con-J

dition by remedying that food.

Those due to an abnormal state of the glane

dular system I have discussed at full length, I

Lastly, all the pai^asitic diseases must 1

healed by remedies strong enough to destro

sucli parasites ; i.e., such drugs as carboliffl

acid or mercury.

The constitutional forms of skin diseai

such as Psoriasis, or, in other words,

those maladies which occur on both sid^j

of the body, which are prone to relapw

which are inherited, and which do not inter-fl

fere witli the general health, require arsenia

given internally, and tlie tar preparationi

externally.

Syphilis again will play Its part, and

must be met by appropriate remedies,

also must scrofula or gout.

THE Fathers of our art used tlie word lichen

to denote a circular blotch of eniption,

which looked to them like a wafer stuck on

by licking its surface as we do a label. The

botanist has borrowed tlie word from us and

applied it to the moss varieties of plant life.

And if we care to trace the history of the

word down fi-om Hippocrates to our own time,

we shall be surprised to find how many dif-

ferent maladies have been classified as lichen.

Sir Ei-asmus Wilson, to whose labours as a

dermatologist, not less than to his large

generosity to our profession, we owe a debt

of deep gratitude, made use of the following

sentence in his lectures given in the year

1871 at the Royal College of Surgeons. Sir

Erasmus had been dwelling upon the confu-

sion which had arisen from the number of

J

LICHEN.

instmctors iB the world of cutaneous medi-

cine, when he suddenly broke off and said,

" I ask you to forego all human teachers, and

come to this college to learn from the face of

natm'e herself;" and he goes on to say,

will not alai'm you with classification, we will

only refresh your memory as to the early

rudiments of medicine." Such a lesson from

such a master gives me courage, and I will

follow his high example to the best of m;

powers in discussing lichen.

I remember Sir William Gull once saying'

to his class in Guy's Hospital, " The

book in medicine is to be found in the ward8_

of Guy's Hospital. There are as many pj

as there are patients, and there is not .

on any one of the pages."

I said in my lecture on acne that I

met at the entrance to my subject with

difficulty which I experienced, in actual pi

tice, in discriminating acne from lichen,

drew attention to the intimacy which

between the hair follicles and the

sacs, and 1 ventured to observe that it

only by graspmg this difficulty that we

hope to gain an accurate and useftil I

01 I

? J

m

LICHEN. 63

ledge of either disease. I repeat the obser-

vation with renewed emphasis to-night.

By a lichen spot I mean an altered condi-

tion of a liair follicle, and by the simple word

I mean a papule which rises up fi'om the

surface of the skin, which neither becomes

vesicular or pustular ; it may become scaly.

We will ask oureelvea what ia it which

influences the growth of hair, and the answer

we shall receive will be, the commencement

of the respiratory function in a child, the

irritation of the clothing, the advent of pu-

berty, and the constitutional tendency of the

individual ; and we must add the influence of

external causes, such as dust, sun, soap,

special callings, or the low forms of plant

life.

The first form of lichen to which I will call

yom* attention is known as strophulus or red-

gum, or tooth-rash. It is a condition very

common duruig the first few months of a

child's life, and is recognized by a number of

minute red spots, which are more abundant

on the face than elsewhere, which attack

every portion of the body excepting the

palms and soles. The mode of production

U LICHEy.

of these spots has been pointed out by Von

Barensprung, who suggests that the hair foHi-

cles become distended with their contents,

which congeal and occlude the neck of the

minute hau- follicles.

The spots sometimes converge, when the

condition has been designated strophulus con-

Jertus ; on the other hand strophulus infcr-

tinctxis is used to indicate an isolated condi-

tion of each spot.

These spots usually fade and disappear

in about tlu'ee weeks, and require nothing

more than the application of a dusting pow-

der made with equal paita of bismuth, starch,

and oxide of zinc.

Sometimes, however, the irritation is ex-

cessive, and where an eczematous proclivity

exists, the malady passes into an eczema ; in

point of fact, many of the cases of infantile

eczema owe their parentage to activity in the

hau" follicles. This is why the forms of this

disease met with in cliildren do not keep

relapsing, as we find occurs with such con-

stant persistency in adult life. The cause of

the disease being the physiological growth of

hair, when that process comes to an end the

LICHEN. 65

exciting cause is removed and the disease

The association of the lichenous and ecze-

matous process lias givea rise to the use of

the compound word lichen-eczema.

In other cases where the skin is pruri-

ginous, this gi'owth of hair gives rise to the

most riotous scratching, which produces blood

crusts, linear markings of the nails, and great

torment to the child ; and in very many

instances the papules become urticarious.

These are the cases which have been called

lichen-prurigo, or lichen-xirticatus. M. Hardy

designated them pruriginous strophulus, which

indicates that he recognized the cause of the

condition.

About the age of puberty we shall meet

with another group of cases of lichen ; it is

at this age that the whole hair system takes

a rapid stride. The outer aspects of the

limbs, and certain regions of the face, grow at

this epoch fine hairs, and where the cutaneous

area is in harmony with this growth the

process goes on without any disturbance of

  • I have treated this diseQBe at length in my lec-

ture on prurigo.

function, but where the hah-s experience a

difficulty in making their exit from the mouth

of the sac, we have a morbid condition which

we are called upon to treat. The most com-

mon cause of this want of })hyeiologiciJ ba-

lance is a scrofulous diathesis ; a diathesis

where the hair, the teeth, the skin, the nails,

and the mucous membranes are pitched in a

low key, or as the histologist would phi-ase it,

the epithelial structures are too exuberant.

Now what is the effect of this epithelial in-

crease ? Why, the mouths of the hair follicles

are choked, and the hairs are imprisoned, and

often absent. We find on stripping these pa-

tients a thick, harsh skin, which feels rough

to the touch, and has scattei'ed over the

outer aspects of the limbs a number of flat-

tened papules, flattened from side to side,

which are colourless, scaly at their bases, and

each one, if examined minutely, will be found

to have a depi'ession at its summit, tlius prov-

ing it to be a bloated follicle. These are the

patients who come from a scrofulous race ;

they are worse in cold weather than hot, and

they complain of not sweating.

These cases are known as hckai scrofulosus.

They improve markedly under the influence

of cod-liver oil, nitric acid, and quinine, and

an inunction with a cream made with equal

parts of lime water, nut oil, and glycerine,

but they ai'e never absolutely cured.

A class of case which is well indicated by

the following notes has been described by

dermatologists under the appropriate name

oi lichen ciivuniscnptus : —

J. N., set. 21, has on his trunk, both back

and fi'ont, in his axOlte, between his scrotum

and thigh, and amongst his pubic haira, cir-

cular patches varying in size from a sixpence

to the top of a tea-cup ; each patch has a

weU-defiued margin. The surface is dotted

with red papules, pointed, not pustular, vesi-

cidar or scaly, and out of some of these

papules hairs are growing. He complained a

good deal of the itching. He had a distinctly

scrofulous family history, and his scalp was

covered with epidermic scales.

A precisely similar eruption is met with

between the scrotmn and the thigh, and

what cei'tainly is curious, very often in this

spot alone. The patch of ei-uption is well

defined, the surface is brick red in colom", and

68 LIGHEN.

the exact adaptation of the two parts is \

most marked feature in these cases. ThJ

surface does not weep like an eczema and tha

iiTitation is most troublesome.

I should feel disposed to group all these

cases as paiusitic lichen. The disease spreads

so markedly from a centre to a circumference,

it involves so cleaily the hair follicles,

yields so i-apidly to a lotion made withJ

1 dram of carbolic acid, 12 grains of per-]

chloride of mercury, 2 drams of boi-axj

12 ounces of spirits of wine, and 12 ounces of*

distilled water, that I cannot believe it has

any relation to the other constitutional skin

diseases, and in point of fact many of these

cases are not distinguishable from common

ringworm. I am aware of the statement that

ringworm has an eczematous edge, that it is

healed in the centime, and that it does not

occur simultaneously on both sides of the

body. But I venture to assert with a good

deal of confidence that very many undoubted

cases of ringworm do not have vesicular

edges, that they have not centres of sound

skin, and I have many notes of cases where

the disease has appeared as a pretty general

LICHEK 69

eraption, just as we soiiietiines see moUuscum

contagiosura all over the body.

I cannot leave this part of my subject

without alluding to a series of cases of which

I have notes, cases whei'e the hair follicles on

the ai'ins and legs liave become inflamed and

suppurating, cases which I have been in the

habit of calling sycosis of the limbs. I simply

allude to these en imssant because they ai'e

inflamed hair sacs, due probably to some

sources of irritation, and in the greater num-

ber of my cases I have been able to detect

the mycelium and sporules of the Tineas.

A group of cases which have their type in

the following iUustratiou, will baifie our diag-

nostic acumen, unless we bear in mind the

fact that hair follicles may be invaded by

ciyptogamic life on any region of the body.

J. G. a groom, ast. 24, came to St. John's

Hospital on July 2, 1883. He complained of

an iiTJtable emption in his arms. His famUy

history was fi'ee from any skin disease. The

eruption in the skin had existed for about

nine months.

On inspection I found he had on the outer

aspect of both arms, but only as far a.s his

^^

70 LICHEN.

elbows, an eniption which consisted of an area

of inflamed and thickened skin. A careful ex-

amination revealed in this area a number of

pimples, some of which consisted of inflamed

tissue with a dark centre. Others had their

tops scratched off, and were scabbed, whilst

a third variety consisted of an island of pus,

with the hair shaft springing out of the

centre like a tree. The ei'uption was present

to a slight degree on the hacks of his hands.

The other part of his body was free from

any skin disease.

A microscopical examination showed dis-

tinctly garlands of spores, living in and

around the hairs like hops on a pole.

I may add that an ointment composed of

sulphur, iodine, carbolic acid and lard, effected

a rapid cure.

Lichen Ruber. Hebra, Wilson, Hutchin-

son, HiUier, Duhring and THhui-y Fox have

written on this interesting malady, and it

has received a variety of names. When I

fii'st became acquainted with the disease

whilst attending Mr. Hutchinson's class at

the Stamford street hospital for diseases of

the skin, we were acc\istomed to i

iJflBUai

LICHEN. 71

form of psoi-iasis, which was not, as a rule,

extensive in its distribution, wliieh began as

a flattened papule, and which did not scratch

with the spermaceti surface of true psoriasis.

Mr, Hutchinson had then, as he calls to mind

in his lectures on skin diseases, three names

for this condition, " smooth psoriasis," "papil-

lary psoriasis," and " lichen psoriasis."

Sir Erasmus Wilson described the malady

as lichen planus. Obviously the subject is

beset with some obscurity, and when I first

investigated the subject I was met with great

difficulty in selecting from psoriasis on the one

hand and eczema on the other, the cases

which. I could relegate to my note book under

the heading Lichen niber.

It will bring more vividly before our notice

the aspect of this disease, if I read the notes

of a case which was in every way typical of

the disease,

J. C, 42 years of age, was under ray care

at St. John's Hospital for some months. He

came first on August let, 1882. He com-

plained of an eruption which was very irri-

table, which had continued for about eighteen

months, and which had gone on increasing.

72

LICHEN.

His father had scurvy of his legs, "whid

used to weep (eczema). He had been mud

troubled with indigestion, and bad a red a

inflamed great toe (gout).

Inspection, — He was a dai'k type of mai

with grey hair, worn down teeth, nails "v

were brittle. He had on each side of the clefl|

of bis nates an eruption, wliich was exactly

occupying the same spot on either

The eruption, at first, looked scaly, but (

could not scratch it into silveiy flakes ]

true psoi-iasis. The patch was not of unifon

colour, some portions of the surface being a

dark, and resembling closely sheep's

whilst other parts were lighter, and lii

brick red. The whole surface was

and had raised papules. There were som

clefts on the surface, which corn

the natui-al folds of the skin.

The edge of the area of emption was fairljj

margined, but a few of the angular i

papules with a hair in tiie centre could 1

seen in the neigbbom'hood of the edge.

He had not any eruption elsewhere.

On the inside of his cheeks, especially c

the right side, were some small white spote

LICHEN.

73

and ill some situationa these had run into each

other, and formed white streaks. I dictated

at the time the following remarks : —

The eruption is not like an eczema, because

it has not wept at any stage of its career.

It is not like a true psoriasis, because I

cannot scratch up scales which look like sper-

maceti. It evidently consists of the aggre-

gation of solid, raised, unchangeable papules,

wliich have been matted together by an in-

flammation of the skin between them. These

papules are obviously aborted hair follicles,

as each one can be seen at its apes, either to

have a puny hair peeping from its summit,

or else the summit is occupied by a depressed

and dark centre.

I might multiply tliis case by many others.

I have the notes of a great many cases before

me now, and should sum up the peculiarities

of this oif-shoot ofhchen in the following

postulates :—

I. The disease is associated with a

bloated hair foUicle.

II. Its situation is determined by some

obstruction to the growth of the

hair, such as the flexures of the

  • LICHEN.

joints, under the breasts, the waia

or where there is any constriction.

III. All the cases occur with more (

symmetry.

IV'. They consist in the fii-st instance i

angular raised papules, which

V. They do not become eczematous i

scaly.

VI. They are always associated v

white spots, or white lines in thi

mucous memhi-ane of tlie mouth (

tongue.

I have not seen any case where the

cutaneous area has been involved ; su(

are represented in the atlas of skin disef

published by the late Tilbury Fox (fig. siv.)

or such as are described by Wilson, Hilllej

and others.

There can be no doubt that Lichen rub

is a branch of the constitutional skin

eases, and illustrates the well recogi

law that the effects of an irritation can i

way be a guide as to the in'itant. '

water will cause an eczema in some !

and, given a proclivity towards a skin dii

the exciting cause need only be prolonged

and the manifestation occura.

Any paper on Lichen would be incomplete

without a reference to the part which syphilis

plays in the procesa. The syphilitic skin

eruption very commonly assumes a liehenous

type, and often it is a very general and con-

spicuous eruption, almost eveiy hair follicle

on the trunk and limbs stands out in bold

relief, and the papules are of curiously regular

size ; sometimes a few will become exagge-

rated. The appearance on the skin is very

much like a strawberry.

In other cases the eniption will arrange

itself in rings, when it is known as Lichen

syphilitlvus ammlrtliis.

In the later stages of syphilis the hair fol-

licles sometimes become much increased in

size by the irritation of the syphilitic virus ;

when this occurs it presents a series of groups

of lichen spots, an-anged like bunches of

grapes ; to this condition the epithet lichen

syphiliticus corynibosiis has been attached.

I will now pass on to the part of my sub-

ject, which has for me a pereonal Interest,

and as I believe very gi'eat use often comes

76

LICHE])f.

from an accurate observation of our own

nesses, I will ask you to pardon a piece

personal experience.

I come from a family, which is in no w

disposed to any form of skin disease. My

skin is not influenced by fleas or other ani-

mals to an unusual degree.

In the year 1875 I was staying at Yar-

mouth, and went for a bathe on a beautiful

August day. I stayed in the sea about

twenty minutes, and did not experience any

thing unusual uiitil four hours afterwards,

when my akin began to prickle, in a

manner which gave one the idea of a con-

stant Buccesaion of small stabs by

of gorse, and the irritation was quite iiTesis-

tiUe.

On stripping, I found eveiy pai-t of

body, except the soles of my feet, absolutely

spattered with vividly red pimples. But

those portions of my body, which, in the

usual course of my lil'e were exposed to the

sun's rays, were unafiected. The line of

demarcation on my neek was abi-upt, and on

the forehead, where my hat protected

there were my tonnenting spots.

ece

I on I

me, J

LICHEN. 77

Where the hair grew abundantly I was

free from the rash.

My skin felt thickened and inelastic, and

in the course of four days, with no other

treatment than washing wltli Wilson's tar

soap, I was quite well.

I always gained relief by stripping. The

friction of my clothes iixitated me ten'ibly.

I may add that, to be perfectly certain my

eruption was due to the sun's rays, I took a

series of sea baths indoors without any incon-

venience.

Such cases as my own are known as lichen

tropicus, acute lichen, or prickly heat.

In the Torrid zone the disease is much

intensified, and has called forth articles

from Dr. Winterbotham, Hillary, Bontius,

Clark, Morley and others ; but Dr. Johnson

in a Treatise " On the effects of Tropical

climates on European constitutions," writes

with so much force, that I am tempted to

quote him at length.

" Among the primary effects of a hot cli-

" mate (for it can hardly be called a disease),

" we may notice prickly heat, a very trouble-

" some visitor, which few Europeans escape.

78 LICHE]f.

" This is one of the miseries of a tropical

" climate and a most unmanageable one it is.

" From mosquitoes, cockroaches, ants, and

" numerous other tribes of depredators on

" our personal pTOperty, we have some de-

" fence by night, and in geneiul a respite by

" day ; but this unwelcome guest assails us

" at all, and particularly the moat unreason-

" able hours. Many a time have I been

" forced to spring from table, and abandon

" the repast, which I had scarcely touched,

" to walk about in the open atr, for a quai-ter

'? of an hour ; and often have I returned to

" the charge with no better success against

'? my ignoble opponent. The night affords

?? no asylum. For some weeks after arriving

" in India, I seldom could obtain more than

" an hour's sleep at one time, before I was

" compelled to quit my couch, with no small

" precipitation, and if there were any

" water at hand, to sluice it over me, for

" the purpose of allaying tiie inexpressible

" irritation. The sensations arising from

" prickly heat are perfectly indescribable,

" being compounded of pricking, itching,

" tingling, and many other feelings, for

LICHEN.

79

" which I have no appropriate r.ppella-

" tion."

I believe many sources of iiTltatioii other

than the rays of the sun will induce an at-

tack of acute lichen. I have known common

soap, the use of powdera for the complexion,

face washes, the wearing of coloured gai-ments

next to the skin, coarse flannels, and many

other irritants bring out a copious crop of

this tonnenting malady.

Violent exercise. Some dioisuch as the

iodides and balsams will produce it, also aiticles

of diet, and in some organisms violent emo-

tions will do the same. What is ceitainly

very curious, I cannot remember cold winds

ever producing a true lichen eruption.

During a very hot summer in London, we

see very many chUdi-en who come out in a

copious rash, whicli is indistinguishable from

scarlet fever (the eruption of wh i ch is

really of a lichenous type), and veiy

many of these children are constitutionally

ill, but if we look carefully into their

mouths, we shall find the follicles on the

tongue and the mucous membi"ane con-

spicuous and white. There is a characteristic

80 LICHEN,

pufl&ness of the lower eyelids, and some irri-

tation of skin. If we bear these facts in mind,

and remember the throat is not involved, we

shall avoid sending these children to fever

hospitals, or alarming a neighbourhood by-

making an error in our diagnosis.

These lichen spots, in some instances, have

an erythematous base, when they may readily

be mistaken for measles.

I CANNOT help thinking that every intel-

Hgent member of our profession must at

times have been sorely puzzled as to what

significance he could attach to the substantive

word prurigo.

I find on a search into the literature of the

subject that the word has been applied to the

most variable conditions of the cutaneous sur-

face. At one period we find almost any akin

disease which itched was designated prurigo.

Later on (I allude to the time of Willan and

Batenian) when a new era in dermatology

commenced, we find aU the varieties of lichen

figuring in their atlas of skin diseases as pru-

rigo with a fanciful adjective stuck on. Th\iR

we find in theu- atlas, plate VI. —

Fig. i. Prurigo mitis.

Figs. ii. & iii. Prurigo formicans and pru-

rigo senilis.

82 PRURIGO.

Fig. iv. Representing an insect which

was found in the skin of an old man

affected with prurigo senilis—

which is probably a hair in its folhcle.

Again, it would appear that e^'en Hebra se-

lected a number of scratched skins, scratched

to an intense degree of thickening, and

sketched them with his masterly hand, desig-

nating these cases, and these alone, prm'igo.

It was this graphic description which

brought into the field Mr. Hutcliinson, who

has written a most suggestive and interesting

article on Hebra's Prurigo, in his work on clm-

ical surgery.

On tracing my own ideas of pnu'igo which

1 caiTied away from student's days, I am

obliged to confess the image which I then

had of the disease has slowly, hut surely

become obscured, then obhtei-ated, until I

find myself doubting the very existence of a

malady which I was once examined in, and

doubtless described with more or less minute-

ness, and which is still asserted by many to

be a clinical entity as much as cholera, or

psoriasis.

It wiU he best, I think, to relate with som

detail three cases of skiii disease, each dift'er-

ing in moat important details, eacli having its

own phenomena, history, and teiToination, and

each fitting into descriptions of pnirigo as

delineated by deiinatologists.

The histoiy of my &st case is written by

my patient, a most intelligent Austrian, and

I will give you his own words : —

J. T., aged 38 years. "I was bora at

"Trieste. The first symptoms of irritation

  • ' were apparent on the calf of my right leg

"in the year 1875, but as they were but

" slight and passed away again quickly by

" change of air, little notice was taken of

" them. The nest sign took place in the

" spring of 1876, on the backs of both bands,

" which, however, was also easily disposed of

" by the application of carbolic acid and gly-

" cerlne. The following year, 1877, I was

" vaccinated, and about tliree months after-

" wards (1 should say about April) I bad the

" first serious signs of an ei-uption on my face

" and ears, and it was at this time that I fii'st

" became awai'e of the name of my complaint,

" namely eczema, a word which up to that

" tune I had never beard. In the latter part

84

PRURIGO.

" of the same year my legs and feet were

" attacked, and gi-adually it spread to other

" parts of my body. While this disease was

" in progress I had another ailment to contend

" with, viz., abscesses in various parts of my

" body, on my eyelids, thighs, and buttocks,

" &e. The nails were also attacked, and in a

" most peculiar manner ; first came a burning

" sensation round the base of the nail, accom-

" panied with an eruption of a yellow thin

" fluid ; shortly afterwards the naU, in growing

" up, showed on the spot where the burning

" was most intense one or more small li

" The nails grew up, but have never since be*

" of the same s!ia]3e or colour as before tin

" attack."

" At the commencement of the attack

" the skin wept ; but about two yeai-s afiter-

" wards the whole surface began to sweat,

" and this sweating is at times so severe that

" I am obliged to change my Hnen two and

" three times a day, and also at night.

" hands and feet are very painful with lar

" cracks, which heal up at times very quickli

" and as quickly re-appear again without

" apparent cause."

les.

PRURIGO.

" I have gradually lost my hair on the aur-

" face of the body, and pai-tially on my face

" and scalp. I may also add that when I

" have had a severe fit of sweating I am very

" cold. Sleep at night is more the exception

?? than the rule, and though I eat heaitily I

" lose flesh. My father and mother died of

" cholera when I was an infant. I am without

" brothem or aisters."

"When a cliild I suffered much frem emp-

" tions on my face, and the skin on the hacks

" of my hands has always been very coai-se."

I have several notes about this most inter-

esting case, hut I will not trouble the Society

with more than the last, which were made

on May 14th of this year. They are as

follows : —

" He complains of a continual sweating and

" irritation of tiie skin, especially is it irritable

" when his skin is dry. He is losing flesh,

" his uruie is creamy (it was alkaline and

" loaded with amoi-phous phosphates). The

" skin is decidedly better now than it was in

" the winter, but he is worse when the weii-

" ther is extreme. After he has been sweating

" he feels chilly. He ha.s a slight cough."

PRURIGO.

" On taking off liis garments his shirt wai

" distinctly wet with sweat, although he 1

" changed it twice during the day."

" His skin is of a salmon-red colour, an

" there is a smell of decomposing matter, lik«

" a horse's hoof, about him."

" I can roll up masses of epidennis like ond

" sees in such situations as the flole of th

" foot or between the toes."

" He has under his skin, especially whew

" he says it itches the most, i.e., between 1

" shoulders and on the front of the sternum,

" masses about the size of peas, only flattened,

" wliich are movable and white. The limbs_

" ai"e haii-lesH."

" He has great enlargement of the paroti4

?' cervical, axillary, inter-costal, and inguinal

" giands. These glands are dense, painlei

?' and look like potatoes under the skin. The j

" natural depressions and elevations of thi

?' skin are much exaggerated. This conditio

?' is most intensified on his liands, knees,

' elbows."

" The nails are black, lustreless, and deep™

' furrowed."

" He has deep rhagades of his hands."

" He has ectropium of his lower eyelids."

" His skin is not in the least scaly, neither

" does it weep like eczema,"

" When he stands in my room he keeps

" shivering and scratching himself,"

Can we doubt this is a case of eczema '?

Let me pass on to another case.

W. R. G., iet. 45, is without any known

inherited tendency to skin disease. He is

subject to attacks of spasmodic asthma.

Three years ago he had skin disease on the

flexors of elbows and knees. This was cured,

hut returned eight months ago.

Inspection. — His trunk is free from any

diseased conditions. On both his arms, but

only on the outer side, he has a mixed rash

composed of scratched papulse, lichen spots,

hypertrophied skin structures, and pigment.

The hypertrophy is most marked at the bend

of the elbow.

A similar hut much exaggei'ated condition

affects both his legs.

There are very few hairs on the posterior,

anterior, or external surfaces of legs, and in

these positions the hairs can be seen in some

instances broken off short ; in others just

PRURIGO.

peeping from tlieii' follicles, whilst other folli-|

cles ai'e closed.

He has a good crop of hair on his stemu:

pubis, and axillse, also on his scalp and ]

and where the hair grows he has ueith^3

itching or eniption. He has slight adonitia

of his inguinal glands.

I take these two cases as Ulustratiug ihsm

group which Hebra described as pmiigo ;

first one, who is curiously an Austrian, fits

exactly iiito his description. The malad

seems to have grown up with him, has gone

on increasing in severity, is woi-se in cold

weather, when his skin is not pleasantly _

moist ; has produced enlargement of tin

lymphatic glands, and looks as if it woulq

go with him to his grave.

My second case comes lower down in thcH

scale, but it is in the same group.

These cases must be veiy common in thi

practice of any dermatologist, and are pn

bably designated eczematous, a classificatioi

which I should in no way question. As i

matter of fact I should simply classify then;

as cases of eczema occuning in jiatients wiU

pruriginous skins, which skins had bet

PRURIGO. «9

scratched into the intense and incui-able

condition of the patient whose case I related

first. I have now seen tliree instances of this

condition ; the history was in each instance

similar, a history of an initable and harsh

skin spreading over the patient's hfe, a skin

which was influenced by many irritants, such

as flannel, cold winds, sun, dust, dirt, &c.

But when the elephantoid condition, the en-

larged glands, the phosphatic urine, and the

loss of flesh took place, the patients were

hopelessly and in-emediably iU,

I will now relate briefly the history and

symptoms of a case of piniriginous skin in a

patient with obstructed hair follicles.

J. B. is 42 years of age. He complains of

itching and dryness of the skin which has

existed since he was 20 years of age. The

itching is worse in the winter than in the

summer, and is increased by the heat of the

fire.

Inspection. — He is a well-built man, whose

occupation consists in playing eight instru-

ments at the same time. The outer aspects

oi' his limbs feel thy and shotty. This applies

especially to his legs, and on the prominent

90

PRURIGO.

positions, such as the huttocks, the outer a

front aspects of his legs. Over the

condyles of the femores he is without surfac

hairs, but where the hairs should he ]

are situated, which papules have ;

centre, can easily be dug out with a penknife,

and in many of these can be found a hair, _

Bometimes curled up like a watch spring

pi-aetically a hair which ia imprisoned in it

own cell. There ai'e a few blood crusts whei

he has scratched himself, but there is not 1

slightest weeping or scaliness of skin,

says he often digs a little seed-like body ou

of the skin.

I believe if we strip all our cases of whi

Mr. Hutchinson and Professor Duhring i

winter prurigo, we shall find these obstructs

hair follicles in them all. It will be remem-

bered that some discussion took place as i

gards priority of discovery respecting this c

dition, but it was described by Dr. Handsen;

of Munich, in 1845, as pruritus hiemalis, i

you will find the late Mr. Startin and othen

have drawn attention to the association i

itching and obstriction of hair follicles,

doubt the muscles of the skin which an

PRURIGO. 91

serted into the hairs on the surface where

they start, are irritated by the cold weather,

ajid being in-itated they become active ; this

activity would i-alse the hair in such a manner

that it would iiTitate the liair sac. We see

the best example of the action of these mus-

cles in the horse on a cold day. His coat

is said to stare, or, as we should express it,

the erector pili muscles are stimulated by

the cold and i-aise the hairs perpendicular to

the plane of the horse's skin. It is by the

action of these siirface muscles that the horse

and other animals jerk off flies or other ob-

noxious bodies.

As a digi'ession bearing on this, I may call

attention to the gi-eat irritation which is

associated with the development of the acne

of puberty ; in many cases it is the symptom

which brings our patieiits before us. We are

frequently consulted for a case of m-itation in

one spot. I have in my mind a patient I saw

the morning I wrote this paragi'aph. He

came to see me for an itching in one spot,

wliicli was worse when he had finished his

day's work. On stripping him I found a spot

not larger than a half-crown over the spine of

tlie right scapula, which spot was cleai"ly de-

fined and without a single hair growing upon

its surface. The epidermis was distinctly

thickened. I liave another instance attending

me here as an out-patient who has, over the

bend of his right tibia an oblong patch of

raised colourless and hairless structure, which

gives him a gi'eat deal of trouble. This patch

has existed for over 30 years. Both my pa-

tients have a good crop of hair elsewhere.

I will now take another group of cases,

those which Mr. Hutchinson, Sir Erasmus

. Wilson, and others have written upon, and

which have received such names as varicella

prurigo, lichen urticatus, and Hchen pnirigo ;

cases which occur in early life, which get

well as puberty approaches, and which form

such a lai'ge proportion of the young children

which are brought to a skin hospital. The

condition comes on from the first to the

fourth year as a rule ; and consists of

scratched lichen spots, which scratclies in

some instances become urticarious. The

eruption always appears on the outer aspect

of the limbs, across the loins, and the lower

part of the belly. It is not always easy to

PRURIGO. m

define the exact character of the eruption.

Sometimes it is a solid, colourless papule ; if

this is scratched it becomes red, often vesi-

cular, and where an eczematous diathesis

exists, eczema follows, with enlargBment of

the lymphatic glands. The itching is worse

in the spring, but it never entirely disappears

until the puberty hairs grow. The eruption

varies much even from day to day ; as it dies

out it goes away like a bruise.

It has been suggested that where the

wheals appeal' on the soles or the palms, it is

a proof that the pruriginous condition was

set up by a blood disease such as measles, or

chicken pox, hence the name varicella-pnu'igo ;

whilst in those cases where these situations

escape, the condition is said to have its origin

in an external irritant such as fleas or bugs.

My own experience would show that this

distinction is not clinically accurate, as in

some of my cases I have not been able to

discover that the rash was in any way a

sequence of an exanthem, although there have

been distinct wheals of soles and paJms, to-

gether with the scratched lichen elsewhere.

Rather should I believe that this form of

M PRURIGO.

prurigo is a liclieii occurring in a pruriginous

akin, and I assert this the more confidently

because the natural history of these cases

shows that when a copious crop of haire is

produced on the tnmk at the age of puberty

the activity of the hair foUicles comes to an

end and the condition ceases.

The following case came under ray obsei"va-

tion some years ago, and at the time it made

a lasting impression on me : —

E. B. was aged 68. There was nothing

in his previous history which called for

comment.

When I saw him fii-st, which was in May,

1879, he was sitting in a chair in his dining-

room, with his trousers oif and a shawl thrown

over his legs, so that he might easily scratch

his legs, and scratchuig them he was most

unmercifully. He had also a clothes brush

with a long handle, which he used for allaying

the in-itation.

He complained of a succession of chills, and

was extremely iiTitable, sleepless, and dis-

tressed by his condition.

I searched most carefully for insects and

other causes of itching, but 1 found none.

His skin was a good deal damaged by his

nads, but with tlie exception of a condition

which the laity know as goose skin, he had

no manifestation of disease. The initability

was always relieved when he was in a hot

bath ; lotions and sedatives afforded him but

little relief He got thinnei', tenibly de-

pressed, and in the September of tiie same

year he became aphasic without loss of con-

sciousness, and in Octobei' siiddenly hemi-

plegic, and soon died.

Living as I do in an ancient part of the

town I frequently see men advanced in years,

who live in secluded rooms about Gray's Inn

or the other inns ; men whose nerve centi'es

are givmg way, and I can call to mmd several

instances where itching of the skin has been

the first warning of the beginning of the

end.

Elimmating from this group all those in

which the cause of the itching ?was dis-

covered, I have been driven to the conclusion

that this special class of caaej which comes on

suddenly and without any discoverable ex-

citing cause, is in reality due to disease in

the nerve centre, and my obsei"vation woidd

k

96

PRURIGO.

lead me to the conclusion that there is i

centre which governs the sensation of ?

skin. We know there are centres whic

govern speech, micturition, sight, respiratioi

&c., and I cannot help believing that thei

cases are due to disease of a special skia

centre. This, I am aware, is purely speculw

tive, but if you will stnp a patient with bodll

lice before a class, and demonstrate befon

that class the cause of the ttchiug, it is :

difficult to see amongst these several whd

will commence scratching themselves, Thi

scratching goes on for some time. A

allusion to itching will set the listeaej

scratching. These are, surely, examples

pruriginous conditions of skin excited

psychological cause.

I allude to these minor points because

am so sure that it is only by so doing thi

we can hope to get behind the scenes i

find out the manifold causes of pruriginou!

skins. I suppose many a pruriginous skin \

first started by the pleasure which is

perienced in having the cutaneous sin

gently irritated. We see this especially iq

the lower animals. Dogs and pigs becoin

PJilJRlGO,

docile wlien you scratch tlieir backs. The

trout is taken by tickling in some counties, a

fact not generally known, Init noticed by

Shakepeare and Tennyson.

Dean Swift said, in his "Polite Convensa-

tion," tliat eating and Rcratcliing were two

things we only had to commence doing and

we should prolong. There is proluibly more

significance in tlie observation than even this

sublime wit saw himself.

I should detahi the Society nuich too long

if I were to even mention the manifold catises

?of a pruriginous state of the skin, but I nmst

call attention to the distressing itching of the

skin which comes on in cases of drojisy of tlie

legs and varicose veins occuiTing in tliose

?who have thick skiiss. This itching is veiy

commonly the greatest annoyance these pa-

tients experience, ;nid is most difficult to

subdue.

I will just call attentiiiii to the piurigiiiuus

state of some skhis whicli is set u)) by Heas

and other irritating animals. In any rase

we nnist search most carefully for these

causes. We nmst iilso be alive to the kind

?of garments worn ; sc»me rough ttannels and.

h

PRUlill!

some dyes, especially magenta and utlit

line colours, will cause itching.

Hydrocyanic acid, tlie balsams, and prob-

ably the iodides and bromides will cause

j)i'ni'!ginous conditions, winch never a-ssume

a definite type of skin disease ; or atmospheric

conditions, such a.s east wind, fierce sunlight ;

and special occupations, such as those of glass

blowere or smiths, or other employments where

the surroundings consist of dust or other iiii

tating matter, \rill excite a pniriglnous (

dition in those who are jiredisposed.

I must trespass on your time for a ft

moments and drag in what is knoflm

] iruritus. We apply the word to any <

tion of itching either around tlie anus or t

vuh'a, and we very often trip most uncom

fortably in tipplying our lotions oi' our

ments without making a complete es

nation.

I am quite ])repared to admit that I haw

imder observation at the present time fi

eases of itching around the anus and spi"ei

ing forward towards the scnitum, where ]

smiply discover a glazed and tlilckened lo<

about the skin, with all the elevations !

PHI'lUGO.

cle| ut'ssions incveased, iiml \vlt!i tlitiiioHt.

"tfonblesonje inntution. lint m tliese -cases,

if 0111- jiiitlents are atte-iitlve to their symp-

tLiiiis. iUid if ^'e i[iiestinu tliem narrowly, wti

.shall ho ahle to iiiid .s[K)ts which are so dls-

tinctly obstructed hair ftillicles that I cannot

doubt the mijirisoned hair is again the source

of initatioii. There are undoubtedly other

exciting causes, such as piles, ulcer, jwlypua,

worms, or fissure of the rectum, which set up

and keep up the h'ritatioii. Sitting occupa-

tions again produce thin itching in some

eases. In others it is simply an expression

of a general eczeniatouH tendency, and for

ttiese reasons must he treated on its merits.

The piTiritus of the vulva which sometimes

masks the happiness of a woman's life, has

many sources of origin. It is conmioiJy

hut an e.-ipressioi I of a, general dartrous dia-

thesis, locally determined hy special anatomi-

cal conditions. It seems unusually common at

the climacteric period of hie, but in some

instances it will be found to be associated

with a gmwth in tlie urethra. One of the

most brilliiuit tliinrrs I e

the discove

aiK

rer saw acconif

excision of a

tail

100

PRUHIGiK

papLIloinii of the urethi-al orifice, whicli coia

pletely ciii-ed n long-standing case of i

pniritiiH. I tell this story witli some sbama

because I had treated in vain thin c

many months, and it was not until my |

tient had passed Into otlier liands that '

cause was discovered.

T am awai-e that the microscopist has di

covered a bacillus hi cases of pna-Itus of i

vulva, hut whetliev this is the cause or t

effect oi' the condition lias still to be det(

nnned.

I will now pass on to the treatment

])ruriginou,s skins. By fai' the most impois

tant element in treating any initable stati

of the skin is to use every endeavour ?

stop the scratching. Tliis is not difficult

with those wiio have work, but with the

young, the aged, and the idle, or in othea

woi'ds, with those who ha\'e little work anq

less will, your difficulty is almost

mountable. It is amongst this portion of t

human I'ace that we see the most itchisj

skins. The working-man {I use tlie word I

its largest significance) who has an hritaW

state of skin, itches most after bis work j

PRURIGO.

(lone ; lie itt-lies most wlieti lie lias tlitt

greatest leisure.

In the first grou]> of cases where an ele-

phantoid state of the skin has been jiTOdueefh

we can only allay the itching; we ave power-

less to accomplisli more.

In the second gronp. where the IiTitatiun i»

due to a patch of eczema, the eczema miist he

treated on general principles, id est, if the

dieease is recent, smear freely with oil, car-

holic acid and oxide of zinc, hnt if the eczema

is old, awake up fresh inflanimatoiy action

with an irritant in which you have confidence.

I know of Toothing better than carbolic acid.

The cases where obstructed hair follicles-

are the cause of the itching will be i-elieved

l)y prolonged hot bathing, an<|

on these jiatients often drop into joint i

tions.

I do not wish it to be utiderstodd tha

pnirigiiious skins are dense aiid dark ; in the

young tlie revei-se is often tlie case, hut in

the majority of cases which come before us of

scratched skins we shall, 1 think, find

these sucIl ii histuvv as I hnw tried brieflfl

to sketcli.

The fnllowlng Is lint :\u nnnmiini.n lii

torv :- I liave a patient under observa

J'llL'HKl).

103

L

the jiresent time, ^vho lived in ^.Jeylon for

twenty yeai'8. She baa round patches of

•eczema ahout her upper extremities, and what

is curiuus, tlieae patches undergo the most

marked eiianges, which alteniiite regularly

with copious diaiThosa, Of the two e\iiis my

patient pi'efem the diaiThiea.

I had aoiue misgivings when I comme:ieed

tliis [mper, about the poswibiUty of arranging

the matter which was floating about in my

brain, in a. form wbicli would convey to othei-s

4iny precipe opinions on iiritable skhis, and

whicli might to a shght extent cleai" the

ground of some of the obstacles which so

surely make the sultject of dermatology

obscure and unhiviting. This misgiving is

inteusifie«l hy a penisid of what I have

written. I am conscious that 1 have ad-

vanced but little, and what every gentleman

present kno^\'s as well ws I di> myself. But I

have tried to keep in view the causes of wliat

Is known as pnu'igo. Undoubtedly the no-

menclature of skin disease can be cairied by

ingenuity and research to a nuicli further

•extent than it now is; but is not tliis dividing

iind siili-dividing of classes most confusing {

IU4

I'liVliKiO.

It is for tliis veasou that I would asdc, Why

retain the word prurigo ? Clearly, it means an

itching, l)ut it is more in accordance with

common sense, If we get rid of these words,

which simply indicate a Ryinjitom, euch as

pmpina or (Uan'hcea, and the state we ai'e

?discussing to night. I have ventured to

put forward the belief, that we shall always

find iu all cases of itching skins an exciting

?cause. It is veiy different \vhere we have a

?clinical entity, such as psoriasis or eczema.

These wonls convey at once to our mind a

<;ontlition which is unique, and nothing but

?confusion would ensue, if we were to siibsti-

tute other woitIs for these, which have the

?simction of birth and anti(|uity.

I would sum up ray observations by the

following postulates, so that I may lia>'e tlie

advantage of the lai'ge experience of some of

the meml)ers of the Society assisting me : —

I. There is not such

III

pniviyo.

II. That all cases of Itching skins have

a recognizable ai n ! discoverable

cause.

all the gi'ouiJ of sym])ton]

PRURIGO. 105

'which are known as prurigo, are

the result of scratching, and are

simply symptoms.

IV. All scratched skins which have ad-

vanced to an elephantoid state,

and which have set up enlarge-

ment of lymphatic glands, are

beyond the reach of remedies or

hope.

V. That the pruriginous skin of chil-

dren, which progresses from birth

to puberty, when it stops, has

its origin in developing hair fol-

licles.

VI. That excessive itching does not

occur in those situations where

the hair grows luxuriantly.

VII. That what is known as winter

prurigo is due to imprisoned hairs.

VIII. That an irritable state of the skin

is always associated witli an irri-

table state of the nmcous and

synovial meml)ranes.

2197.84 .1. wuicjUT ani> «o., i'uintkkh, buistol.

8

lien 1-1/ Kimplait's PiihUcationx.

TOM IIOBIXSON, M.I).

Nocturnal Incontinence of Urine. l.«. I880J

SAMXJEL W. GROSS,

J-f^'

n jl/<(ii<.Y

A Practical Treatise on Impotence, SteriliJ

TV. AXD Ai,Ln;n Diwrdehs of thf "

ORtiASs. .Sccuml lOditinu. Flvii. 17-1 iiiiftfs. irii/i I

tllnatfitlimis. Is. Gd.

" Di'. OroBB ia n foi-oiblc uiul iuturestinwriter, nud he hes

w^sbiita, ill Bii attrootive style, very mnuh valuable inform&tioB ^_

The '([ueHtiou of Impotence and its numerous caiUM it exhiuia-

tivuly discussed. Ho i

PniatatoiTlice.1. TLit i:

be read by every no

Sprriiiltil.

a Sterility, BperinatorrhiBt .

Lusually valnablQ book, and must

thnronsli p!iy«iuiaii. " — A mericau

TOM IlOlilNSON. 1

On Baldness and Qreyness ; their Ktiologi

I'atliology, uiitl Treatment. Suoond Edition, nitid

t'lilnrgcd iind eiitirciy re-WTitten, Hmnll 8vo, 2s. 6d.

"Tilt rcHHUof a largo oxperieiioe.'' — Clieminl aiul Dmijgiet.

" 111 tbis (wpital little volume. Di-. Roiirasos, Pliysioi

St. John's Hospital for ISkiu DiaeaseB, givet ua a Very exluugtiM

account of the niiinan bair ; its sti-uctura, diseasea, and preaervM

tion. The Imok ia divided iuto seven chapters, devoted to tliff

anatomy, pbysiolwj', uolflur and textare, lUaeases and thuir

treatment, cosmetics, liair-wnaliea, depilatories, tc. The Inat

ahapter coutaiiia many nsefiil formula'. The work ia neatly Hot

up, is carefully written, and is well worthy of perusal."— .^otun/y

iaagn-JM qf Pharmitt;!, Jan., 1884.

Ilnu-n Klmpl-m>! P.ihUc.duw

FREEMAN J. BUM8TRAD akd 11. ^v. TAYLOlt.

Just [lublishwl. Fiftli I!iliti-i)i. ReviBei! ami Tte-written « [tlk

inany ad.lLLiniis. liiiyiil Svii, iiii. flOli, with i;i9 W'on.iuuts

The Pathology and Treatment of Venereal

DiSiiASKB. lly FbkKM.VX .1. BtSlsTKAJJ, M.D., litte

Profesfioi- nt Yeuei-eul Discuses nt tht CoUeji;e of

Physicians tiiid Stirgeous, New York ; and li. W,

Taylor, m.d., Pi'ofessor of Venereiil ninl Skiu Diw-

eases in thi; University of Vei-im.nt, ft;i-. Dtu. 1883.

" On foniier occosiniis wo Imve weluiutied tUu several txliti'tiw-

rif tliis admirable work ; luiil it is tiow uur very jileiuiaiit duty to

I't'cnmrnmiil mint higbly tUia tliu fiftli oilitiuii, revisnd mid rU'

\i ntten, with many wlditimis, by Dr. Toyloi-. Aa sii addition ti»

the illuetrSitions are two pages of chmmo-lilbogTaphic drawings,

ddinuiitiiitlie cbief venereal lesioua in a moBt accurate iiianiii.'r.

A i;bapter on sypliilia ftiid uiarringu li;is lie«n appended, (jiving

tlie best aihiceon this important question." — Ediiiliai-gh SMimf

Jouraal, Marcli, 1884.

" Wo do not iiesiUtto ev[.lt^as the l>elief Hint tliie is not

tiidy the best work in the Eii|jli«ih hiiij:nA|je upon the sulijeeta i>E

ii'luch it truttts, lint also one whieli haa no Hi|nal iu other tiiiiijnus

for its cluar. eMnpi-ehioiHive, mul pi'aotifu! LBudiiji|j of its

themes. Witli rospeut to the appearance of tlie Ixiuk, including

its typocmphy and iltustratioDS, we have merely tu cuuolnde hy

saj'iug thut the pnblisherH have done their tmrt witii their oucua-

toimed skill ainl task-." — --lim.-iw.n /f,"ri»i' of' llir Mr-'i^tt

dVioiCM, .lanuaj-y, I8S4.

"Reu^irdinu tli,iMiik ;i-l :. wlinle it ia uuulidantly MSBited that

ii'i rilu . -II -I M.I. ii , ... i.i wishes to learn how to recognise

i.i I . ! , ' tit venereal diseases, or to Jiave

.1.1 liii . .- ' : .1111.^: the latest and best viawB on

II.1.-.I i,i|. . i.i.i- .1.11.1 i.. n.-letittoread ami keep the latest

" Buinsteul's

reviewing. Tli . ,

hears mark of earefnl anil enidite preiiiration Must

take tii-Ht rank annni;: tlio works in the Kiiglish laiii'uaini on

Venereal DiBeasehi."-/.")-.W, -Inly aiM. 1880,

  • d

h

Ileiiiii Kimjil'm^t I'liUirntiuni,

Syph lis ta Mo b d Anatomy D agnosis

I nddi-

P h -UUBVI-

•a ui nu V Wh urer on

D % d D m cry in

U rs )i udsomc

of aJiii-

be Dserteil

ith tliu

Lol atum;.

tin both iu

ua tioieiioy


Author: Gina Verginis.

Reviewed: Saturday, May 15, 2010.


Further Information: Archive: Lectures On Acne, Acne Rosacea, Lichen and Prurigo — Dr. Tom Robinson : Domenico Ghirlandaio: An Old Man and His Grandson : Juliet in Shakespeare's Romeo and Juliet : Origin of the Word "Rosacea" : Rosaceae Plant Information : Vitis Vinifera Seed (Grape Seed) References :




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