Eczema of

the ears.

Eczema of the ears, in the majority of cases, is confined to the soft and tender skin lining their posterior aspect, which in an early stage gives rise to a thin discharge. This finally disappears, and leaves a few thin scabs on a red ground. The complaint is sometimes, however, seen in front of the ear, and it may block up the external meatus, and so interfere with the sense of hearing. It offers no special characters, but its locality is very pathognomonic. The same may be said of eczema of the lids, which is not an infrequent attendant upon ophthalmia.

CHAPTER VIII.

HERPES.

characters.

HERPES is the term or name employed to designate General a collection of vesicles, disposed in irregular patches, which vary in extent from the smallest size to several inches in diameter. The vesicles are commonly larger than those of eczema, and almost hemispherical in shape. The disease, after a certain course, terminates usually in resolution; and except in one species, is not contagious.

A frequent variety of simple herpes is herpes phlecty- Herpes phlectynodes, which may be often seen on the face or the cheek. nodes. Its earliest sign is shown by the appearance of a red spot, which somewhat smarts or tingles, and in the course of a few hours becomes covered with vesicles; of the latter, some remain small, while the majority rapidly enlarge. At the end of twenty-four or thirtysix hours, the vesicles are opaque, and as they burst the fluid concretes and forms crusts, which drop off, leaving only slight reddened discolorations. Herpes phlectynodes, or "brow shingles," will sometimes take place on the eyebrows or upper lid after an acute attack of ophthalmia. Of a similar character is herpes iris, Herpes iris. where concentric circles of vesicles are grouped around a single and central vesicle. It is in consequence of this disposition of the vesicles that the term iris is applied to the eruption.

Herpes of

When found on the tongue, or soft palate, it is only in the early stage that the disease is recognised; owing to the surface being constantly bathed with saliva, no crust can form. The thin mucous membrane is easily broken, and the superficial ulceration consequent upon it soon disappears.

Herpes of the prepuce is evidenced by a small group of the prepuce. vesicles, filled with serum, which soon dry and give rise to thin scabs. They are generally seen at the free edge of the prepuce, sometimes on its under surface, and seldom on the glands. The eruption is accompanied by slight itching, and occupies an extent of an average size of a threepenny piece. Situated on the mucous lining, the vesicles soon maturate and break, and thus cause a superficial excoriation, which, left to itself, is soft, and quickly heals. It is sometimes otherwise, if the complaint has been subjected to caustic treatment, in which case it is not always distinguished from a syphilitic sore. When on the integument, the scab mostly heals without any ulceration or enlargement of the glands at the groin. Herpes is less common in the female, and in this sex it is usually found on the labia, either after menstruation or in the course of pregnancy. Provided the complaint be not interfered with, herpes of the genitals rarely lasts beyond a few days, and is altogether a slight disease.

Herpes labialis.

Herpes labialis occurs on either lip, at the junction of the skin and mucous membrane, or at the angle of the mouth, or it may affect the greater part of the exposed mucous membrane of the lips, which is then raised like a series of blisters. Little inconvenience follows, unless the part be hot and swollen, which is the case sometimes. When confined to the corner of the mouth, the vesicles

are separate, and do not often suppurate. At the end of ten or fourteen days or less, the crusts lose their attachment at the circumference; they fall off, and no further inconvenience is felt.

zoster.

Herpes zoster or shingles, called by older writers St. Herpes Anthony's fire, or ignis sacer, is a well-marked vesicular eruption, more frequent in early life than advanced age. In most cases it follows the course of one of the intercostal nerves, not far from the vertebral column; or it may commence near the sternum. On the trunk,

the complaint is represented by several distinct patches, which are largest in their transverse diameter, and oblique in direction. They are successively evolved as so many red stains, which soon become studded with closely packed vesicles. These often attain a large size, equal to that of a pea, and are flattened at their summits from the pressure of the clothes or other causes. A slight pricking or burning pain precedes their first appearance, and in many cases some degree of constitutional disturbance is shown. Occasionally, severe dyspnoea will be a precursory symptom; the patient may complain of a "catching" pain when taking a deep inspiration, which might be mistaken for commencing pleurisy. Sometimes the clusters are so arranged as to resemble a belt or zone encircling one half of the body. Authorities widely differ as to the side which is most affected; thus, the occurrence of herpes zoster on the right side is mentioned by Cazenave and Schidel as having happened nineteen times out of twenty in their experience, whereas Rayer and Reil note the left as that most frequently attacked. The point is unimportant; but it is most rare to meet with herpes zoster completely encircling the body, an event which in former days was

I

Causes.

deemed a singularly bad omen to the patient. The zone is generally incomplete, being deficient at either extremity or the centre. Starting from the vicinity of the vertebral column, the eruption may pursue the track of one of the cutaneous nerves of the abdomen, of the thigh, or of the upper extremity; or one of the branches of the superficial plexus of the neck, or of the facial after its exit from the infra-orbital foramen. Less frequently do the supra-orbital or occipital nerves suffer in a similar manner. Any of them may however present at their periphery, or at various points in their course, a cluster of vesicles identical with herpes zoster of the trunk.

In the young and otherwise healthy subject, herpes zoster runs an acute and rapid course; the degree of constitutional disturbance varies in different cases, and sometimes is wholly absent. A young woman, aged 17 years, became a patient at the Hospital with herpes zoster of the left side. Many of the vesicles were single, and quite separate, while others were disposed in groups of three or four; the whole formed an unequal line from the sternum, and passed close under the nipple to the axilla, where a large patch was observed. The eruption was well developed, and of four days' duration. It was only by accident that the patient's attention was directed to the vesicles, which were unattended by any constitutional symptoms. In the aged, on the other hand, or in those in whom the health is much impaired, the scabs are apt to be succeeded by troublesome ulcerations, which are tedious in healing, and occasionally become the seat of acute neuralgia.

Herpes of the lips sometimes appears towards the close of a catarrhal affection, bronchitis or pneumonia, or fever intermittent or typhoid. The same discase will attack