Baths.

specific cause. In chronic or confirmed impetigo, mercury, in my experience, has proved of little advantage. Such cases mostly improve under arsenical treatment, the same precaution being taken in its administration as suggested when eczema and its sequence, impetigo, was considered in a previous chapter.

Acute impetigo, especially if of recent origin, is often relieved by simple remedies. Supposing the complaint to appear on the hand in a patient otherwise in good health, a mixture containing steel and from one to two drachms of the sulphate of magnesia for each dose, will generally suffice for internal treatment. Locally, the ammonio-chloride of mercury, a scruple to an ounce of lard, should be applied night and morning. In these cases it is very necessary that the hand be supported in a sling, and kept perfectly quiet, as long as the complaint continues. Nothing sooner lessens the amount of swelling. With respect to internal remedies, a method of treatment similar to that described above applies to other examples which are also acute, whatever their situation. As a rule, however, if the affected surface be of considerable size, a preparation of sulphur as a drachm of the precipitate to an ounce of lard with the addition of three or four grains of calomel, answers better as a local application than mercury alone. When impetigo involves the hair of the face, the latter should be cut close and the scabs removed before the ointment is used.

Sulphur baths, whether artificial or natural, are recommended by some writers for impetigo. Rayer speaks of them as suitable at any age, for the weak as well as for the strong. I cannot say that I place much faith in them, as impetigo is seldom a general disease

unless it be complicated with syphilis, when these baths can scarcely be expected to relieve it. For the sake of personal comfort, an ordinary water bath may be used, as often as occasion requires.

Whether in the old or young subject, and impetigo scabida may occur in both, the disease will usually be found to arise from a weakened state of the general health. It should always be our aim to improve the latter by means of bark with the sesquicarbonate of ammonia, or the chlorate of potash, if the patient has been already subject to mercurial treatment in excess; the ammonia, of which five grains for a dose will suffice, should not however be continued for more than ten days or a fortnight, as it is apt after a time to lose its effect. If the state of the urine exhibits any alkaline, or even a neutral tendency, we should do well to withhold it, and substitute for it from five to ten minims of dilute hydrochloric or nitric acid. In children, steel wine or some other preparation of iron is often more serviceable than vegetable tonics. It is very essential to remove the thickened adherent crusts of this disease.

In impetigo of the mucous membrane of the lips much benefit may be derived from the internal exhibition of mercury and arsenic, if the disease be met with at an early stage. The patient may also apply a mild form of mercurial ointment at night. In cases of relapse or in a chronic stage, it is more serviceable to resort to a lotion of this kind; acid nitrici dil. one drachm, liq. hydrargyri bichloridi one ounce, and water four ounces. With this the affected lip should be painted twice a day with a brush. In more severe instances, the acid nitrate of mercury seems to be the only local remedy which asserts any influence over the diseased surface.

Simple

rupia.

CHAPTER XII.

ECTHYMA AND RUPIA.

THE term ecthyma is used to notify a pustular disease of the skin; the pustules are large, "phlyzaceous," and encircled by a red and inflamed margin. Rupia rather signifies a complaint vesicular at its commencement, and which afterwards approaches in character to ecthyma. The close analogy between these affections has been remarked by nearly every writer since the time of Alibert; and as each disease pursues a similar course, we may regard them as one, divisible into the following kinds :-rupia simplex, rupia cachectica, and rupia escharotica.

Simple rupia or common ecthyma is not often attended by any constitutional symptoms, nor are the latter severe when they do occur. The pustules vary in size from a pea to a marble, and when first formed are like blind boils, attended by a slight shooting pain. For the first three or four days they increase in size, and then suppuration begins in the centre, but the swelling retains its surrounding hardness. At the end of about a week the pustule reaches maturity, and it either bursts or a greenish-yellow or dark scab is formed. If the latter be forcibly detached, much pain is felt and an ulcer is exposed, which becomes the seat of another scab. If allowed to remain, the crust usually falls off, and the ulceration is very slight. Sometimes

several scabs unite, as when the eruption is situated on the face, but as a rule they are distinct. The locality generally selected is the lower part of the loins or the inferior extremity, sometimes the neck and upper extremity, but rarely the face. In old patients the pustules are larger than in the young subject, and sometimes surrounded by a livid base, whence the name of ecthyma lividum applied to this species by Willan. The scabs occupy a long time in separating, and the skin around is hard and tender.

As a cachectic or syphilitic complaint, rupia, in the Cachectic or syphilitic majority of instances, commences as a small subcutaneous rupia. tubercle, which is smooth, shining, and of a pale red colour. There may be only a single growth of this kind, or a cluster; and should the general health give way, successive groups of tubercles will arise, and the complaint be observed in every stage. When the disease is confined to a single locality, a frequent situation is that near one of the larger joints, as the knee on its inner side; or the thigh immediately above it; or the front of the wrist. Sometimes the face, scalp, neck, or upper extremity is attacked, or the anterior aspect of the leg. The period at which suppuration takes place in the tubercles is uncertain; thus it may happen in a few days, or be delayed to several weeks. If a crust be allowed to form, it is deeply set and very adherent; beneath is an ulcer, which mostly varies in depth with the thickness of the scab over it. Should there be a group of ulcers, their average size is seldom more than about half an inch, but if occurring singly, the ulcer becomes often as large as a florin; and sometimes encloses a space of several inches in diameter. The edges are cleanly cut and circular, as though the part

Escharotic rupia.

had been scooped with a punch. On introducing a probe the margin is considerably undermined, and a dark red or purplish zone extends for some distance around it. Sometimes the affected surface shows a series of small and deep ulcers, filled with a sero-sanguineous fluid, which is offensive; or they contain a dark slough; or a tubercle is found at the base of the ulcer. As the disease improves under treatment the discharge diminishes, and becomes more healthy, but the skin does not recover itself and resume a natural condition; it is somewhat depressed, and long continues of a dark red colour. Besides the above characters, one or more points are to be noticed in connexion with the ulcers. Not only is the discharge from them commonly tinged with blood, but they are easily provoked to bleed. The disease is also apt to return. In chronic cases we often discover traces of the same malady in other parts of the body, or that an old cicatrix has given way. Much pain is experienced, although this symptom may be postponed to a later period. The bone sympathises, when the ulcer occupies the scalp, or is situated over the tibia; and sometimes so great is the pain in the latter case, especially towards night, that the patient can scarcely walk.

Rupia escharotica is the most severe of any variety. Occurring generally at an early age or in middle life, it is almost always associated with a bad state of the constitution. It begins as a dull red or livid spot, which soon becomes the seat of a dark sanious effusion. Whether the bleb bursts of its own accord, or is broken by accident, it discloses a deep and foul ulcer. children, rupia escharotica usually appears on the genitals, or the legs, or scalp. These are its usual situations. If extensively developed at this time of life it gives rise

In