few and far between, and that in gastric or hepatic disorder will he found to have preceded the eruption, especially where the herpes affects the tongue and mouth. Hydroa febrilis is too restricted, as fever is not necessarily the precursor of the eruption, and herpes phlyctoenodes has been used in a too widely differing a sense by authors to be applied satisfactorily to this form ; thus "Wilson (Ed. 1868) uses it for all forms of zoster not forming a demizone, whilst Fox (Ed. 1869) and others use it to designate a group which includes H. facialis and progenialis and zoster. The difference between zoster and this form, ag pointed out by Hebra, is, however, very marked; for in herpes facialis or symptomatic herpes, the eruption is more often central or irregularly bilateral than unilateral, is most often recurrent, is not preceded, accompanied, or succeeded by neuralgia, whilst the groups of vesicles are single, or but few in number, and are usually developed in the train of febrile (hydroa febrilis) or other complaints. On these grounds he does not consider that Barensprung is justified in classifying herpes facialis and progenialis as limited forms of zoster of the trigeminal and sacro-genital nerves. Hebra, however, considers those patches of herpes that occur on the trunk and limbs, and which are often known as II. phlyctoenodes, as limited zoster, but they seem in no way to vary from ordinary symptomatic herpes. In this form of herpes the hjpersemic patches are such
cases
most
or
are
exceedingly
all of them
some
smaller than in zoster, the vesicles fewer and smaller, and the ot each group shorter (4 or 5 days). Occasionally vesicles are not developed, and we have then a herpes sine
duration
vesiculis.
recognised to
exist
as
In the mouth the vesicular stage is with difficulty it is of short duration, and the vesicles soon cease
as
such, owing
left visible
being hypersemic
to the moisture of the parts, nothing excoriations on
but small whitish sodden
bases.
The first symptom is smarting and burning of the part, but this may be very slight; neuralgia there never is. The tendency of H. facialis is to recur at regular or irregular intervals. It is occasionally met with in children and others annually at certain seasons, or as in the case recorded in the Journal of Cutaneous Medicine (vol. 3, p. 200), it may return every four to six weeks, after once having originated in acute febrile catarrh. Herpes facialis may be either idiopathic or symptomatic, hut the latter is by far the most common, if indeed idiopathic herpes,
i.e., herpes independent of any disorder of the system, does occur, which, I think, is unlikely. Herpes of the mouth or tongue I have frequently suffered from, but it has invariably been connected with derangement of the hepatic functions ; in or gastric disorder I believe to be at the bottom of most idiopathic so called" cases. There is hardly a febrile complaint in the course of which herpes symptomatica may not occur. In Europe it is most frequently met with in connection with acute febrile catarrh, of which, according to Tilhury Fox, it forms an integral portion, and is then situated principally on the lips and nose. It also intermittent and remittent fever, in occurs in pneumonia, typhoid fever, in typhus fever according to Hebra (Barensprung denies this), erysipelas, cerebro-spinal meningitis, and according to Hutchinson in any inflammation of a shut sac. The simple passage of a catheter has been known to produce it, and Paget mentions H. progenialis as regularly following coitus. In this country it is more often seen during intermittent fever both amongst Europeans and Natives. The reason is manifest ;
fact, that
"
of the
ON HERPES. A. Garden, M.D., Civil Surgeon, Saharunpore.
(Concluded from page
Herpes
labialis
seu
facialis.
286
)
Hydroa febrilis.
This form of
confined ta the the face, and as it is not llP3, Hebra considers that H. facialis is the more appropriate tur?, though not the most commonly used, as it includes all the varieties met with in that position, II. nasalis, palpebralis, compreauricularis, and labialis. It is, however, hardly 'tiUsive enough, as the disease is frequently met with on the t0?Rue (H. linguae) and on the mucous membrane of the and gums, and fauces, hard and soft palate, cheeks on the neck and trunk, and on the penis as herpes progee^yn for ni?ilia. to me the best term,
'erpes is
met
with
on
facialis,
Pharynx,
Symptomatic herpes appears though all authors admit the existence of idiopathic cases, is that occurring in otherwise healthy persons, my own belief
intermittent and remittent fevers are far more common than acute febrile catarrh. the years 1869, 1870, and 1871. when malarious fever in this district, herpes facialis was by no means unfrequently met with amongst Europeans; but I can find notes
During
was
of
severe
very
only 2,
the
cases
which I shall quote further with amongst natives.
on
in connection with
met
In the dispensary
returns
only
23 cases are
recorded, but
I do
THE INDIAN MEDICAL GAZETTE.
314
not consider that these in any way represent the total number with, as all those which occurred during the course of ague, &c., in cases already under treatment, would not be specially
met
entered in the column of Sex.?Four a
smaller
hold
good
women
in the ratio of 17'3 per cent., that in zoster. Similar reasons
even
for the smallness of this
attend the
Age.?The Under
than
dispensary
ages were 10 yrs.
10 yrs. to 20 20 ? to 30
as
follows
...
?
...
?
...
9
...
3 6
..
that fewer
proportion, viz.,
men. :?
30 yrs. to 40 yrg. above 60 ?
...
3
...
2
As
his
beyond
prime.
the side affected, the record is unsatisfactory, inasmuch as it is left doubtful in 12 ; but as in 9 of these the lips
regards
were affected, we may ed in the middle line.
fairly
conclude that in them it was situat-
In 11 the side is mentioned?in 2 it left, and in 4 central.
was on
the
right,
in 5
on
the
Locality.?The distribution was as follows :? total cases 17, alone in 9, combined H. labialis, 2 H. facialis, 7 ,, ? ,, palpebralis, auricularis,
Not
8 5
?
5
?
1
?
4
3
,,
1
?
2
?
1
?
1
,,
is mentioned as affecting the mouth amongst people with weak digestions they
one case
though
in
?
H. nasalis. H. H.
From the above statement was
affected,
we
on one or
find that in 14
both
sides,
cases a
single
and that in 9 nerpes
in two or more places. In 14 cases it is noted as being symptomatic, once during convalescence from small-pox, and 13 times in connection with
appeared
attack of ague, ague. It is generally supposed, during any to occur only once, and then between the second and third paroxysms. In none of the cases is information on this point " given, after ague" being the only note ; and I can only find notes
rule, They
of 3 cases, which all seem to point to the fact that, as a it is developed early in the attack, and nothing more.
are as follows :? I. Mrs. G. suffered from tertian fever on the 11th, 13th, and On the 16th she took 25 grains of qui15th of August 1869. nine, and another paroxysm did not recur. On the 16th a red
patch appeared supra-trochlear
on
Soon after similar both
By
both upper
nerve.
eyelids
in the
JBoth conjunctivae
patches appeared
on
were
both
Before evening small vesicles were the 18th the whole had disappeared.
2.
lips.
Mr. H.,
a
great sufferer from ague,
tidian ague in October 1869.
wa3
position of the deeply injected. nostrils, and on developed on all.
attacked
by quosingle marked
On the first day a herpetic patch was developed on the right side of his chest. It disappeared in 4 or 5 days. It had none of the characteristics of zoster.
May 1870 the first paroxysm of an attack was accompanied patch of herpes on the right side of his neck. by In August 1870J on the day of the second paroxysm, a patch of herpes was developed on his right upper eyelid. On the fifth day, patches were seen on the sides of the nose. This case I consider of interest, as showing that symptomatic herpes need not be necessarily herpes facialis or progenialis. 3. M., aged 35, subject to ague. After the second paroxysm of an attack the disease was cut short by quinine. On the morning of the first day a herpetic patch was noticed in the position of the left supra-trochlear nerve, and vesicles were developed on the second day. The eyelid and face were much swollen, and there was much pain when the uerye was pressed. The febrile In a
similar
both had
was
most marked
preference for locality ; thus in
as
seem
the
eyelids
another
the left side.
on
patch w;is formed disappeared.
a
case
on
the
right
Oil the second side.
if malarial
symptomatic herpes
and
and for
nose,
day
four days
In
more
had
than one
I find it recorded that both
eyelids,
botli sides of the nose, both lips, and the chin were affected. Though pneumonia is by no means a rare disease in these parts, 1 cannot find a note of symptomatic herpes in connection
and Gazette, February 1862 :?" Dr. Geissler of Leipzig regards the occurrence of herpes in pneumonia as a favorable sign. In 421
herpes was observed 182 times; and of 87 cases fatally herpes only occurred in 17, and was not observed in 70. The herpes appeared in two-thirds of the cases on the second, third and fourth days, and in one-third of the entire number on the third day alone. These three days were proportioned as one, three, two, and the fifth day was as the second; so that 80 per cent, of all the instances of herpes fell on these four days, and 20 per cent, on other days, no case having occurred on the first. The herpes which appeared on the third day had least relation to a favorable prognosis, that occurring on the second and fourth days the most" (Froriep's Notozen, 1861). Other authors also look on the occurrence of herpes during pneumonia as a favorable omen, but Ilebra denies this, stating cases
which terminated
that
tongue, are by no
or
means uncommon.
locality
similar
with it, though in Europe its occurrence is frequent and marked. The following interesting note is taken from the Medical Times
The youngest was one year old, and the oldest 82. As far as such limited figures go, we may assume that the young and middle aged are more liable than the old, remembering that at 40 the native is
a
It would almost
diagnosis. females, or
only were proportion than
headache
1874.
[December 1,
no
inference
as
to
the end
be drawn from it
can
one
way
or
another.
Herpes prceputialis
seu
progenialis.?Thb
form is met with on
the penis, either on the glans, prepuce, or body, but most often on the prepuce. It is also met with in the female genital organs. Desormeaux thinks that some cases of urethritis may depend on herpes of the urethral lining membrane. The patches are
small,
and the vesicles few, and it lasts only for a few days ; are not injured, when the crusts fall nothing
and if the vesicles but
red surface is left.
If the vesicles
injured
excori-
ations difficult to heal may remain. Usually, but not the eruption is preceded by a considerable amount of
always, burning
a
are
smarting. by no means a common complaint, as only eight cases were registered during the five years, and this is the more remarkable considering the amount of syphilis that exists amongst the natives. Possibly it may depend on the fact of the great preponderance of hard chancres, and severe constitutional syphilis amongst natives, and herpes progenialis never follows them. In four cases it was situated on the body of the penis, in three on the prepuce, and in one on the glans. Desormeaux, as before noticed, thinks it may occur on the urethral mucous membrane, and I have seen recently two cases in which it seemed to or
It is
that it was the urethra in children.
me
child, aged
cause
of contraction of the orifice of the
In one, which occurred quite lately, the 6, was brought on account of difficulty in passing The The stream of water wits the size of a thread.
his urine. orifice of the urethra
was concealed by two small vesicles on inflamed base. This disease had been in progress for 18 months, but no information could be gained from iiis parents about its details. As regards the iiges of the eight patients, the youngest was 1$ an
years and the oldest 72 years; the other six being between 30 and 50 years. No note is made as to recurrence, and only one is recorded as syphilitic; but I believe that most of them were so, as probably nearly all cases are. The best worK on this a
subject
review of which will be found
is
probably that of M. Doyon, journal of Cutaueoua
in the
Medicine, vol. 2, p. 280. The title of the work is "De' 1' herpefl recidivant des parts genitules," and the following note is taken from the review above named.
December 1, 1874.]
ON HERPES.?BY A. GARDEN".
-Aft>t a venereal affection of the genital organs, of whatever a cluster of i vesicles of herpes makes its appearance, and
which
315
undergo compression by that artery when in a state during a rigor. It will in no lecurs and very regularly, at the end of every way account for the occurrence of herpes on parts where the periodically, tW0 En?iiths, for a number of years. The eruption shows itself nerve does not run through such a bony channel, nor for the in close proximity with the seat of the foregone disease; it lasts occurrence of herpes at only a particular period of a disease, e.g.y a period of five or six days, and terminates spontaneously by as generally stated between the second and third paroxysms If the rigors were most marked, then and without leaving a trace of cicatrix behind. of intermittent fever. Js most there might be- some reason in it, but there is no necessary common in succession to soft chancre, and next to gonorihoea. It never succeeds indurated, chancre', and as it never relation between the number of the paroxysm and the severity 11
can
of dilatation after contraction
^tsquamation
?CCUIS
independently
of the fever in any of its stages. The French attempt to simplify matters by admitting the influence of certain diatheses, the arthritic, the herpetic or dartrous, the scrofulous, and the syphilitic. Bazin considers that
of venereal disease, its appearance may be
as Regarded n) and
diagnostic of a previously existing venereal affecnotably of a kind that does not give rise to contamination of the system." It shows itself first two or three weeks after the healing of the venereal sore, on or near the cicatrix, and its site of election is
herpes belong to the arthritic group, placing prseputialis under the arthritides comnrines, II. circinatus and iris under arthritides pseudoexanthematique vesiculeuse, and zona and hydroa febrilis under a new division, the pseudexantheme idiopathique. M. Panot (Gaz. Hebd. VIII, the different kinds of H. labialis and
situated within a radius of inch round this, until late in the ? w^en it may extend further, and it is never seen beyond eaS6'. th
genital organs. It is most frequently seen after soft chancre 6 lnucous SUI"face of the prepuce. It is usually bi-mensual Ist, but the periods are longer later on, and may be inenced by constitution and habits. Occasional coitus is a *nost frequent cause of relapse when the period of attack is ''ear, whilst frequent coitus is not. Its duration is five or six ^
prove that there is a morbid condition to the name of " Herpetic Fever," under which should be included the majority of cases described as synochial, ephemeral, gastric, and other fevers (fievre angiotenuque
374) attempts
fi
at
(Hardy says eight), syphilis, whilst in itself it constitutional affection. eat
and
itching
which he
augine herpetique) ; that this morbid condition is characterby the presence of various herpetic eruptions, and by an acute lobu lar pneumonia, to which the name herpetic pneumonia should be given ; that the whole of the affections named have a and
ised
and hence it cannot be mistaken for is pathognomonic of the absence of
bond in the disturbance of the nervous system, and that in febrile affections the appearance of herpes is almost always a favorable prognostic sign" (Sydenham Society's Tear Book, common
mark the onset of the disease.
ever, that the absence of itching is
a
Hardy says, diagnostic symptom.
2^11 30 hours the itching is followed by red puncta, from the entre of each of which rises up a minute papule, which is converted in.o a vesicle. Small scales are left when ury up. As regards the etiology, he ridicules the
Rapidly
upposed influence of friction, dirt, discharges, stricture, Cu
or
us ns
irritants. The cause the prolonged irritation Vt'nereal affection, sometimes of gonorrhoea in a person ^nr*10U8 diathesis. Tlle Pathology of symptomatic herpes as yet wants the light
0?
.
"
?n
and microscopic is contained e paragraph from Hebra :?" Hence, if we choose ^ apply what is true of H. zoster to the other forms of herpes ?> it appears probable that the Varied diseases above referred ^? (some of which are whilst others are amongst ob
by post-mortem
zoster
>
t-rvations,
and all that
can
be said
on
the
subject
following
inflamatory disorders) all generate this peculiar skin by acting on the peripheral nervous system." Beyond 8 we cannot go, nor is it possble to tell the connection w een the various remote causes and the eruption itself, ttUch les8 why one part should be more often affected than e
so-called
nervous
ection
am,ther. Tilbury Fox indeed says : "In almost all cases we enabled to understand how it is that the irritation is ?
are
reflected along 0
going to the exact locality "When catarrh affects the sensitive membrane of the air passages, the occurrence of rpes of the lip or nose c:in be readily understood; the play ? cold air (chilling) or the direct application of cold to a a'ed surface will account for the appearance of H. phlyctoe'?des; herpes pneputialis has come after an emission, after and after other irritation of the urethral mucous the
jnncous
connection, Membrane; e
the
nerve
trunks
herpetic eruption.
leave no doubt as to the co? regularly ation. The now been passage of a catheter has before V a rigor and herpes lahiulis. Tnere i3 no great iu this latter occurrence. The only (the
difficulty
so
so
as
to
admitting
1tulica are mine) point on which we require enlightenment is *kat which concerns the why and the wherefore of the reflection the nerves, that go to the lips, and I may add nose, cheeks, ear, eyebrows, neck, chest, tongue, &c.
Even Gerhardt'8 ingenious explanation so often quoted by authorities on the subject will only answer for certain nerves, which are confined in restricted channels with arteries, and
to
gives
1871-72. p. 175). Our summing up
must, I think, be that the why and the
wherefore of herpes has yet to be determined, whilst we may admit that in itself it is a neurotic affection. As regards diagnosis, I do not think that it is necessary
to say anything as regards symptomatic herpes. Syphilitic prceputial herpes, however, as pointed out by Hebra, may It is sometimes impossible to determine involve more doubt. whether we have to deal with a simple herpes or syphilitio affection. This doubt, however, according to Doyon, can last but a short time, and whenever it occurs the diagnosis should not be finally given until after six to eight days. I he prognosis is a matter of no doubt, and belongs more to the original disease than the herpes, which subsides in a few days. With regard to treatment, the expectant is the best in all forms The disease is so mild 'that nothing but herpes progenialis. need be attempted in ordinary herpes. In II. progenialis, M. Doyon lays down the principles of treatment as consisting in five points?(1) to harden the skin and mucous membrane, and thereby remove its morbid sensibility, by the application of dry lint between surfaces that touch, by exposure to the air, and by the application of astringents, tannin, alum, sulphate of zinc, acetate of lead, perchloride of iron, aromatic wine, tincture of matico or rhatany, dusting with calomel, camphor, lycopodium, or starcti, or glycerine of tannin, sixteen grains to an punce. But tannific ition, he admits, is not likely to come up to the expectations of the Sur-
geon ; derivatives he does not approve of. To modify the exciting causes he recommends moderation and regularity, and not abstinence, and he relies on certain
marriage
of cure. As the disease is constantly associated with debility and irritability, he recommends tonics. He says the disease He warns against the use of mercury. is not venereal, and is connected with venereal disease only as far as that is the excitant. as
a
means
Herpes Iris et Circinatus. (Hebra). Herpes Circinatus. (Willan, Wilson, Fox, Neumann, &c.) Herpes Iris. (All modern authors but Bazin, who names it
Hydroa vesiculeus).
THE INDIAN MEDICAL GAZETTE.
316
Hebra considers that H. circinatus is only an advanced stage of H. iris, in which the development continues at the circumference, whilst the central groups of vesicles have undergone
involution, leaving nothing within the vesicular margin surface, the seat of pigment or of scales, or restored to its normal condition. The distinction, however, between H. circinatus and iris is based on good grounds, for cases are undoubtedly met with in which the central vesicle is not formed and the erythematous patch has reached a considerable size before the vesicles are formed. In this country they are rather their but
a
more
common
than true H. iris.
Herpes circinatus differs from herpes phlyctenodes in the fnct a central surface left clear from vesicles. According to Wilson it most often commences in the night, with
tingling, itching, and smarting followed by hyperaemic patches, small at first, but rapidly extending they reach the size of one
to
two inches
or
more
in diameter.
be slightly depressed in the centre, and with
It is then found to a
further extension
the color in the centre is changed and becomes yellowish, and The border is somewhat raised above the a ring is formed. level of the general surface, and is somewhat lighter in tint. On this margin the vesicles are produced ; they rapidly dry up, and at the end of four or five days there is nothing but With this the redness disappears, brownish or black scabs. As this and in a few days there is no mark of the disease.
only one in a succession of outbreaks of the eruption, the disease may continue for ten or twelve days, or longer, as in the case which Wilson mentions as not being well at the end As modifications, Wilson mentions red patches of two months.
is
interspersed amongst the others without any vesicles (herpes sine vesiculis), and others in which one large bulla is. formed. He has noticed this herpes circinatus bullosus twice associated with pregnancy. Hardy has described it as Pemphigus pruriginosus. The eruption may be very general, as in the case mentioned by Wilson, but it is by no means necessarily or generally so. Fox says he has seen it in the neck, face, and forehead. Bazin states that its seat is on the trunk, especially chest and the neck, and rarely oil the anterior part of the He also says that it is usually preceded by on the face. general malaise and anorexia, febricula, and pricking sensations in the part; but these symptoms are slight, and disappear with the appearance of the eruption. He mentions also that several
circles may meet at the circumference \ and he says that the duration is 21 days or more. The total number treated at the Dispensary was 15, 11 males and 4 femaleS, or in the ratio of 26 6 per cent of females. The ages varied much, from 7 months to 72 years. Of the 15 the ages were : Under 5 years 1; 5 years to 10 years, 2; 10 years to 20 years, 3; 20 years to 30 years, 3 ; 30 years to 40 years, 4; 40 ?
cases
50 years, 1; above 50 years, 3; so that the disease appears to be one of middle and advanced life. The patches were developed on the neck and trunk in 6 cases; on the face in 1 ; on the upper extremities in 4 ; and
Tears
to
the lower extremities in 2 ; on arms and legs in 1, and the is not mentioned in 1. In the majority the duration was about a month. The number of patches was in -only two or three of the cases very
so on
It has
by syphilitic treatment; it is symmetrical, and accompanied by special concomitant evidences of syphilitic infection. Herpes iris is looked on by Wilson as an abated.form of II. circinatus. It occurs very often on the backs of the hands of elderly persons, and the patches and vesicles are small. On the limbs the central vesicle is often a bulla. An inflamed disc or spot first makes its appearance, the day
vesicle
or
bleb, whilst
a
no
ring
diminishes
constitutional symptoms, and is always associated Tilbury Fox considers it an unimportant variety,
debility.
and with truth. Hebra give3 the duration as 15 days for a single complete involution, or 30 if consecutive rings are formed. It has a tendency to recur at tho same season each year It may be very chronic, ring after ring succeeding each other with intermissions of various duration, as in the following case : M., aged 25, weak and anaemic. The disease commenced two months ago on the back of the right arm. This spot reached a
diameter of 2| inches one way and 2 inches the other. At 1 873) the skin is reddish-colored, and has not
present (January
resumed its natural tint. Twelve days ago a second
patch commenced, and the diameter The inner vesicle has dried up. In the outer ring the vesicles are coalescent. He was treated with quinine. On March 1st, he returned and stated that his arm remained is
now
1'9 inches.
well for
a
appeared
on
fortnight, the left
and that then He
arm.
was
(10 days ago) a fresh patch again treated with quinine
and tonics. In another case, in a youth 18 years of age, it had recurred annually for 10 years, and continued through the hot months? March, April, May, and June. The former patches were marked, not by excess but by diminution in pigmentation, an unfrequent circumstance. The and legs, a few on the body, slight itching, then a red patch with single large vesicle which dried up in four days. Around this, successive circular rings, which ultimately joined neighbouring patches. The crusts did not fall for a month, and then leave a red surface. The man was dyspeptic and out of health. Twelve cases were treated in the dispensary, and all were
patches appeared
none on
the facc.
on
the
arms
At first
males. The ages were as under :? Under 10 years, 3 ; 10 years to 20 years, 4 ; 20 years to 30 years, 1 ; 30 years to 40 years, 3; 40 years to 50 years, 1. Only one case was observed on the chesi, and the rest on the extremities ; five omthe hand and arm ; six on the foot and leg. On the backs of the hands there were of the feet three.
positions, viz., (1)
upper arms and thighs ; very rarely on the face.
The
diagnosis, like very difficult,
and
on
the dorsa
quite
(3) (5)
means
four;
agrees witli what Hebra gives ns hands and feet; (2) forearms and legs;
This
the
(4) exceptionally
on
the trunk;
in the other forms of herpes, is by no if ordinary care is taken. The only dis-
with which it can be mistaken is Tinea circinata, which great justice considers as the proper term for the
T. Fox with
cured
until the
size of the vesicles
ease
'
a
has attained its full size. The as the disease proceeds. In elderly persons it may never become vesicular, and remain in the condition of erythemic iris (Wilson). 13ulla) may be formed, and then there is a pemphigus iris.
border, and
position
Hebra says it is most frequently met with in the young. This will be seen to be the case as regards H. iris, but as above noted, it is certainly not in H. circinatus. 4 Tilbury Fox notices a chronic form of syphilitic nature and
by
border of red appenrs round its circumference ; on the third day this narrow border is turned into a vesicular ring, and the redness has crept on for another stage, forming another red
in
extensive.
covered
1874
narrow
with
that in it there is
this disc is
following
[December 1,
Tinea circinata is the
parasitic form. the body, and
ordinary ring-worm of
in certain stages presents a true herpetic charac* ter; but in this country the vesicular stage is by no means common or marked. Any one can satisfy himself of this by
studying the dadli" of the natives, especially in the rains. In my experience, it is extremely rare to meet a fresh case* and only in these could any mistake be made. In the chronic cases, the remains of previous years' growth of the trichophyton tonsurans are sufficiently marked indications of true nature of the disease. In a few of these cases vesicle? do at times appear in the fresh growing margin, hut they ore' as a rule, small, and quite unlike herpes. Even in fresh cases*' where an erythematous herpetic-looking patch is seen, the microscope will determine the nature of the disease. "
OF THE SKULL DscraiBt* 1, 1874.] SEVERE INJURIES As
in
-As is
there is nothing to be said, they are both II. circinatus and H. iris, non-fatal diseases. said is, that there cause, the only thing that can be
regards prognosis,
themselves, regards
general debility, nutritive
Treatment.?In
or
nervous.
affections
dependent given to remedy
on
general debility,
our
?first attention must be the constitutional defect. .Quinine, arsenic, mineral acids and bitter tonics are all of
advantage.
and
buf with natives after it cod-liver oil.
always
used and
good As
diet is the first of all for local
remedies, applications, I have
been satisfied with the benzoated zinc oint-
ment, the present ling, zinci of the London pharmacopoeia.
Itching
and
irritation may be
allayed by
cyanic acid in emulsion of bitter almonds. 1rntant treatment ia to be avoided.
-August 2nd,
1874.
a
lotion of hydroAny thing like
& BRAIX.
BY E. A. BIRCII.
317
cases
most
or
are
exceedingly
all of them
some
smaller than in zoster, the vesicles fewer and smaller, and the ot each group shorter (4 or 5 days). Occasionally vesicles are not developed, and we have then a herpes sine
duration
vesiculis.
recognised to
exist
as
In the mouth the vesicular stage is with difficulty it is of short duration, and the vesicles soon cease
as
such, owing
left visible
being hypersemic
to the moisture of the parts, nothing excoriations on
but small whitish sodden
bases.
The first symptom is smarting and burning of the part, but this may be very slight; neuralgia there never is. The tendency of H. facialis is to recur at regular or irregular intervals. It is occasionally met with in children and others annually at certain seasons, or as in the case recorded in the Journal of Cutaneous Medicine (vol. 3, p. 200), it may return every four to six weeks, after once having originated in acute febrile catarrh. Herpes facialis may be either idiopathic or symptomatic, hut the latter is by far the most common, if indeed idiopathic herpes,
i.e., herpes independent of any disorder of the system, does occur, which, I think, is unlikely. Herpes of the mouth or tongue I have frequently suffered from, but it has invariably been connected with derangement of the hepatic functions ; in or gastric disorder I believe to be at the bottom of most idiopathic so called" cases. There is hardly a febrile complaint in the course of which herpes symptomatica may not occur. In Europe it is most frequently met with in connection with acute febrile catarrh, of which, according to Tilhury Fox, it forms an integral portion, and is then situated principally on the lips and nose. It also intermittent and remittent fever, in occurs in pneumonia, typhoid fever, in typhus fever according to Hebra (Barensprung denies this), erysipelas, cerebro-spinal meningitis, and according to Hutchinson in any inflammation of a shut sac. The simple passage of a catheter has been known to produce it, and Paget mentions H. progenialis as regularly following coitus. In this country it is more often seen during intermittent fever both amongst Europeans and Natives. The reason is manifest ;
fact, that
"
of the
ON HERPES. A. Garden, M.D., Civil Surgeon, Saharunpore.
(Concluded from page
Herpes
labialis
seu
facialis.
286
)
Hydroa febrilis.
This form of
confined ta the the face, and as it is not llP3, Hebra considers that H. facialis is the more appropriate tur?, though not the most commonly used, as it includes all the varieties met with in that position, II. nasalis, palpebralis, compreauricularis, and labialis. It is, however, hardly 'tiUsive enough, as the disease is frequently met with on the t0?Rue (H. linguae) and on the mucous membrane of the and gums, and fauces, hard and soft palate, cheeks on the neck and trunk, and on the penis as herpes progee^yn for ni?ilia. to me the best term,
'erpes is
met
with
on
facialis,
Pharynx,
Symptomatic herpes appears though all authors admit the existence of idiopathic cases, is that occurring in otherwise healthy persons, my own belief
intermittent and remittent fevers are far more common than acute febrile catarrh. the years 1869, 1870, and 1871. when malarious fever in this district, herpes facialis was by no means unfrequently met with amongst Europeans; but I can find notes
During
was
of
severe
very
only 2,
the
cases
which I shall quote further with amongst natives.
on
in connection with
met
In the dispensary
returns
only
23 cases are
recorded, but
I do
THE INDIAN MEDICAL GAZETTE.
314
not consider that these in any way represent the total number with, as all those which occurred during the course of ague, &c., in cases already under treatment, would not be specially
met
entered in the column of Sex.?Four a
smaller
hold
good
women
in the ratio of 17'3 per cent., that in zoster. Similar reasons
even
for the smallness of this
attend the
Age.?The Under
than
dispensary
ages were 10 yrs.
10 yrs. to 20 20 ? to 30
as
follows
...
?
...
?
...
9
...
3 6
..
that fewer
proportion, viz.,
men. :?
30 yrs. to 40 yrg. above 60 ?
...
3
...
2
As
his
beyond
prime.
the side affected, the record is unsatisfactory, inasmuch as it is left doubtful in 12 ; but as in 9 of these the lips
regards
were affected, we may ed in the middle line.
fairly
conclude that in them it was situat-
In 11 the side is mentioned?in 2 it left, and in 4 central.
was on
the
right,
in 5
on
the
Locality.?The distribution was as follows :? total cases 17, alone in 9, combined H. labialis, 2 H. facialis, 7 ,, ? ,, palpebralis, auricularis,
Not
8 5
?
5
?
1
?
4
3
,,
1
?
2
?
1
?
1
,,
is mentioned as affecting the mouth amongst people with weak digestions they
one case
though
in
?
H. nasalis. H. H.
From the above statement was
affected,
we
on one or
find that in 14
both
sides,
cases a
single
and that in 9 nerpes
in two or more places. In 14 cases it is noted as being symptomatic, once during convalescence from small-pox, and 13 times in connection with
appeared
attack of ague, ague. It is generally supposed, during any to occur only once, and then between the second and third paroxysms. In none of the cases is information on this point " given, after ague" being the only note ; and I can only find notes
rule, They
of 3 cases, which all seem to point to the fact that, as a it is developed early in the attack, and nothing more.
are as follows :? I. Mrs. G. suffered from tertian fever on the 11th, 13th, and On the 16th she took 25 grains of qui15th of August 1869. nine, and another paroxysm did not recur. On the 16th a red
patch appeared supra-trochlear
on
Soon after similar both
By
both upper
nerve.
eyelids
in the
JBoth conjunctivae
patches appeared
on
were
both
Before evening small vesicles were the 18th the whole had disappeared.
2.
lips.
Mr. H.,
a
great sufferer from ague,
tidian ague in October 1869.
wa3
position of the deeply injected. nostrils, and on developed on all.
attacked
by quosingle marked
On the first day a herpetic patch was developed on the right side of his chest. It disappeared in 4 or 5 days. It had none of the characteristics of zoster.
May 1870 the first paroxysm of an attack was accompanied patch of herpes on the right side of his neck. by In August 1870J on the day of the second paroxysm, a patch of herpes was developed on his right upper eyelid. On the fifth day, patches were seen on the sides of the nose. This case I consider of interest, as showing that symptomatic herpes need not be necessarily herpes facialis or progenialis. 3. M., aged 35, subject to ague. After the second paroxysm of an attack the disease was cut short by quinine. On the morning of the first day a herpetic patch was noticed in the position of the left supra-trochlear nerve, and vesicles were developed on the second day. The eyelid and face were much swollen, and there was much pain when the uerye was pressed. The febrile In a
similar
both had
was
most marked
preference for locality ; thus in
as
seem
the
eyelids
another
the left side.
on
patch w;is formed disappeared.
a
case
on
the
right
Oil the second side.
if malarial
symptomatic herpes
and
and for
nose,
day
four days
In
more
had
than one
I find it recorded that both
eyelids,
botli sides of the nose, both lips, and the chin were affected. Though pneumonia is by no means a rare disease in these parts, 1 cannot find a note of symptomatic herpes in connection
and Gazette, February 1862 :?" Dr. Geissler of Leipzig regards the occurrence of herpes in pneumonia as a favorable sign. In 421
herpes was observed 182 times; and of 87 cases fatally herpes only occurred in 17, and was not observed in 70. The herpes appeared in two-thirds of the cases on the second, third and fourth days, and in one-third of the entire number on the third day alone. These three days were proportioned as one, three, two, and the fifth day was as the second; so that 80 per cent, of all the instances of herpes fell on these four days, and 20 per cent, on other days, no case having occurred on the first. The herpes which appeared on the third day had least relation to a favorable prognosis, that occurring on the second and fourth days the most" (Froriep's Notozen, 1861). Other authors also look on the occurrence of herpes during pneumonia as a favorable omen, but Ilebra denies this, stating cases
which terminated
that
tongue, are by no
or
means uncommon.
locality
similar
with it, though in Europe its occurrence is frequent and marked. The following interesting note is taken from the Medical Times
The youngest was one year old, and the oldest 82. As far as such limited figures go, we may assume that the young and middle aged are more liable than the old, remembering that at 40 the native is
a
It would almost
diagnosis. females, or
only were proportion than
headache
1874.
[December 1,
no
inference
as
to
the end
be drawn from it
can
one
way
or
another.
Herpes prceputialis
seu
progenialis.?Thb
form is met with on
the penis, either on the glans, prepuce, or body, but most often on the prepuce. It is also met with in the female genital organs. Desormeaux thinks that some cases of urethritis may depend on herpes of the urethral lining membrane. The patches are
small,
and the vesicles few, and it lasts only for a few days ; are not injured, when the crusts fall nothing
and if the vesicles but
red surface is left.
If the vesicles
injured
excori-
ations difficult to heal may remain. Usually, but not the eruption is preceded by a considerable amount of
always, burning
a
are
smarting. by no means a common complaint, as only eight cases were registered during the five years, and this is the more remarkable considering the amount of syphilis that exists amongst the natives. Possibly it may depend on the fact of the great preponderance of hard chancres, and severe constitutional syphilis amongst natives, and herpes progenialis never follows them. In four cases it was situated on the body of the penis, in three on the prepuce, and in one on the glans. Desormeaux, as before noticed, thinks it may occur on the urethral mucous membrane, and I have seen recently two cases in which it seemed to or
It is
that it was the urethra in children.
me
child, aged
cause
of contraction of the orifice of the
In one, which occurred quite lately, the 6, was brought on account of difficulty in passing The The stream of water wits the size of a thread.
his urine. orifice of the urethra
was concealed by two small vesicles on inflamed base. This disease had been in progress for 18 months, but no information could be gained from iiis parents about its details. As regards the iiges of the eight patients, the youngest was 1$ an
years and the oldest 72 years; the other six being between 30 and 50 years. No note is made as to recurrence, and only one is recorded as syphilitic; but I believe that most of them were so, as probably nearly all cases are. The best worK on this a
subject
review of which will be found
is
probably that of M. Doyon, journal of Cutaueoua
in the
Medicine, vol. 2, p. 280. The title of the work is "De' 1' herpefl recidivant des parts genitules," and the following note is taken from the review above named.
December 1, 1874.]
ON HERPES.?BY A. GARDEN".
-Aft>t a venereal affection of the genital organs, of whatever a cluster of i vesicles of herpes makes its appearance, and
which
315
undergo compression by that artery when in a state during a rigor. It will in no lecurs and very regularly, at the end of every way account for the occurrence of herpes on parts where the periodically, tW0 En?iiths, for a number of years. The eruption shows itself nerve does not run through such a bony channel, nor for the in close proximity with the seat of the foregone disease; it lasts occurrence of herpes at only a particular period of a disease, e.g.y a period of five or six days, and terminates spontaneously by as generally stated between the second and third paroxysms If the rigors were most marked, then and without leaving a trace of cicatrix behind. of intermittent fever. Js most there might be- some reason in it, but there is no necessary common in succession to soft chancre, and next to gonorihoea. It never succeeds indurated, chancre', and as it never relation between the number of the paroxysm and the severity 11
can
of dilatation after contraction
^tsquamation
?CCUIS
independently
of the fever in any of its stages. The French attempt to simplify matters by admitting the influence of certain diatheses, the arthritic, the herpetic or dartrous, the scrofulous, and the syphilitic. Bazin considers that
of venereal disease, its appearance may be
as Regarded n) and
diagnostic of a previously existing venereal affecnotably of a kind that does not give rise to contamination of the system." It shows itself first two or three weeks after the healing of the venereal sore, on or near the cicatrix, and its site of election is
herpes belong to the arthritic group, placing prseputialis under the arthritides comnrines, II. circinatus and iris under arthritides pseudoexanthematique vesiculeuse, and zona and hydroa febrilis under a new division, the pseudexantheme idiopathique. M. Panot (Gaz. Hebd. VIII, the different kinds of H. labialis and
situated within a radius of inch round this, until late in the ? w^en it may extend further, and it is never seen beyond eaS6'. th
genital organs. It is most frequently seen after soft chancre 6 lnucous SUI"face of the prepuce. It is usually bi-mensual Ist, but the periods are longer later on, and may be inenced by constitution and habits. Occasional coitus is a *nost frequent cause of relapse when the period of attack is ''ear, whilst frequent coitus is not. Its duration is five or six ^
prove that there is a morbid condition to the name of " Herpetic Fever," under which should be included the majority of cases described as synochial, ephemeral, gastric, and other fevers (fievre angiotenuque
374) attempts
fi
at
(Hardy says eight), syphilis, whilst in itself it constitutional affection. eat
and
itching
which he
augine herpetique) ; that this morbid condition is characterby the presence of various herpetic eruptions, and by an acute lobu lar pneumonia, to which the name herpetic pneumonia should be given ; that the whole of the affections named have a and
ised
and hence it cannot be mistaken for is pathognomonic of the absence of
bond in the disturbance of the nervous system, and that in febrile affections the appearance of herpes is almost always a favorable prognostic sign" (Sydenham Society's Tear Book, common
mark the onset of the disease.
ever, that the absence of itching is
a
Hardy says, diagnostic symptom.
2^11 30 hours the itching is followed by red puncta, from the entre of each of which rises up a minute papule, which is converted in.o a vesicle. Small scales are left when ury up. As regards the etiology, he ridicules the
Rapidly
upposed influence of friction, dirt, discharges, stricture, Cu
or
us ns
irritants. The cause the prolonged irritation Vt'nereal affection, sometimes of gonorrhoea in a person ^nr*10U8 diathesis. Tlle Pathology of symptomatic herpes as yet wants the light
0?
.
"
?n
and microscopic is contained e paragraph from Hebra :?" Hence, if we choose ^ apply what is true of H. zoster to the other forms of herpes ?> it appears probable that the Varied diseases above referred ^? (some of which are whilst others are amongst ob
by post-mortem
zoster
>
t-rvations,
and all that
can
be said
on
the
subject
following
inflamatory disorders) all generate this peculiar skin by acting on the peripheral nervous system." Beyond 8 we cannot go, nor is it possble to tell the connection w een the various remote causes and the eruption itself, ttUch les8 why one part should be more often affected than e
so-called
nervous
ection
am,ther. Tilbury Fox indeed says : "In almost all cases we enabled to understand how it is that the irritation is ?
are
reflected along 0
going to the exact locality "When catarrh affects the sensitive membrane of the air passages, the occurrence of rpes of the lip or nose c:in be readily understood; the play ? cold air (chilling) or the direct application of cold to a a'ed surface will account for the appearance of H. phlyctoe'?des; herpes pneputialis has come after an emission, after and after other irritation of the urethral mucous the
jnncous
connection, Membrane; e
the
nerve
trunks
herpetic eruption.
leave no doubt as to the co? regularly ation. The now been passage of a catheter has before V a rigor and herpes lahiulis. Tnere i3 no great iu this latter occurrence. The only (the
difficulty
so
so
as
to
admitting
1tulica are mine) point on which we require enlightenment is *kat which concerns the why and the wherefore of the reflection the nerves, that go to the lips, and I may add nose, cheeks, ear, eyebrows, neck, chest, tongue, &c.
Even Gerhardt'8 ingenious explanation so often quoted by authorities on the subject will only answer for certain nerves, which are confined in restricted channels with arteries, and
to
gives
1871-72. p. 175). Our summing up
must, I think, be that the why and the
wherefore of herpes has yet to be determined, whilst we may admit that in itself it is a neurotic affection. As regards diagnosis, I do not think that it is necessary
to say anything as regards symptomatic herpes. Syphilitic prceputial herpes, however, as pointed out by Hebra, may It is sometimes impossible to determine involve more doubt. whether we have to deal with a simple herpes or syphilitio affection. This doubt, however, according to Doyon, can last but a short time, and whenever it occurs the diagnosis should not be finally given until after six to eight days. I he prognosis is a matter of no doubt, and belongs more to the original disease than the herpes, which subsides in a few days. With regard to treatment, the expectant is the best in all forms The disease is so mild 'that nothing but herpes progenialis. need be attempted in ordinary herpes. In II. progenialis, M. Doyon lays down the principles of treatment as consisting in five points?(1) to harden the skin and mucous membrane, and thereby remove its morbid sensibility, by the application of dry lint between surfaces that touch, by exposure to the air, and by the application of astringents, tannin, alum, sulphate of zinc, acetate of lead, perchloride of iron, aromatic wine, tincture of matico or rhatany, dusting with calomel, camphor, lycopodium, or starcti, or glycerine of tannin, sixteen grains to an punce. But tannific ition, he admits, is not likely to come up to the expectations of the Sur-
geon ; derivatives he does not approve of. To modify the exciting causes he recommends moderation and regularity, and not abstinence, and he relies on certain
marriage
of cure. As the disease is constantly associated with debility and irritability, he recommends tonics. He says the disease He warns against the use of mercury. is not venereal, and is connected with venereal disease only as far as that is the excitant. as
a
means
Herpes Iris et Circinatus. (Hebra). Herpes Circinatus. (Willan, Wilson, Fox, Neumann, &c.) Herpes Iris. (All modern authors but Bazin, who names it
Hydroa vesiculeus).
THE INDIAN MEDICAL GAZETTE.
316
Hebra considers that H. circinatus is only an advanced stage of H. iris, in which the development continues at the circumference, whilst the central groups of vesicles have undergone
involution, leaving nothing within the vesicular margin surface, the seat of pigment or of scales, or restored to its normal condition. The distinction, however, between H. circinatus and iris is based on good grounds, for cases are undoubtedly met with in which the central vesicle is not formed and the erythematous patch has reached a considerable size before the vesicles are formed. In this country they are rather their but
a
more
common
than true H. iris.
Herpes circinatus differs from herpes phlyctenodes in the fnct a central surface left clear from vesicles. According to Wilson it most often commences in the night, with
tingling, itching, and smarting followed by hyperaemic patches, small at first, but rapidly extending they reach the size of one
to
two inches
or
more
in diameter.
be slightly depressed in the centre, and with
It is then found to a
further extension
the color in the centre is changed and becomes yellowish, and The border is somewhat raised above the a ring is formed. level of the general surface, and is somewhat lighter in tint. On this margin the vesicles are produced ; they rapidly dry up, and at the end of four or five days there is nothing but With this the redness disappears, brownish or black scabs. As this and in a few days there is no mark of the disease.
only one in a succession of outbreaks of the eruption, the disease may continue for ten or twelve days, or longer, as in the case which Wilson mentions as not being well at the end As modifications, Wilson mentions red patches of two months.
is
interspersed amongst the others without any vesicles (herpes sine vesiculis), and others in which one large bulla is. formed. He has noticed this herpes circinatus bullosus twice associated with pregnancy. Hardy has described it as Pemphigus pruriginosus. The eruption may be very general, as in the case mentioned by Wilson, but it is by no means necessarily or generally so. Fox says he has seen it in the neck, face, and forehead. Bazin states that its seat is on the trunk, especially chest and the neck, and rarely oil the anterior part of the He also says that it is usually preceded by on the face. general malaise and anorexia, febricula, and pricking sensations in the part; but these symptoms are slight, and disappear with the appearance of the eruption. He mentions also that several
circles may meet at the circumference \ and he says that the duration is 21 days or more. The total number treated at the Dispensary was 15, 11 males and 4 femaleS, or in the ratio of 26 6 per cent of females. The ages varied much, from 7 months to 72 years. Of the 15 the ages were : Under 5 years 1; 5 years to 10 years, 2; 10 years to 20 years, 3; 20 years to 30 years, 3 ; 30 years to 40 years, 4; 40 ?
cases
50 years, 1; above 50 years, 3; so that the disease appears to be one of middle and advanced life. The patches were developed on the neck and trunk in 6 cases; on the face in 1 ; on the upper extremities in 4 ; and
Tears
to
the lower extremities in 2 ; on arms and legs in 1, and the is not mentioned in 1. In the majority the duration was about a month. The number of patches was in -only two or three of the cases very
so on
It has
by syphilitic treatment; it is symmetrical, and accompanied by special concomitant evidences of syphilitic infection. Herpes iris is looked on by Wilson as an abated.form of II. circinatus. It occurs very often on the backs of the hands of elderly persons, and the patches and vesicles are small. On the limbs the central vesicle is often a bulla. An inflamed disc or spot first makes its appearance, the day
vesicle
or
bleb, whilst
a
no
ring
diminishes
constitutional symptoms, and is always associated Tilbury Fox considers it an unimportant variety,
debility.
and with truth. Hebra give3 the duration as 15 days for a single complete involution, or 30 if consecutive rings are formed. It has a tendency to recur at tho same season each year It may be very chronic, ring after ring succeeding each other with intermissions of various duration, as in the following case : M., aged 25, weak and anaemic. The disease commenced two months ago on the back of the right arm. This spot reached a
diameter of 2| inches one way and 2 inches the other. At 1 873) the skin is reddish-colored, and has not
present (January
resumed its natural tint. Twelve days ago a second
patch commenced, and the diameter The inner vesicle has dried up. In the outer ring the vesicles are coalescent. He was treated with quinine. On March 1st, he returned and stated that his arm remained is
now
1'9 inches.
well for
a
appeared
on
fortnight, the left
and that then He
arm.
was
(10 days ago) a fresh patch again treated with quinine
and tonics. In another case, in a youth 18 years of age, it had recurred annually for 10 years, and continued through the hot months? March, April, May, and June. The former patches were marked, not by excess but by diminution in pigmentation, an unfrequent circumstance. The and legs, a few on the body, slight itching, then a red patch with single large vesicle which dried up in four days. Around this, successive circular rings, which ultimately joined neighbouring patches. The crusts did not fall for a month, and then leave a red surface. The man was dyspeptic and out of health. Twelve cases were treated in the dispensary, and all were
patches appeared
none on
the facc.
on
the
arms
At first
males. The ages were as under :? Under 10 years, 3 ; 10 years to 20 years, 4 ; 20 years to 30 years, 1 ; 30 years to 40 years, 3; 40 years to 50 years, 1. Only one case was observed on the chesi, and the rest on the extremities ; five omthe hand and arm ; six on the foot and leg. On the backs of the hands there were of the feet three.
positions, viz., (1)
upper arms and thighs ; very rarely on the face.
The
diagnosis, like very difficult,
and
on
the dorsa
quite
(3) (5)
means
four;
agrees witli what Hebra gives ns hands and feet; (2) forearms and legs;
This
the
(4) exceptionally
on
the trunk;
in the other forms of herpes, is by no if ordinary care is taken. The only dis-
with which it can be mistaken is Tinea circinata, which great justice considers as the proper term for the
T. Fox with
cured
until the
size of the vesicles
ease
'
a
has attained its full size. The as the disease proceeds. In elderly persons it may never become vesicular, and remain in the condition of erythemic iris (Wilson). 13ulla) may be formed, and then there is a pemphigus iris.
border, and
position
Hebra says it is most frequently met with in the young. This will be seen to be the case as regards H. iris, but as above noted, it is certainly not in H. circinatus. 4 Tilbury Fox notices a chronic form of syphilitic nature and
by
border of red appenrs round its circumference ; on the third day this narrow border is turned into a vesicular ring, and the redness has crept on for another stage, forming another red
in
extensive.
covered
1874
narrow
with
that in it there is
this disc is
following
[December 1,
Tinea circinata is the
parasitic form. the body, and
ordinary ring-worm of
in certain stages presents a true herpetic charac* ter; but in this country the vesicular stage is by no means common or marked. Any one can satisfy himself of this by
studying the dadli" of the natives, especially in the rains. In my experience, it is extremely rare to meet a fresh case* and only in these could any mistake be made. In the chronic cases, the remains of previous years' growth of the trichophyton tonsurans are sufficiently marked indications of true nature of the disease. In a few of these cases vesicle? do at times appear in the fresh growing margin, hut they ore' as a rule, small, and quite unlike herpes. Even in fresh cases*' where an erythematous herpetic-looking patch is seen, the microscope will determine the nature of the disease. "
OF THE SKULL DscraiBt* 1, 1874.] SEVERE INJURIES As
in
-As is
there is nothing to be said, they are both II. circinatus and H. iris, non-fatal diseases. said is, that there cause, the only thing that can be
regards prognosis,
themselves, regards
general debility, nutritive
Treatment.?In
or
nervous.
affections
dependent given to remedy
on
general debility,
our
?first attention must be the constitutional defect. .Quinine, arsenic, mineral acids and bitter tonics are all of
advantage.
and
buf with natives after it cod-liver oil.
always
used and
good As
diet is the first of all for local
remedies, applications, I have
been satisfied with the benzoated zinc oint-
ment, the present ling, zinci of the London pharmacopoeia.
Itching
and
irritation may be
allayed by
cyanic acid in emulsion of bitter almonds. 1rntant treatment ia to be avoided.
-August 2nd,
1874.
a
lotion of hydroAny thing like
& BRAIX.
BY E. A. BIRCII.
317
