gerous secondary affections supervene. In relation to the probable duration, ultimate violence, and obstinacy of the chronic form of the disease, the prognosis is in general very uncertain. Some cases continue moderately for eight or ten weeks, and then disappear; others, apparently equally mild during the first four or five weeks, gradually acquire more and more severity, and continue for many months in an aggravated and very distressing form, and may even terminate fatally. The degree of danger depends, of course, in a great measure, on the extent of the eruption, the obstinacy of its progress, the nature of the visceral affections with which it may be complicated, and the degree of constitutional vigour of the patient. When the vesications assume a livid or bluish appearance, there is much reason to apprehend unfavourable consequences. (Reil.) Old, worn down, relaxed, arthritic, and nephritic subjects, are most apt to suffer severely from this affection.

• Treatment.-In the acute form of the disease, it will in general be sufficient to put the patient on a simple and unirritating diet; to prescribe an occasional mild laxative; cool acidulated diluents; rest; and to avoid a humid and variable atmosphere. If inflammatory symptoms supervene, or the eruption is very extensive, a more active antiphlogistic treatment is required. Gentle purgatives; the ordinary saline diaphoretics, particularly the alkaline effervescing draught (potio Riverii;) tepid bathing; and venesection, must be used with an energy corresponding to the degree of the general and local inflammatory excitement present. Richter recommends calomel in such cases above all other aperients. He also advises the use of diuretics, if the disease manifests a disposition to continue beyond its ordinary course-and of these, he says, digitalis is the best, squills being, according to his experience, objectionable. All local applications must be avoided, nor should the vesicles be disturbed or opened. Cazenave recommends the application of leeches to the

anus.

In chronic pemphigus, (pompholix,) we should in the first place endeavour to ascertain whether any visceral or other general disorders co-exist, or preceded the eruption. Should there be grounds for presuming the presence of a syphilitic taint, or of an arthritic or calculous diathesis, or finally of hepatic or some other visceral affection, recourse should be had to remedies suited to counteract the lurking affection. (Richter.) In general, a moderately antiphlogistic treatment-such as acidulated diluents, mild aperients, and tepid baths, will be proper in the commencement. The German writers speak very favourably of the employment of diuretics in this variety of the disease. They are particularly indicated where the urinary secretion is scanty or unnatural. Richter says that he cured an inveterate case in a short time by the following mixture,* in conjunc

*R.-Extract. digital. purpur. gr. iii.-iv.-vi. Submuriat. hydrarg. mitis gr. i.

tion with the free use of an infusion of juniper berries. The same writer recommends dulcamara, in union with antimony.* Limewater in large portions; infusions of herba jacea; sarsaparilla; precipitated milk of sulphur; belladonna; and opium, have all been mentioned as remedies in this affection. I have met with but one case of chronic pemphigus. It continued for six months, under various modes of treatment, and at last disappeared under the use of Fowler's arsenical solution. When diarrhoea, with more or less obtuse abdominal pain, supervenes, opium is particularly serviceable. When pulmonary irritation occurs, attended with frequent and violent cough, spitting of blood, and oppressed respiration, local and general bleeding becomes necessary, after which opium and calomel may be administered with benefit. When, by the long continuance and severity of the disease, the strength of the patient is exhausted, or when the disease occurs violently in old, relaxed, and worn down subjects, quinine, with the sulphuric acid; a nourishing diet; occasional opiates; chalybeate preparations; and other supporting remedies, should be employed. Cazenave and Schedel state that they have observed several examples in the Hospital St. Louis, of the very good effects of tonic remedies even in young subjects, where the eruption was of long continuance.

SECT. III.-Urticaria.-Nettle-rash.

The nettle-rash, a very common cutaneous affection, is characterized by hard elevations of the cuticle, of irregular forms, with a pale or whitish centre, and generally a diffuse redness round their margins, attended with intolerable itching, and a stinging or smarting pain.

Its course is often very rapid, the eruption appearing suddenly, and vanishing again in the course of a few hours; although in such cases, it usually reappears for several days in succession. It may also assume a chronic character, and continue with occasional transient intermissions or remissions for many months, or even years.

Urticaria febrilis.-Symptoms of general indisposition, such as nausea, languor, drowsiness, slight chills, headach, anorexia, pain and anxiety in the epigastrium, with an accelerated pulse, precede

Opii. puriss. gr. ss.

Sacch. albi. gr. xv.-M. Divide into twelve equal parts. S. Take one three times daily. The proportion of digitalis should be gradually increased. If the gums become affected, the use of the medicine must be suspended for a while.—Loc. cit. p. 615.

* B.-Antimon. crud, nigri.

Pulv. stipit. dulcamar. ää zi.

Extract. trifol. aquat. zii.-M. Divide into two grain pills. S. Take

ton three times daily.

the appearance of the eruption. At first, a general itching with a feeling of tingling heat is felt over the whole body; to relieve which, the patient is apt to rub or scratch the skin, which never fails to bring out, almost instantaneously, large patches of red elevations or wheals, with whitish central disks and irregular crimson areola, attended with an extreme degree of itching and tingling. The eruption speedily becomes more or less extensively diffused over the surface, particularly on the palmar aspect of the fore-arms, around the knees, along the loins, on the inner part of the thighs, and on the shoulders. The irruption vanishes irregularly on different parts of the body, but is almost immediately recalled "on any part of the skin, by strong friction or scratching." During the day the eruption subsides, but as the evening approaches, it returns, together with slight febrile irritation; and in this manner the disease is usually protracted to the sixth or seventh day, before it finally subsides. The parts principally affected become swollen and uniformly red; but the swelling always soon subsides after the eruption disappears. More or less languor and febrile irritation accompany the disease throughout; "the disorder of the stomach, however, is relieved by the appearance of the eruption, but returns whenever the eruption reappears." (Bateman.)

Urticaria evanida.-This variety of the disease is unattended by fever, and often continues for many months under a succession of transient wheals, appearing here and there on the body, and vanishing again in a few hours, at short and irregular intervals. An eruption will perhaps appear on one arm in the morning, and disappear again in a few hours; in the afternoon, the wheals may come out on the legs and remain for a short time; and after a short interval, or only on the following morning, they may appear on the body. In this way the disease may go on to a very protracted period-the eruption appearing and disappearing frequently, "according to the temperature of the air or the exposure of the patient, and the degree and kind of exercise which he uses." The slightest friction or scratching will almost immediately bring out the wheals on any part of the body; but when thus excited, they usually recede again in a very short time. The eruption consists of irregular patches slightly raised and firm to the touch, or of elongated wheals, "like those produced by the stroke of the whip, or they are round, resembling the firm, elevated tumours produced by the bite of a mosquito." These wheals are not surrounded by an erythematous areola, although sometimes encircled by a very narrow and faint streak of red. They are always attended with violent itching, and a sensation of tingling or stinging pain, more particularly "on undressing and getting into bed." Languor, headach, transient pains, and derangement of the digestive functions, are apt to occur during the course of the disease; but in some instances scarcely any symptoms of constitutional or sympathetic disorder, except the cutaneous affection,

attend.

"Its course varies from a few days to many months, and even years." (Bateman.)

Urticaria tuberosa.-This rare variety of the disease is characterized by hard, prominent wheals, or tuberosities, attended with deep-seated pain, tension, and difficulty of motion. The eruption occurs chiefly on the loins and on the extremities. It generally comes out at night, and disappears before morning, leaving the patient "weak, languid, and sore, as if he had been bruised or much fatigued." Cazenave and Schedel state that they saw at the Hospital St. Louis, an instance accompanying a quotidian fever, which, after having lasted for four years, finally terminated "in swellings, great distention, ecchymosis, ruptures, and ulcerations." Some paroxysms were attended with so much general tumefaction, as to produce oppressed and hurried respiration, a livid and puffed face, weak and intermitting pulsation of the heart, and other very alarming symp

toms.

Urticaria subcutanea.-In this variety the wheals seem, as it were, to lurk beneath the skin, and make their appearance only at distant intervals, An almost constant tingling sensation, however, is felt in the skin, with occasional severe pricking sensations, as if needles were thrust into the surface, limited at first to a single part, but extending afterwards to others. Individuals affected with this variety of the disease, are apt to suffer frequent pain in the stomach, and cramps in the muscles of the legs. (Bateman.)

mer.

Causes.-Urticaria is most commonly met with in children, young females, and in persons of a sanguine and nervous temperament. The seasons most favourable to its occurrence are spring and sumSome individuals are so strongly predisposed to the disease, that the least friction or scratching almost immediately brings out large wheals. The irritation of dentition, mental excitement, and various articles of food, such as strawberries, raspberries, mushrooms, honey, oatmeal, green cucumbers, almonds, dried or smoked fish, lobsters, shrimps, crabs, and particularly muscles, are apt to produce febrile urticaria in some individuals. The internal use of valerian and balsam copaiba produce extensive urticaria in some persons. Chronic urticaria is frequently connected with an irritable and deranged state of the digestive functions. The tuberous variety "seems to be excited by excess in diet, overheating by exercise, and the too free use of spirits." Urticaria is also produced by direct irritating applications to the skin, particularly by the leaves of the common nettle (urtica dioica) and by the contact of certain caterpillars, as the phalana processionacea. It occurs sometimes in the course of various febrile diseases, and is often speedily produced by taking a draught of cold water after the body has been excited or heated by exercise. In many instances, however, the disease makes its appearance without any manifest exciting cause; and its occasional dependance on peculiar idiosyncrasy or constitutional habit is unquestionable. In children it often occurs during the process of

dentition, or apparently from acidity in the primæ viæ, and is in them usually called hives.

Prognosis. Although often an extremely tormenting affection, from the intolerable itching and stinging pain which attend, urticaria is almost universally wholly devoid of dangerous consequences. Werlholf, indeed, observes, that it has in few instances terminated fatally; but death probably occurs only where the eruption is secondary, and associated with some other more serious malady. Richter says that in children the disease is sometimes accompanied with great difficulty of breathing. The sudden recession of the eruption does not appear to give rise to any unfavourable consequences.

Treatment. In the febrile variety of the disease, advantage may sometimes be obtained from an emetic of ipecacuanha. Richter states that the operation of an emetic will occasionally put a speedy stop to the progress of the disease. In general, however, one or two mild laxatives, rest, simple diet, cooling drinks, and the occasional use of the tepid bath, will be sufficient. Where there are symptoms of acidity in the primæ viæ, magnesia or alkaline remedies, particularly lime-water, will be proper. When the disease occurs in irritable and debilitated subjects, or in persons of weak and disordered digestive powers, benefit may be derived from moderate doses of quinine, sulphuric acid, and the usual preparations of iron, after the alimentary canal has been evacuated by emetic and laxative remedies. Reil says, copious draughts of cold water often produce a very good effect. In the chronic variety of urticaria, particular attention should be paid to the diet; for, in some instances, it would seem to depend on some article of food rendered oppressive or irritating to the stomach by constitutional habit or idiosyncrasy. "I have," says Willan, "desired several persons affected with chronic urticaria, to omit first one, and then another article of food or drink, and have thus been frequently able to trace the cause of the symptoms. This appeared to be different in different persons. In some, it was malt liquor; in others, spirit or spirit and water; in some, white wine; in others, vinegar; in some, fruit; in others, sugar; in some, fish; in others, unprepared vegetables." Almost all the useful diaphoretic alterative remedies, such as sarsaparilla, the root of burdock, the golden sulphuret of antimony, dulcamara, Lisbon diet drink, &c. have been at times recommended, but they rarely appear to afford any particular advantage. Fowler's solution, however, is a very efficacious remedy in the chronic form of the disease. It is mentioned by Cazenave as having been successfully used in a very obstinate and distressing case of this kind. Dr. Dewees has used it frequently with success, and I have myself employed it in a few obstinate cases with the happiest effect.

To relieve the extreme itching, various external applications have been recommended. Vinegar and water, or lemon juice diluted with water, will sometimes procure considerable relief. The tepid bath also, may be used as a palliative for this purpose. Sea-bathing, or